Adam Bisaga, MD: Overcoming Opioid Addiction

Dr. Mark Leeds [00:09] Welcome to The Rehab on the Mental Health News Radio Network. I am Dr. Mark Leeds and I will be your host. Join me in exploring the world of addiction treatment. How can we improve the ways that we help individuals to overcome addiction? The goal of treatment is to save lives and help people to get back on track to a path towards success and happiness in life. Adam Bisaga, MD, is an addiction psychiatrist, clinician, researcher, and professor of psychiatry at Columbia University. He conducts research on new treatments for opioid addiction and oversees a national program that mentors physicians treating opioid addictions. He is a UN expert involved in international addiction training and program development. Dr. Bisaga, thank you for joining me and welcome to the Rehab Podcast.

Adam Bisaga, MD [01:06] Well, thank you, Mark, for inviting me. I’m very happy to be here and speak with you.

Dr. Mark Leeds [01:10] Today we’re going to be talking about your new book, which is coming out soon, Overcoming Opioid Addiction, the authoritative medical guide for patients, families, doctors, and therapists. And I just completed the book and I really loved it. This is a book that I believe should be in the hands of definitely every doctor, and maybe not just doctors who are currently treating opioid use disorder, but doctors who are considering it, pretty much everybody across the board. In fact, I was going to ask you about something a few years ago, actually 2007, so about 11 years ago, I received a book in the mail that was called Responsible Opioid Prescribing, and it had been sent out by the Federation of Boards, or actually the Federation of State Medical Boards. It was by Dr. Scott Fishman. And at that time, it was great that they had paid for that and sent that book out to us, and it was a nice reference to have. I feel like they should do that with this book. I mean, whether it’s the Federation of State Medical Boards or some other organization, I mean, if this book could be put in the hands of every doctor in the country, it would be really excellent. And I think every doctor really needs to read this.

Adam Bisaga, MD [02:20] Well, I’m glad to hear that. And that was definitely one of the intentions I had when thinking and then writing the book was that there is really a lack of knowledge. And for a variety of reasons that we could discuss later, the education about addiction has been really removed out of the medical school education. And then the doctors were expected to deal with patients who had these issues. So how they were able to do that if no one really taught them. So they relied on the kind of common understanding of addictions that is shared by many people in the society, which I think was very, very limiting. And it, I think, in some way contributed to this problem that we have, which the problem that I recognize is the treatment gap. That, you know, there are so many people that have a problem and we have effective treatments, but we are unable to deliver treatment to people. So definitely, my book was kind of, in some way, trying to fill the gap of knowledge. But I think that much more has to be done to actually change that. But I’m glad that you’ve kind of noticed that. And I appreciate your support.

Dr. Mark Leeds [03:34] I was wondering also, was there ever a consideration of possibly actually making this three or four different books, you know, or maybe smaller pamphlet versions? For example, if I, you know, I’d love for my patients to have this book. In fact, I may even make it a requirement, and the family members also separately. I just imagine, of course, I’ll tell them to get the book or I’ll give them the book and say, read Section 4 if you’re a patient, Section 3, I think it is if you’re a family member. Did you ever consider that, having actually four separate books?

Adam Bisaga, MD [04:06] Right. No, we certainly, I did consider that. But then again, I thought that the book is really based on my experience working with patients and their families. And what I’ve noticed over the years, I end up telling the families and the patients all parts of the story. I tell them about how some people develop the problems because of, again, kind of overprescribing in a medical setting without paying attention to the potential of some of those medications to become addictive. And then I definitely tell how to educate patients and their families, why in their case the response to the drugs was different than in people, many other people who got, you know, painkillers but never developed an addiction. You know, how then the medical treatments are able to help overcome some of those vulnerabilities in their brain that caused them to have an addiction. I certainly talk a lot to families about what’s the best way for them to deal with having a loved one affected with this problem, how to protect themselves, and also how to be most helpful. And I certainly tell the families and the patients a lot about how to go through the necessary processes of stabilizing on medication and being able then to overcome the problem. So at the end, I’ve decided that I think there is something from all this perspective that could be useful to the families and the patients. But then it could also be useful to professionals because professionals need to know how to advise the families and how to help patients go through the process of stabilizing on medication, which they may not know what’s like to be a patient in the grips of dealing with this kind of very intense physical and emotional experiences when they give up drugs. So I’ve decided that in some way it could be actually useful for, as you’re saying, primarily read the chapter designed for them, but also to have access to the other perspectives. And I would definitely, if they already, encourage them to read about the other perspective to have a more kind of complete pictures. And that’s why we decided to have it all in one book.

Dr. Mark Leeds [06:17] It seems like the main underlying message of the book is that medication must be a part of the treatment of opioid use disorder. And it must be part of that treatment of that chronic disease long term.

Adam Bisaga, MD [06:30] Right. You know, that the medical perspective is really necessary to be at the center of treatment, definitely at the beginning of treatment. And again, for some people, it may need to be a part of the kind of long-term treatment. Others may be able to move beyond the medical stabilization and maybe, you know, have the rest of their life in a more kind of non-medical treatment focused on recovery work. But at the beginning of treatment, it’s absolutely necessary because the disease is so deadly, right? And unless we provide the medical stabilization, we really don’t give patients a kind of way. We give them less of a chance to kind of conquer it, to come out of it. No different than from other serious medical disorders, be it a cancer or some other heart attack, that at the beginning of treatment, it’s really important to have a kind of stabilized, constrained effect of the disorder on the brain using medical interventions. And then over time, we can focus on the lifestyle changes, spiritual changes, you know, other support changes, and kind of less so of a medical focus because patients are actually way beyond the most acute phase. So that’s exactly, as you were saying, that the medical model at the center of treatment and definitely the beginning of treatment for everybody with this disorder.

Dr. Mark Leeds [07:55] And as far as the medications, there’s three medications you described, basically for the treatment of opioid use disorder. We have three medications available, methadone, buprenorphine, and naltrexone. Now, I learned some new things about methadone. I kind of have always had a negative view of methadone, and I didn’t realize that it’s considered to be the gold standard of treatment and has a 75% success rate, which is well above the 50% success rate of buprenorphine and naltrexone for people who can get on those medications. And it seems like, you know, for some people that may be the answer. You know, someone just cannot get to the point of, and I had a patient in this situation, he couldn’t get through even the 12 to 16 hours to get onto the buprenorphine. And that may be the right option for a lot of people is to get started by going to a methadone program.

