A Transcript Of My Conversation With Dr. Sederer, Psychiatrist, Public Health Expert, And Author.
In this podcast episode, I speak with Dr. Sederer about a variety of topics. We discuss psychedelics for depression and how they might help in treating addiction. We also discuss Suboxone medication assisted treatment and the importance of naloxone harm reduction and how it can help people who overdose on addictive substances such as heroin or fentanyl. Do you know why people become addicted? How does the reward center of the brain work and how does it relate to different types of addictions? To learn more, please read, or listen to the episode here.
We start out by talking about Dr. Sederer’s new book, “Ink-Stained for Life,” which is a memoir that includes 14 stories about growing up in New York paired with 14 essays that connect each story to the present, providing a narrative arc between events in the past with later outcomes that may have seemed unlikely.
In addition to this episode being published on the Mental Health News Radio Network, I have also published it to YouTube on my official channel, LeedsTube.com. Some time stamps below are also links to the corresponding location in the recording published on YouTube. If you do click on these links and visit the YouTube version of this interview, please click or press the “like” button and the “subscribe” button. I appreciate your support. Thank you.
[00:00:03.240] – Mark Leeds, D.O.
Welcome to The Rehab Podcast.
[00:00:05.370] – Lloyd Sederer, M.D.
It’s great to be here, Dr. Leeds, it’s an honor to speak with you.
[00:00:11.190] – Mark Leeds, D.O.
Thank you. So, Dr. Lloyd Sederer, you’ve been working in public health for about two decades now. In New York at the state level. You’ve worked at the city level. And, previously, you worked at McLean Hospital, which is the psychiatric teaching hospital for Harvard Medical School. And, I believe that was 1989 to 2000?
[00:00:31.560] – Lloyd Sederer, M.D.
[00:00:32.160] – Mark Leeds, D.O.
And, you were the psychiatrist in charge. You rehabilitated the whole program, got them up to date for managed care. I just read your new book, “Ink-Stained for Life”, which is a memoir of your life, going back to, I think, is it the ages of eight to 17 years old?
[00:00:48.150] – Lloyd Sederer, M.D.
Yes, it is. But each story, I tell 14 stories, but I match, or pair, each story with an essay on the theme of the story. The story might be about family. It might be about family business. It might be about running away from home. It might be about gambling, rich people, Jewish people. So, I write an essay developing the theme and relating it to 20 20.
[00:01:16.680] – Mark Leeds, D.O.
That’s one thing I like about it. When I first picked it up and said, oh, this is going to be about your childhood, I wasn’t sure if it was going to be a book I was going to enjoy reading, but as soon as I got into it, I really enjoyed it. And you do bring things back to the present. You talk about addiction. You talk about, like you said, rich people and Judaism. And, I think there’s a lot in there for a lot of people. I would recommend this book to anyone. Anyone in the medical field, anyone who’s a doctor or resident, medical student, thinking about going into medicine. I would recommend it to people who are addicted or have family members who are addicted, or people interested in what it’s like to grow up in New York in the 50s. There’s so much in there for a lot of people. I think pretty much anybody could get a lot out of the book. It’s almost like sitting with you, and you being a mentor or a friend and getting your life story and history and your opinions on things, your philosophies. I love the story about the chicken farm. There’s just really so much great stuff in there. You know, people interested in public health and why we really need public health and good people running it. I mean, it’s just it’s just so much good information in there.
[00:02:16.880] – Lloyd Sederer, M.D.
It’s very kind of you. I also hope it will demonstrate, if people read it, how improbable my future was. Eight years old, I was this skinny, nervous, shy Jewish kid in the Bronx. And as you describe in the beginning, I’ve had a lot of jobs, really great jobs. So it’s an improbable leap from eight years old to recent decades.
How to consume shrooms. Could psilocybin be part of the treatment plan for substance abuse in the future?
Are shrooms legal or are shrooms illegal? Currently, the drug psilocybin, the active ingredient in a particular variety of mushroom, is not legal in the U.S., but that may be changing soon. A synthetic form of the drug has been studied extensively and shows promise in treating a variety of mental illnesses, including addiction. Imagine going to the addiction specialist for psilocybin-assisted treatment with mushroom capsules or sublingual strips. In this segment, Dr. Sederer explains that while psilocybin and ketamine are promising new medication-assisted treatment drugs, he is not at all a cannabis advocate.
[00:02:45.840] – Mark Leeds, D.O.
And you’ve had a lot of really interesting life experiences. And I definitely want to talk about addiction and your experience in treating addiction, helping people with addiction. One interesting topic, you did talk a little bit about the use of of psychedelic drugs in the treatment of addiction, maybe for other mental health disorders. People have asked me about it. Now we have legal marijuana everywhere. And marijuana feels like when they say that if you have one tool, you have a hammer, everything looks like a nail. And they say it’s good for everything, but there’s definitely dangers. And maybe it’s not as good as they say. But we have these psychedelic drugs that, they tried them in the 60s, and there werer Harvard professors and psychologists studying them and some good things being done. And then, suddenly it just got out of control.
[00:03:30.470] – Lloyd Sederer, M.D.
First, let me make a comment. I am not an advocate for widespread access to cannabis, to marijuana, because of its effects on the brain of young people, teenagers, young adults. Their brains are under-construction. It’s a really potent drug. It’s 60 times more potent than the stuff I smoked in college. So, I think we have a lot more to learn about cannabis and about quality control and limiting access, particularly to young people. But I am an advocate for one particular psychedelic drug, psilocybin. I am because psilocybin has been studied very rigorously in the Imperial College, London, Stanford, NYU and others. And, it was used first with patients who were facing their death. They were terminally ill with cancer, and they were also in enormous emotional distress facing the end. And the first cohort was five hundred people treated with an 80 percent improvement. Namely that that fear of facing the end went away, and it was replaced by a sense of, life is continuous. We are part of a larger universe, a much more comforting way of thinking about our moment on Earth and subsequently. Another thing about it is that it is safe when administered properly, which is namely synthetic psilocybin. Therefore, no contaminants, in a safe place with an experienced guide, and one or two trips do the job. So it’s not just the trip, which is maybe six hours. It is in perpetuity, months and months and months, a year later, that the effects of altering a person’s view of their life and therefore, what stress they feel. It persists.
[00:05:38.340] – Mark Leeds, D.O.
And that makes sense. There’s a lot of spiritual philosophies where they talk about having a connection with the universe, or the universal mind. And and how thought is the problem. All of our problems come from our thoughts. And, it’s easy for someone to sit down with a patient and say all these things. But, if someone is in active addiction or just coming out of it, it may not be easy to focus on these concepts and really understand what they mean.
[00:06:01.620] – Lloyd Sederer, M.D.
This is one treatment sometimes, two, and it works immediately. And we’re all disposed to treatments that are quick, safe and effective. And that’s what psilocybin is and it’s been around for a long time. Thousands of people have been given it, and I think it may well be a big step forward for addictions and for other terrible states, refractory depression, OCD.
[00:06:30.930] – Mark Leeds, D.O.
And, another one you’ve talked about is ketamine, which is a different kind of drug, a disassociated anesthetic, used as an anesthetic for humans, for children, in fact, in the E.R., and has been proven effective in treating depression.
[00:06:44.850] – Lloyd Sederer, M.D.
Yes. And now ketamine is available as an inhalant, not just as an infusion. And, so it’s become quite popularized. And there are many clinics, I imagine, in Florida, certainly in New York, where a person can go and receive it under the care of a physician. But, it’s not without its side effects or ill effects, like you’re saying, that some people become quite dissociated during and after it. And, it can be habit forming because it is that kind of drug. People have this extraordinary experience of energy and engagement with the world, and the first experience blows people away and it’s hardly ever obtained again.
Next, we discuss medication-assisted treatment of opioid addiction with methadone, buprenorphine, and naltrexone. While each of these three treatment drugs has its place, buprenorphine, the active drug in Suboxone, seems to be the best in terms of safety and efficacy. The problem is that there are not enough buprenorphine doctors to meet the needs in many areas. Dr. Sederer, during his public health career in New York, was able to implement policy that ensured that all mental health facilities worked with local Suboxone doctors to make medication-assisted treatment for opioid use disorder available to anyone who needed it. We also talk about Narcan spray, which is an overdose reversal treatment containing naloxone. Nasal Narcan administration saves lives, and it is important to make it more widely available and to provide nasal Narcan training to the public. If more people carried a naloxone nasal spray kit with them at all times, as Dr. Sederer does, we would have more opportunities to reverse overdoses and save lives.
[00:07:34.150] – Mark Leeds, D.O.