Adam Bisaga, MD [08:53] Right. So, you know, as I’m trying to make the case over and over in this book, that we have three very different medications that may actually offer something different for a patient and hopefully we will be able to find the best match for the given patient at a given time. It doesn’t mean that they have to stay with this medication for the rest of their life. It means that when we are kind of trying to engage them and stabilize, one medication may be more acceptable or, as you’re saying, easier to work with than other medications. Once the patient is stable, then we have options of either continuing on this medication or actually transitioning them to another medication. Methadone seems to be the one that we have the most experience with. We’ve had methadone since late 60s. We’ve had millions of people around the world treated with methadone. We have a broad, broad range of scientific literature showing, you know, how to do this treatment properly. You know, and that’s why it’s and it appears to be when done really well, appears to be most effective, defined as people who are able to have a stable life with improvement of physical and mental health and improvement in well-being. Methadone seems to offer this to more people than other medication. That’s why it’s there. Now, of course, methadone has a very tumultuous history in our society and many other societies. And certainly, there is a lot to be talked about that why methadone has such a kind of bad reputation in some circles. But yeah, definitely it’s a highly effective medication. It’s very potent and very effective, but it’s a difficult medication to use. There’s a lot of restrictions and regulations, which makes it unlike any other treatment. The two other medications can be given pretty much in kind of most medical settings and also give most patients an option to use. Methadone, as you may know, it’s available in very few centers around the country, primarily urban centers. Methadone programs or opioid treatment programs, as they are known these days, are kind of very complicated to set up and run, and therefore, this medication may not be really available as widely as we would hope.

Dr. Mark Leeds [11:14] And of course, as I know my practice and my patients, of course, know, buprenorphine works very well. Patients do very well on it. And as you said, it is possible to transition from methadone onto buprenorphine. And I think in the literature they recommend tapering down on the methadone to 30 milligrams first before going to buprenorphine. I’ve had some patients transition from a little bit higher because they were just determined that they didn’t want to go to the methadone clinic anymore. And it takes them a little while to get used to it. They feel sick in a lot of cases for the whole first month, but then they do really well after that. And the buprenorphine, it’s incredible. And I think you even describe it in the book as very rewarding for a doctor to see the change that happens. And I sometimes don’t recognize my patients when they come back after three or four weeks. I mean, they look like completely different people sometimes walking in.

Adam Bisaga, MD [12:09] Well, that’s really interesting to hear that. And that’s certainly true that the change is pretty dramatic, especially in people who are, you know, coming to using heroin every day and really have their life really completely wrecked. You know, they’re in severe depression, hopeless, you know, on the verge of thinking about ending their life, coming to you for help. And then you know, stymobuprenorphine and it’s like in a few days, they start kind of being amazed of how is it possible that they can feel so differently so quickly. And then you see them every week after that, they have even more and more of this kind of enthusiasm uses for life. And of course, often depression goes away, they start being hopeful, you know, this may not last, you know, because then the reality of daily life hits them back. But definitely, the change is pretty, pretty dramatic, pretty powerful. Unlike, you know, very few treatment in psychiatry that we have that the change may be so quick. So it’s extremely rewarding for the doctor and for therapies, for someone else to see that patients can suddenly feel so well so quickly. And you want to be a part of this, right? You want to share this with a patient. You want to tell others about it. Patients want to tell others about that. And that’s why we are in helping professions to be a witness to this change. And you’re absolutely right that I wish more people had more doctors and therapists had opportunity to witness that.

Dr. Mark Leeds [13:36] In fact, it works so well that it almost works too well that in some cases, and I think you also described this in the book, that some patients feel they’re doing so well, they feel like they’re cured. And I’ve had this happen with patients where they try to quit their medication, and they may even feel fine for the next day after quitting it. And then they realize, wait, I’m getting sick again. And then sometimes they even get upset, like, well, you know, now I’ve just traded one addiction for another, and, you know, I’m dependent on something else. And you go into this in the book. You’re not really, when you go from, say, heroin or oxycodone onto buprenorphine, you’re not really trading one addiction for another. It’s not an addiction when you’re on medical treatment.

Adam Bisaga, MD [14:15] Right. So I think it’s important that the patients, because, again, the patients have these notions about what it should and should not be the part of treatment. And they are strongly influenced by those notions. And many of them are not kind of accurate or use the perspective that it’s not a medical perspective, so it doesn’t really match their experience. But you’re absolutely right. There is this notion that because you are taking medication every day and if you stop the medication, you feel unwell, that means that you are addicted. You know, I can understand how people who have not been, you know, working with patients or actually addicted may feel that way, but that the patient cannot see the difference from what’s like to be addicted, where your mind is constantly preoccupied with getting the drug and doing whatever it takes, destroying their lives to have a supply of the drug, and a physical kind of discomfort because they don’t take medication every day and there is some physiological adaptation. While the families can maybe think that way, oh, they’re taking medication, that means that they’ve been taking painkillers, now they’re taking this, it’s kind of the same. But the patients, I think, would be easily taught or worked with to reframe how they’re thinking about themselves, that this is not really an addiction, that they need the medication to have a stable life, and they rely on medication, they’re dependent on medication to have a stable life. But they’re certainly not addicted to the medication because they can have a normal life. They can devote their energy and time to pursue other things in life. Most of them don’t really think much about taking medication, except that, you know, every morning when is the time for next dose, they think about the medication and that’s about it. And the rest of the days they are, you know, devoting to other pursuits in life, which is very, very different from addiction, right?

Dr. Mark Leeds [16:05] And also, you know, with buprenorphine, you know, people when they’re taking heroin and other opioids, abusing them or misusing them, they, you know, their thinking is clouded, you know, they’re, of course, they’re also constantly thinking about, you know, how do I get the next dose and how do I keep from getting sick? But they also, because of the drug itself, they’re not thinking clearly. And people, when they take buprenorphine, they tend to, their thinking clears up. They have a clarity of thinking and, you know, they’re able to do their daily activities a lot better and function better.

Adam Bisaga, MD [16:36] Right, right. Absolutely. So their mood is stable because there is no up and down of on and off the opiates. They are not sedated or in physical discomfort through the withdrawal, which is a part of being on heroin or painkillers, they are pretty much even stable throughout the day, which is what medications do. They kind of stabilize the functioning of your opiate system. So, you know, the most destructive for your brain is the kind of constant changes up and down, which again have negative impact on your cognition or your mood, on your, of course, sleep and wake cycle, on your feeding and on your sex functioning, on everything else that we are about as human being not having a stability, it kind of interferes with. And then when you’re on medication, whether it’s buprenorphine or naltrexone that keep the system on a kind of very constant level, that allows the body to kind of reset the kind of, you know, normal physiological functioning in all those spheres that you mentioned, which again is very different than addiction. So, those two points, again, should make everybody realize that taking medication every day is not like an addiction to the medication. If you have a good response, of course there are patients who don’t have a good response, and that’s another story to discuss, but 50% or more have an excellent response to medication. And in those people, their life couldn’t be any different while on medication as compared to their life when they were addicted before they started medication.

Dr. Mark Leeds [18:08] Now with buprenorphine and the most common brand being Suboxone, In fact, a lot of people just call all of it Suboxone. They call the doctors who prescribe it Suboxone doctors and Suboxone clinics. With Suboxone or Buprenorphine, a common starting dose is, for a lot of people, I think is 16 milligrams a day. Now, just for example, just say that there’s a patient who stabilizes very early on at 16 milligrams a day. They have no problem with side effects. They’re functioning very well in their life. And they kind of are in a critical situation of that they have a job, they can’t afford to lose, they’re taking care of children, and they’re doing really well. Is there any reason, any physiological reason, why the doctor should start pushing that patient at some point in the future and say, well, it’s time to start trying to cut back a little bit, we need to go down to maybe 12 and 8 milligrams and stabilize you at the lowest effective dose? Because how do you know what the lowest effective dose is and that maybe they’ll start having breakthrough cravings at some point?

Adam Bisaga, MD [19:09] No, you’re absolutely right that somehow people expect then that treatment with buprenorphine will be different than treatment with any other psychotropic medications, right? That somehow the goal should be to get people off medication as soon as possible as opposed to provide stability. So that is one kind of difference that I think is reflected by this tendency of patient-led actors to lower the dose. Of course, if we try to find the right dose, which is the most effective with the least of the problematic adverse or side effects. And sometimes people do have side effects on higher doses, right? They may be sedated, although that’s rare. You know, often they may be sweating too much or they may have sexual problems or they may have swelling in their feet. You know, sometimes there are some side effects, although they are rare. And then we do try to lower the dose to try to kind of preserve the beneficial effect without the side effects. And then lowering the dose is absolutely justified. People do want to see that they’re making progress. And people do want to see that they’re making progress towards the goal, which in their mind is the life without the medication. And I can certainly understand that. Who wants to take medication for years or for the rest of their life? And that certainly could be indicated to think about, to work with a patient on lowering the dose. In my experience, most patients kind of tend to, over time, lower the dose. There are certainly a group of patients that want to just have a guarantee beneficial effects and they stay on the same dose, but many patients tend to gravitate to lower doses. So patients will be on medication more than a year or two. They tend to be closer to 8 milligrams rather than 16. And some people who have been on medication for 10, 15 years tend to be on very low doses, one, two milligrams, sometimes four milligrams. And that’s certainly appropriate as long as they are open to monitoring how they’re feeling and how their life is going and making sure that they tolerate medication well. So I don’t think, in other words, that wouldn’t be any different from treating patients with any other psychotropic medication, be it antidepressant, mood stabilizer, anti-anxiety medications, when you would at first try to maintain the clinical response and then over time you do try to maybe lower the kind of medication load with the idea that less medication is better for the body.

Dr. Mark Leeds [21:35] But there’s not a definite protocol, and I know that there’s no one-size-fits-all, but as far as like, you know, there’s no need to push the patient and say, okay, that’s your first month at 16, now we go to 12, then we go to 8, or maybe not that fast, but, you know, so a person could in theory stay on, say, 16 milligrams for a long time, And then when the patient’s ready and they’ve been doing well in counseling, then, you know, we can ask the patient, do you feel like you’re ready? Do you want to try going back down a little bit?

Adam Bisaga, MD [22:05] Right, right. Or listen to the patient because patient may have an interest. Most patients do have interest to maybe take, again, a little bit less of the medication and you help them get there. So I think that the main problem we have is that patients come off medications too quickly. That’s the primary problem. You know, most patients, on average, patients stay on buprenorphine from anywhere three to six months, and that’s clearly not enough on average. It may be appropriate for some patients, but majority of patients need to be on medication for at least longer. So most of the time we try to kind of encourage patients to stay on medication rather than encourage them to come off. That’s how it should be. That’s what the evidence tells us. Now, of course, the practice may be very different, and you can certainly see the doctors who have a limited understanding of addiction. They haven’t had much experience working with these patients over a long time. They haven’t seen devastating effect of relapses. They may feel like coming of medication should be one of the goals up on the list. I’m always saying that coming of medication should be one of your treatment goals, but should be really very, very low on the list. On the top of the list should be, of course, to stay alive, to stay healthy, be able to move on with your life, have all the other things that addiction may prevent you from getting that we should be focusing on working in treatment, and medication, stopping medication should be really very low on the list. As it is with any other chronic medical illnesses, right? When you treat someone with diabetes, you don’t really have coming off insulin as one of the primary goals of treatment. You have it some patients are able to come off insulin or oral anti-diabetic medications when they have made all the other changes in their life but that is never on top of the list and somehow we want to have the same approach for treating of addiction.

Dr. Mark Leeds [23:57] Now with when it comes for example when it comes to vaccinating children you know sometimes people get confused because they look at stuff online and they see you know these anti-vaccinating movements where they say well, vaccines are dangerous, they can cause further illness, the drug companies are trying to make profits by selling us vaccines, and they have all these great sounding arguments against vaccines. But the truth is, vaccines are important for protecting the population, and doctors are responsible for, the medical community is responsible to educate the public that vaccination is important. Now, we have the same problem with the treatment of opioid use disorder or opioid addiction, where we have people that are in a position of influence, people running treatment centers for addiction, you know, that are saying either medication is it should not be used at all, or it should only be used for a very short period of time, maybe one or two weeks or a month at the most. And that’s a dangerous position. And they’re the ones who are educating the public. And so, you know, it’s almost like a minority of the medical profession is providing the correct information. And in my case, I’m completely in line with what you’re saying. But I even feel that influence when patients say, you know, I only want to take this for two weeks. And, you know, I start feeling guilty, like, who am I to tell them they have to be on this for years and years?

Adam Bisaga, MD [25:11] No, absolutely. You’re absolutely right. And I think it is changing. And we certainly, I hope that this book and the work that my colleagues and myself have been doing will help to provide the change faster, you know. But it is still the dominant model. It’s a very traditional, non-medical. So when the medication were always kind of used only as an adjunct treatment for a very short time during the detox, that’s really how, you know, what was the role for doctors in treating opiate addiction was only to provide some relief of withdrawal at the beginning of treatment before the quote-unquote real treatment could take place, which, you know, the treatment, of course, done by peers, the behavioral treatment. And so with this kind of model still predominant in most of the treatment facilities, you know, no wonder that you hear this kind of opinion as a primary one. And the voice of the medical professionals, the scientists, the people who have evidence behind them, you know, is not heard as much. Now, this is changing. A lot of leading addiction treatment programs like Hazelden Betty Ford have certainly been saying, you know, they’ve changed their view of the use of medication in the last few years, and that’s very encouraging. But it’s still a minority of the leading non-medical physicians at Solstice Tools programs or just the program leaders that is giving this new message. I think the traditional treatment industry still really is in the kind of process of changing how they see addiction, not only about using the medication, but also about using harm reduction strategies as a viable goal of treatment. Those are the two kind of changes that we see that traditional programs are evolving. And you do hear voices as you say, people saying, oh, addiction should not be treated with medication or if you really need medication, you should really come off of it as soon as possible. What do we do when we hear these voices? Of course, we have to counteract those voices with different opinions and it’s not an easy process because you don’t want to alienate the whole treatment industry. They have a lot to offer. They have a lot of experience working in this population using behavioral methods that can be all very valuable. To me, it all can have a value as long as people pay attention to the medical component. I don’t think that they have a value without the medical component because, again, they are sending and conflicting messages to the patients. And patients really don’t know much, right? Patients are only relying on their friends and families, and they cannot really differentiate why this doctor says to use medication for as long as possible, while the other doctor says not to use the medications. They do get quite confused, and that’s not fair to the patients.

Dr. Mark Leeds [28:04] Yeah, and hopefully, like you say, this book will get out there, get into the hands of doctors, patients, families, and therapists, and the word will get out there. And that’s another thing. When we refer patients to a psychologist or to a drug counselor, there’s always that fear. For example, there’s a psychologist I’d refer to some patients to who has decades of experience. He’s certified in addiction treatment. He’s credentialed. He has, you know, decades of experience. And, you know, then I’m concerned, you know, what if he’s telling my patients that they shouldn’t be on medication? And, you know, how do I know that when I’m doing all the right things of referring patients out to the therapist and to the meetings, that maybe they’re going to get the wrong message and just stop their medication, not come back and maybe relapse? And it’s a scary thing to even try to do the right thing and recommend patients. You know, you need to see your psychologist and, you know, and develop a support network because those wrong messages can come from anywhere.

Adam Bisaga, MD [29:01] Right. No, absolutely. And the part of my book, the one devoted to families, is to how to find a right treatment provider or the right treatment program. What are the questions you really want to ask? And when do you can trust your loved ones or yourself, you know, to go to this provider? And when you should look for someone else, you know, how to differentiate that. And, again, it may be kind of complicated, but guiding patients through this process is very important. And as you were saying, you know, there is so much that patients can take advantage of from the traditional program, from the self-help groups, and, of course, from the even certified providers that use specific behavioral treatments that it will be a shame to kind of completely separate them from the medical model of treatment. I really hope that those models can be integrated. But sometimes you have to, you know, say that’s not a good idea. A lot of, as you know, self-help groups, especially the ones that grew out of the NA, Narcotics Anonymous movement, far out reject the use of medications. They still, in their charter, I think, reject the idea of medications as a part of treatment. They do not consider anybody who’s taking medication as meeting the criteria for sobriety. I find that AA groups are a little bit more flexible because their medications to treat alcohol have been around for a little bit longer or at least been present in the groups for longer, so they are a little bit more forgiving. But it’s a loss because NA, I think, still has a lot of value. But, yeah, people get confused. When you say certified addiction treatment provider, you think that this person is using evidence-based latest treatment methods and you would trust the certification. But the reality is people get certified even though they do not believe what the science tells us about treatment. They have no opposing views, yet they get certified. That’s one of the many problems that we still have to solve. The same way treatment programs may be licensed to provide treatment, yet they do not accept the use of medication, but they are licensed by the state. And they are licensed by the state to use public funds, right, to fund for treatment. How is it still possible? I think we have a lot long to go. We are changing something. There have been, in the last years, very dynamic efforts to change that, But I think it’s not changing fast enough because the epidemic is still ravaging the country. And as everybody knows, it doesn’t seem to be slowing down, if anything, accelerating.

Dr. Mark Leeds [31:38] Yeah, and I was going to bring that up actually about Narcotics Anonymous or NA. And for years, I’ve loved NA. I thought it was like the greatest thing ever. And originally, that was my goal. I first took the eight-hour course for buprenorphine prescribing in, I think, 2006. And I did some research and I came to the conclusion my goal should be get everybody into NA. And at that time, you know, they’re talking about tapering people off medication faster. And I thought, well, that’s the goal. Get them in NA, get them a support group and working the steps and having a sponsor and they can be prepared for that coming off their medication quickly. And more recently, you know, I’ve looked into it and there’s NA has a document called Bulletin 29 from 1996, where they talk about methadone being, if you take methadone, you’re not considered to be clean. You can sit in on a meeting, of course, but you’re not clean. 20 years later in 2016, another document called NA and People on Medically Assisted Treatment, where they specifically talk about buprenorphine. Again, they say if you’re on what they call replacement medications, you’re not considered to be clean. You can sit in a meeting. You cannot participate you can’t do service probably a sponsor is not going to work steps with you and I think later another document changed that where they said it’s up to the group if they want if they want to allow you to share or not but you still can’t go any further than that

Adam Bisaga, MD [33:01] Right so they’re evolving you know hopefully in the right direction but it is difficult because the whole identity right that the principles of the movements are based on this you know So group confessional, when you confess to your limitations and, you know, in some way it kind of perpetuates a little bit of the moral view of addiction that you’re somehow responsible for what’s happening to you have to take personal responsibility, of course, for the behaviors. And then, you know, a lot of this is true, but it kind of still reinforces the view that it’s up to you and only up to you to change your ways and your behaviors and kind of revert the behaviors that are hallmark of addiction that cause you to wreck your lives. As opposed to, you know, that there is a part that you should be taking care of and watching, but there is a part that is just too difficult, impossible for most people to change. Now, some people can do it, but most cannot. That has to really take advantage of all available treatments. And now that we have a treatment, you should get a little bit help because without it, what we know what’s happening, right? The untreated OP dependence is the most lethal of all psychiatric disorders. You have 2% of people every year dying. And it is indeed, I think, unethical to refuse or reject, especially by program. You know, everybody has the right to do what they want to do, of course. We live in a free country. But if you’re going to really use the public funds and you’re going to really have a kind of regulatory oversight of the programs is unacceptable to still allow programs exist that refuse the evidence. I mean, that’s at least my kind of view on that. It’s difficult. It’s difficult because it’s a very complicated, you know, kind of multifaceted system and treatment system and multifaceted, you know, problem that we deal with that opiate addiction is.

Dr. Mark Leeds [35:14] Just for example, I had a patient who came in once, and he was transferring from another doctor, and I think he had been on buprenorphine for, I think it was at least two years. He was doing very well. His first visit with me, I mentioned going to meetings, and right away before I could finish my sentence, he said, I don’t go to meetings. I’m doing very well with my treatment. And I said, I’m sorry, and I never mentioned it again. I’m not going to get in the way of something that’s working. You know but I know for other people meetings may be the best thing for them and you know everybody’s different so you know there’s no one size fits all therapy that you can just use a cookie you can’t really use a cookie cutter approach for every single patient.

Adam Bisaga, MD [35:55] Right right but I think for those people that are really very connected to the 12-step fellowship that really benefited from that really love the camaraderie and of course the kind of way of living in sobriety. I think for those people, maybe the naltrexone may be an attractive alternative, right? Because I think most groups would be more forgiving when they see someone being maintained on naltrexone, which is, again, non-opioid, or at least, you know, it’s an opioid that doesn’t produce opioid effects. It’s a medication that blocks opioid system and it’s not a replacement therapy or at least cannot be considered replacement or substitution therapy still helps with maintaining abstinence, preventing relapse, decreasing craving. You know, and many people I’ve heard that feel much more comfortable themselves being in a group, again, not being on buprenorphine, but rather being on naltrexone as a way to help them, you know, remain abstinent. So that’s, I always suggest for people who, So, you know, that’s one of the decisions that we consider at the beginning of treatment, which medication to go. Do they want to be detoxed and be on naltrexone to prevent relapse, or do they want to go on buprenorphine? You know, that’s one of the things that we discuss when, you know, I try to talk to them about various options of getting help and what are the differences.

Dr. Mark Leeds [37:18] Yeah, and naltrexone is, of the three medications, it’s the only one that’s not an opioid. It’s not controlled. It’s any doctor can prescribe it without any special training. And in fact, a doctor who’s not even registered with a DEA could prescribe it. Any doctor can prescribe naltrexone.

Adam Bisaga, MD [37:35] Right. Right. And it’s not, quote, quote, unquote, cannot be abused. So, quote, unquote, is non-addictive. So, it cannot really be misused. And, you know, some people just like this idea a little bit more. I do not try to show patients that there is somewhat superior, kind of morally superior medication. I think they are both equally good choices and should be equally good first-line treatments. But for some patients, those differences may be important. You’re absolutely right.

Dr. Mark Leeds [38:06] Now, if a patient comes in, and you did discuss this in your book, and I wasn’t sure about this before, A patient comes in who’s abstinent. They’ve somehow, whether by going to treatment or on their own, they haven’t used any kind of opioid, including buprenorphine, for say two to four weeks or even longer. And now they come in and they’re concerned. They want to be on some kind of medical treatment. Now, suppose the first thing I would recommend would be naltrexone because they’re abstinent. So why put them back on an opioid? Now, suppose the patient says, I have reasons not to take naltrexone. I didn’t respond to it well before. I don’t want to take it. I’d rather take buprenorphine. Now, the patient has a negative drug urine screen. They admittedly have not been taking any opioid for at least weeks. Now, I think in your book, you do say that if the patient requests that we can put them on buprenorphine, is that correct? And how would we start that? Would it be a lower dose?

Adam Bisaga, MD [39:04] Right. So you’re absolutely right that, you know, for methadone, you’re right, You cannot start methadone in someone really who is not physically dependent, right? It’s pretty clear there are regulations. How do you start methadone? What are the good candidates? And you would not put someone on methadone in that case. But for buprenorphine, there isn’t really any regulations or guidelines. You know, if they still have OP dependence, and of course, the fact that you’ve been abstinent for a few weeks doesn’t mean that you got cured out of your OP dependence. We know that those patients will have cravings, urges, will, you know, under stress, will have increased risk of relapse. We know that if you don’t treat them, they will, you know, a lot of them will relapse sooner or later. So if you can offer them medical treatment that will prevent it, you know, that is certainly a viable medical intervention and nothing really stops you from offering that. Of course, patient has to understand that they will be dependent physically again. You know, once they start buprenorphine, they need to take it every day. You’re absolutely right the doses may be may be lower less than eight milligrams maybe two maybe four milligrams they probably wouldn’t need higher doses and you know and then you’ll start induction like like you would do again you there’s no physical dependence so there’s really no wait period you will just start prescribing the medication and try to find you know keep them on a dose and then hopefully help them stay with this for as long as possible I mean it is absolutely, for some groups of patients, are at very high risk. You know, the ones that you mentioned are, of course, people coming out of rehab or people coming out of prison, right? Those are the very high-risk groups. We know that your risk of overdose death goes up by eight times when you’re leaving those type of facilities because, again, you are returning to your environment where you have all these cues and triggers and stressors that somehow maintain your addiction before and of course you have no tolerance to protect so your body has no defenses to protect against overdose so you have a double kind of whammy that puts you at risk of relapse and overdose and it’s absolutely essential that people do understand those risks and do have a choice of restarting medication that will decrease those risks that will decrease cravings, urges and they will protect them with a little bit of the blocking buprenorphine also can protect against overdose if people use because it is very tightly bind to the receptors and it prevents heroin from getting onto those receptors. So there is certainly a medical reason and as long as the patient fully understands the implications of starting this medication and you have a discussion, you check that they do understand risk and benefits, I think it’s fairly justifiable and I think most of the people who do this work would agree that this is a viable treatment option. Again, it has changed. It hasn’t been seen like that maybe 10 years ago, maybe 15 years ago when buprenorphine came to the market. But right now with this opiate epidemic and the fentanyl overdose deaths, I think most of us would feel that this is a right medical decision.

Dr. Mark Leeds [42:15] That makes sense. Now, another thing that has happened more than once with patients that have come in, a patient comes in and they’ve stopped taking heroin the day before. You know, they knew they were coming in. They wanted to be prepared. They wanted to start treatment right away. Maybe a patient comes in with their husband or wife, and they want to start right now. And, you know, we do our evaluation, and everything looks good, and, you know, we give them the prescription to get the medication. And now that patient who’s feeling very sick and just can’t wait to get started, they go to the pharmacy, and the insurance says you need a prior authorization. And I know, I think in 2008, with part of the Affordable Care Act was passed, I think it’s called the Parity Act or has a longer name. But there’s a law that guarantees that everyone will get the same coverage for addiction and mental health conditions as it would get for any other condition. And these patients who may have been able to get prescriptions for oxycodone paid for without a question are now the doctors are given long forms to fill out. The doctor fills out the form. I do them online. In fact, for any doctors listening, if you don’t use CoverMyMeds.com, it makes it very easy to get authorizations. Yeah, so I’ll go and CoverMyMeds, I’ll fill out the form, and then they start asking questions, they want more information, and some insurances will just flat out, you know, they put up roadblocks, they make it very difficult, and now the patient is sick, and they’re calling, and they’re saying, what do I do now? And do you know of any, are there any tricks to make these insurances?

Adam Bisaga, MD [43:45] Right. Yeah, no, that’s absolutely right. Of course, I can hear frustration in your voice, and we’ve been through that because we know how essential it is to provide this treatment as soon as possible, how great of a risk the patient is at if they don’t get treatment when they are ready. And so it’s extremely frustrating that bureaucrats are making this decision, and sometimes some of those pre-screening questions make completely no sense. And I don’t want to waste time to give examples. But so the tricks are twofold. You know, I do tell patients that most likely the medication will be approved. And you should probably ask pharmacists to give you a small supply of medication. You pay out of pocket. You start treatment. And once we get you approved, you will then, many insurance will reimburse you back. This has been a well-identified problem. And many municipalities are kind of making sure that this doesn’t happen. And so there is a law at the local level, at the state level, that prevents it. And I know my state, New York State, have done this law that right now no insurance company can really ask for preauthorization, that it’s illegal to do that because you’re right, it should be consistent with the Parity Act, but still it was a widespread practice even though the Parity Act was on the books. So I think this is changing, and I think what I tell patients again, my trick is that they should really just buy a few medications. You can get coupons. Many of the branded preparations offer you coupons to offset some of the costs in starting treatment. That also could be helpful for some patients. And, again, you’re hoping that most insurance will cover this is a very inexpensive medication as compared to many medications that they are paying for. And it’s a life-saving medication and there is really no reason and it should be outraged if it’s going to be treated any other way. So hopefully that this will be less of an issue in the future and some of the legislation hopefully will target that.

Dr. Mark Leeds [45:49] I wanted to ask you about plain buprenorphine, which a lot of people call Subutex, but I don’t think the brand Subutex is around anymore. And I think in some states there may even be laws about this or it may be more difficult. But do you consider that it’s acceptable in many cases if a patient can’t, say they’re uninsured or they’re having difficulties with the insurance process, to use the buprenorphine as a cost-saving measure, and it makes it accessible for the uninsured. But then I know there’s a concern with not using the abuse deterrent, which is present in suboxone and Zubsolv.

Adam Bisaga, MD [46:22] Right. So that’s a little bit complicated, of course, and it’s really case by case basic. In principle, you would really want to use a combination product, which is buprenorphine with naloxone, because it seems to have a little bit less of an abuse ability. Of course, there is no absolute protection. The combination product can also be misused and abused, but certainly has a lower rate. And then there is a perception in the community that Subutex is somehow more attractive medication because it doesn’t have this deterrent, as you’re saying. So it has a higher market value. And again, some people may be more readily, if people are set on misusing the medication, which some patients can certainly are, they may be more readily to do that with the monoproduct, the Subutex or the buprenorphine on the tablet. So you have to be very careful how do you work with patients who is treated with this medication. You probably want a little bit closer monitoring of this patient. You know, we have a ways of making sure that the patient takes medication properly. You can certainly give smaller doses. You can have a medication callbacks. You know, you can even look at the blood level, urine level of buprenorphine and its metabolites to make sure that the patient is taking medication, you know, using the proper route. If that’s the only way the patient is going to have treatment, of course, you don’t hesitate to provide treatment. It’s just you will need to have a little bit closer monitoring. At the same time, buprenorphine, the monoproduct, is, of course, preferred choice for pregnant women because, you know, there seems to be a little bit more concern with teratogenicity of the naloxone as opposed to buprenorphine. So in this population, it’s definitely medication of choice. In any other patient population, they should be offered combination product unless, as you’re saying, it’s not feasible for them.

Dr. Mark Leeds [48:22] And there’s a lot of clinical issues how to manage patients.

Adam Bisaga, MD [48:27] There is certainly, again, for patients who don’t have optimal response, there is many ways that clinicians have developed how to deal with and help patients have a better treatment response. And certainly we don’t have time to go into that here, But I just have to let people know that there is this mentoring support and training program, PCSS, Providers Clinical Support System. That disclosure, I’m a part of. And we do offer a lot of opportunities for physicians to get access to mentoring, to discussion lists, to small group discussions. A lot of materials have been produced and are available for free that help physicians with all those clinical decisions that they have to make to make them feel more comfortable and supported when they decide to take on this treatment. Because as you probably know, a lot of physicians are very uneasy when they do start offering this treatment to the patients. Most of them, I have to say, feel actually that this was one of the best decisions they’ve made after they’ve treated 10, 20 patients. They feel that there was really no reason why they were so hesitant and they like it. But there is still a big, I think, barrier for entering into the treatment. And unless we have more physicians offering this treatment, we’re not going to really have any grip on the epidemic. I think that the best way to start combating the epidemic is to offer treatment, which is the way that of course all western countries in western europe were able to combat their their epidemics and you know this is not the only epidemic of course that has happened in the past around the world so we have models of how health care system and physicians responded to other epidemics and you know hopefully we’ll have more physicians again my call is for more physicians to be open to provide this treatment it’s no different more no more difficult than prescribing painkillers, which physicians seem to be very comfortable doing. And I would encourage that physicians also give a chance and try offering this life-saving treatment because, as you were saying, it can be a very, very rewarding experience. And of course, you know, it can be very helpful to the community that you’re working with.

Dr. Mark Leeds [50:46] And again, you had mentioned that you’re involved with PCSS, and the website for that is p-c-s-s-n-o-w.org, p-c-s-s-n-o-w.org. I’ve been a member for, I think, the last three years, at least. And yeah, I was introduced through, I went to a, I think it was 2015, I went to an osteopathic convention in Orlando. And I spent my entire time in the addiction lectures. And they introduced us to the program, they gave us the literature. And I went online, signed up, and I got a mentor. It’s all free, it doesn’t cost anything. You can get, you know, your own personal mentor. There’s no grading or anything. You don’t get graded by your mentor. It’s just somebody to ask questions and talk to. And, you know, there’s tons of paperwork and information and a lot of education. I mean, everything you ever want to know about how to treat patients with buprenorphine, with opioid use disorder, is available at pcssnow.org. I highly recommend every doctor, you know, go look that up and get involved and sign up. Again, it’s completely free. It doesn’t cost anything

Adam Bisaga, MD [51:50] Right so this has been available from early on from like early 2000 when there was a need to support providers to start prescribing buprenorphine was called PCSS-B at the beginning and then over the years that the grant was renewed and it kind of the organization evolved and you know we myself and my colleagues from Columbia University came to this about six years ago, six, seven years ago, and we’ve been integral part of this since. Again, trying to, you know, provide developed educational materials, trying to figure out what kind of support clinicians would benefit the most from offering, of course, buprenorphine waiver treatment, buprenorphine waiver courses that are necessary to have a DEA approval to offer this medication. And it again has been a very rewarding if I may say you know for myself equally rewarding to treating patients has been to convince physicians to take a leap of faith and start treating these patients with buprenorphine or even more so naltrexone because many many people are very you know maybe familiar with buprenorphine but will be hesitant to offer naltrexone and then when they do offer extended release naltrexone they feel equally excited about this opportunity. So it’s been very also enjoyable for me to work with colleagues to, again, to expand access to treatment. And I certainly thank you for encouraging people to check the PCSS. There are other support systems available also, you know, the AETC, which is the Educational Network for AIDS, also offers some trainings and support for people prescribing, you know, buprenorphine. So there are other support systems, but I think PCSS is one of the largest and certainly worth checking.

Dr. Mark Leeds [53:41] Now, there’s also recently, there’s been a movement of doctors, you know, there’s a lot of talk about burnout in the community of physicians, you know, doctors are burning out of their jobs, they’re working for abusive healthcare systems, you know, large hospitals, what they call big box clinics, and, you know, and they’re, you know, and now, so there’s now a movement where, you know, doctors are, you know, they want to get away from the burnout. And there’s even, you know, an issue with physician suicide. And so doctors who feel overwhelmed with having to deal with the electronic health records and the bureaucracy, they’re looking to drop out and to start their own small practices, you know, what generally what are considered to be micro practices, you know, where maybe it’s just a doctor in a small clinic, maybe one room and maybe a small staff or even no staff. And the one issue is that doctors, they think, how is that going to work? What is my business model going to be? How do I take insurance? How do I get patients? How do I advertise? And one easy way to start is just to, if you want to become part of the micropractice movement, also become part of the addiction treatment movement and establish a large part of your practice just to get started. It’s fairly easy to get trained in how to provide treatment for opioid use disorder and make that an important part of your practice.

Adam Bisaga, MD [54:58] Right. Right, and PCSS also supports, you know, with the business plan and kind of thinking about, you know, kind of business aspects of running addiction treatment practices. So we can help you on logistics, regulatory aspects the same way as we can help you on clinical aspects to do that. And I think, you know, again, it can be very, whether you can practice alone or you can actually, you know, practice with the addiction treatment program in your community that doesn’t have a medical provider. Most of those programs really crave for medical providers because they do know that offering medication and medical help can increase their success rate. So they do want to collaborate with a medical provider in the community. So reaching out to those programs and offering medical services can be also very rewarding. And there are patients there ready for you to start seeing. You don’t have to really do your own looking for patients. If you’re concerned that you may not have enough patients to start with.

Dr. Mark Leeds [55:59] And in the book, you even describe what’s called the hub and spoke model, where there’s an addiction treatment, maybe a large addiction treatment facility. They see the patient, get them started on treatment, and now they want to pass that patient along to the spoke, which might be a small practice like me, and I would continue the maintenance for the patient. And if at some point, if they need more intense treatment, I can refer them back to the hub.

Adam Bisaga, MD [56:23] Exactly. So one of the concerns, you’re right, the doctors who don’t have experience is that those patients will be very difficult to manage and may have a bad outcome. So who wants to, you know, who wants to expose themselves to do that? So the hub and spoke model offers a solution to that, which is that, as you were saying, you know, and those programs actually have been very successful in Vermont, and now in Baltimore and several other states are embracing this model because it’s much easier for the primary care provider who is even, you know, who is not a specialist to practice in the community when they get stable patients from the hub and they just maintain stability. They always have a way to contact the colleagues at the hub to, you know, to consult when the patient, when there are some issues with the patient and when the patient is too difficult to manage, they can refer a patient back to the hub. And then when the patient is stable again, they can return to the spoke, to the practice. And that way they can manage hundreds of patients, you know, up to 275 patients, which is the maximum. But that’s plenty for most doctors. And feel that this is manageable. So that’s another model you write to see where are the hubs in your community, what your state has the hub. There are other new efforts to expand access to treatment. States have received a lot of money recently to fund addiction treatment programs, and they are very eager to give training and mentoring and maybe even financial help doctors willing to treat those patients. So you should definitely call your state single state agency for addiction treatment to see if they have any ways to help you get involved and be a part of the system, a network of, again, providers in the state that can offer treatment. So that could be another way for you to get involved if that’s what you feel like will be more rewarding, to have more control over how you practice medicine.

Dr. Mark Leeds [58:16] Yeah, I’ve heard of several programs. I think there’s one from Yale University. I know there’s one here in Palm Beach County, and I think in Mississippi, there’s several where treatment is initiated in the emergency room, and then there’s an ongoing program, and patients are able to get their treatment completely paid for if they can’t afford it, if they’re uninsured, and they get the full spectrum of treatment, the medication, the counseling, and the doctor’s visits all included, and it starts in the emergency room.

Adam Bisaga, MD [58:45] Right. Right, so there’s many models, new models of providing treatment that people are trying. Starting in the emergency room is one of those models because that’s where, you know, patients often come in crisis and it’s easy to get them engaged. You know, they walk in clinics, you know, the kind of urgent care type of model is another model that there is kind of low threshold of entry into treatment. Obviously, there, you know, opioid treatment program in your state, patients can go there and get started, and hopefully they don’t have to wait, although, you know, some states there is a wait list. And so there is many, many ways to engage people with treatment. I strongly believe that once the patient is on medication, their view of getting help change pretty quickly. You know, many people are very ambivalent about stopping drugs because they fear of what their life will be like without drugs that will be unmanageable because, you know, they no longer have this sure way of dealing with distress. But once they are taking the medication, they’re thinking about themselves, about their life, about their future, it really rapidly changes, and they are much more eager to accept treatment, to believe that treatment is possible, that life without heroin is a real possibility. So getting people on medication as soon as possible, of course, safely, you know, is a priority. And I strongly believe that the programs that allow patients to get started whenever they are ready is a solution to the problem. Patients should be able to walk into any emergency room at any time and ask for help and get started. A patient with overdose will be definitely brought to an emergency room, right, and treated for acute overdose. And the same should be the case for patients who want to stop using drugs. There should be really no barriers for them to end the treatment, get, you know, evaluated and started, and, of course, have free treatment, especially at the beginning to allow them to do that because those are some of the barriers that we talked about, right? Providers, insurance barriers, many other barriers that keep people out of treatment whenever they are ready.

Dr. Mark Leeds [1:00:50] And there’s just so much here in this book that we couldn’t possibly cover at all. I mean, for how families can deal with the addicted family member or loved one and how they, you know, don’t kick them out on the street, don’t do tough love, doesn’t work, not for opioid disorder. You want to get them medication treatment and don’t hold back your anger. And you talked about motivational interviewing, which I wanted to say you describe it in a way that makes it a lot easier than I took a class that included motivational interviewing training. And but when I read the way you describe it makes perfect sense.

Adam Bisaga, MD [1:01:24] Sure. No, thank you. Thank you for that. And again, book has a lot of like simple, I was trying to make a very simple tips and guides for their for their families, because they often, you know, again, so confused when they are caught in this, you know crisis the constant crisis of having an addicted family member then you know then then simple suggestions can be very helpful some things to try you know many of them may not work but definitely there are some better suggestions than others and the one that you mentioned that the one that you often hear from the traditional treatment providers which is to kind of distance yourself from the patient until they are ready to come back to you maybe it’s acceptable for other addiction, but I strongly feel it’s unacceptable for opiate addiction because we know that many of those people will not come back because we’ll be dead. You really cannot afford this kind of strategy. I don’t think it’s acceptable.

Dr. Mark Leeds [1:02:19] And part of that also is the harm reduction. You talk a lot about that, providing clean needles if someone is just not going to stop using the heroin, places where a person can go in certain communities to be monitored and where they’ll check the heroin and make sure that it’s not poisoned with fentanyl or carfentanil or whatever they put in it. And they’ll make sure that the person doesn’t die, you know, administer Narcan if necessary. And I just don’t want to finish with the most important thing, Narcan. I mean, we have fire extinguishers in the wall everywhere. Now we have automated defibrillators in the wall almost everywhere. We should probably have Narcan on the wall everywhere. And until then, you know, everybody can get a hold of Narcan and, you know, have it with them in the car at home you know you can save a life naloxone narcan reverse an overdose and save someone who’s turning blue and dying because they’re not breathing after using too much opioids

Adam Bisaga, MD [1:03:09] So that’s a good suggestion I’ve never had put it that way but I think it’s it makes a lot of sense I think it will be worth looking at how much it costs to have defibrillators everywhere and how often you actually how much it costs to maintain them and how often you actually use them and what are, again, the costs of having the Narcan available, which is extremely, extremely inexpensive or can be extremely inexpensive medication, you know, should be extremely inexpensive medication, let me put it this way, and why not to have it available whenever there could be a medical emergency, like in the public areas, you know, airports, schools, universities, medical clinics, where fibrillators are. I think that’s a very, very good point. Because you’re right we have to do everything narcan of course is not gonna cure opiate addiction you know if you can reverse overdose but unless you get someone into treatment they are much more likely to have another overdose and many of those people do eventually die the only way to prevent reduce the risk of death is to start them on medication as soon as possible but of course narcan will will you know will allow them to live to be able to do that but unless, you know, Narcan reversal is followed by the medication, I don’t think we’re there yet. I would want to see all people who have Narcan at least be offered medication. They may not, of course, take it. They may refuse it, but they should be offered. You probably have seen yesterday in the paper that there was a lawsuit. The Prince’s family is suing the hospital, claiming that he was seen for overdose a week earlier in the hospital. And they’re claiming that he was not offered evidence-based treatment. Now, of course, we don’t know what really happened, but I think it just exemplifies and brings to people’s attention the fact that if you have someone who comes to the hospital with the overdose, this is an amazing opportunity to have them started on treatment to prevent the risk of overdoses in the future. And even though many people will refuse it and they have the right to refuse it, many will accept it. And that’s really what we want. With more and more people having an accessible, available, and effective treatment.

Dr. Mark Leeds [1:05:23] And that’s something that these treatment centers should consider, the inpatient treatment centers, the residential treatment centers, where they don’t believe in medication or just short-term use of buprenorphine, that could become an issue for them, long-term liability. Maybe even NA, the NA World Services Organization, with this document, and I’ll just read what it says. It says, in NA, addiction is treated by abstinence and through application of spiritual principles. So they’re actually saying, NA is saying, we treat addiction, we treat it with abstinence. Right, right. And they shouldn’t be providing any treatment for a medical condition.

Adam Bisaga, MD [1:05:59] Right, right, exactly, exactly. They do appear to families as if they provide treatment. No, they provide spiritual support and community and, you know, a lot of help, but they do not provide treatment. This is what they offer is not compatible with the evidence-based treatment the way we want the rest of the medicine to be guided by, you know, the principles. But they can provide very useful additional service. And, you know, the whole idea is how to bridge those two perspectives. Because, again, at the end, you know, we care about the patients rather than other organizations.

Dr. Mark Leeds [1:06:32] Again, this book coming out soon, Overcoming Opioid Addiction, The Authoritative Medical Guide for Patients, Families, Doctors, and Therapists. And everybody in that group should get this book. Every doctor in the country or in the world who has access should read this book. Anybody who knows anybody as a loved one, family member who’s addicted, needs to read this therapist, especially.

Adam Bisaga, MD [1:06:59] It’s available actually now as of today. I think it’s available on Amazon and should be hopefully available everywhere. We put it down in a paperback, so it’s inexpensive from the beginning. And again, we would like as many people to be able to have access to information contained there as possible because I think that there is really lack of reliable information on the market. Searching the Internet can be helpful for many things, but I don’t think it’s helpful to help you make decisions about what’s the right treatment. I think there’s too many confusing information on the Internet about treatment. So hopefully the book will fill the gap. And thank you so much for inviting me and talking about this book and, again, for doing this work and educating others and bringing everybody else up with their progress in science because we’ve made a lot of progress that should really be trickled down to the patients and the communities.

Dr. Mark Leeds [1:07:56] Get this book. And thank you very much. Thank you for coming on. I really appreciate it was definitely a pleasure talking to you, and thank you again.

Adam Bisaga, MD [1:08:03] Likewise, likewise. And keep up the good work with the podcast, and all the best to you. Thank you, Mike.

Dr. Mark Leeds [1:08:10] Thank you for joining us today on The Rehab on the Mental Health News Radio Network. I hope that you have found this show to be interesting and useful. If so, please subscribe to The Rehab Podcast and share on social media. I appreciate your taking the time to listen to The Rehab.