From there, I wanted to ask you about, and I know you talk about this in your books also, about MAT, medication-assisted treatment, which mainly applies to opiate addiction, can also refer to alcohol addiction treatment, alcohol use disorder. MAT includes mainly three drugs. There’s methadone, buprenorphine, buprenorphine being Suboxone and naltrexone, which is available in tablets and also Vivitrol, the monthly injection. Especially buprenorphine, since 2002, I think when they approved it and Suboxone became available, and Subutex, the widespread use has not been what we would have hoped for. There’s a lot of fear, I think, of Suboxone being used and misunderstanding about it, but it definitely works in my experience. People who take it for usually at least a year do very well even when they decide to come off of it, and not everybody should come off of it. But people that do they tend not to have drug cravings when they come off. They do have significant opiate withdrawal symptoms that they have to deal with, but not the drug cravings. So it does seem that there’s an actual healing occurring in the brain over that period of time that they’re taking it.
[00:08:40.030] – Lloyd Sederer, M.D.
Yes, those are the three FDA approved medications and the first two are opiate agonists. They provide, they fill the opioid receptors, in some ways block it as well, with the buprenorphine. And the third is Vivitrol, which actually acts differently in that it prevents somebody from experiencing pleasure, so you can shoot up and you’re just not going to get the hit from it. And that’s also not been very widespread. It is a monthly injection. It’s expensive. Not all insurers cover it, including Medicaid in many states. But, it is effective, and its effectiveness was proven, as you suggested, with alcohol as an addiction. It’s a good drug. But, the one drug I want to add, I think may be the most important of all, and that’s naloxone. Because people recover from addictions as long as they don’t die from them first. And, what naloxone is, it’s a reversal drug that, when somebody is going into respiratory arrest, it works immediately, saves lives, and it should be available on the counters, free in every pharmacy. And, New York City has tried to make it very accessible. And what’s also important is that it used to be an injection, and even first responders, like firefighters, didn’t like sticking a needle into somebody. But now it’s a nasal spray and it works just as well. So, naloxone keeps people from dying while they’re trying to get into recovery and stay in recovery.
[00:10:33.700] – Mark Leeds, D.O.
Naloxone is very important, and it’s the rescue drug. A couple of years ago, we were talking about that it should be everywhere, on the walls where they have the automated defibrillators. Why not have naloxone there? And now, we’ve even talked about that it could be as common as hand sanitizer. You know, everyone could have it in their pocket or their handbag. The more of us that have it, the more chance we might save someone.
[00:10:59.080] – Lloyd Sederer, M.D.
I carry it in my backpack.
[00:11:01.490] – Mark Leeds, D.O.
You do carry it with you?
[00:11:02.590] – Lloyd Sederer, M.D.
Yeah. Two pack of nasal spray.
[00:11:05.320] – Mark Leeds, D.O.
That’s great. I actually had a patient a while back that I had prescribed it, and I asked on a visit, the parents were there, and I said, “do you have the naloxone available?” And the mother said, “well, we have it in the house, but I locked it up because I’m afraid he might get to that and do something with it.”
[00:11:22.750] – Lloyd Sederer, M.D.
If she doesn’t understand the drug, she she batches it with others that are more addictive.
[00:11:30.320] – Mark Leeds, D.O.
And luckily, she understood after our conversation that, of all things, he’s not going to abuse the naloxone. Luckily, it came out of the lock box, because it wasn’t, within the year after that, they ended up using it successfully. And that patient is back on track and doing very well now.
[00:11:46.180] – Lloyd Sederer, M.D.
Yeah, I’ve not had a chance, thankfully, to use it, you know, in a shop or somewhere public. But, a friend of mine was in a Starbucks, also a doctor, and the bathroom door was locked and people were lining up and pounding on the door and no response. No response. So they got the owner, opened it and there was a man lying on the floor with a needle in his arm. And this friend squirted some naloxone in his nasal passages and he was revived.
[00:12:18.010] – Mark Leeds, D.O.
If someone is carrying naloxone and you happen to come across a scene like that, you’re not going to hurt a person, giving them naloxone. So even even if you’re not sure why they’re there unresponsive, you can still try it.
[00:12:29.530] – Lloyd Sederer, M.D.
[00:12:30.610] – Mark Leeds, D.O.
And it’s really definitely important. I actually heard a story. From an E.R. about a patient that came in that had actually overdosed in the middle of an NA meeting. And so, in NA, those kind of meetings, they’re not going to be responsible for having it, but members can bring it with them.
[00:12:48.370] – Lloyd Sederer, M.D.
In fact, many people who shoot up, use with other people, so it’s a good idea, if you’re a part of that world, for everyone to carry it, because you’re not going to be able to administer it to yourself, but your buddy might, or one of the people in the room of an AA or NA meeting.
[00:13:08.590] – Mark Leeds, D.O.
Naloxone brings us to harm reduction, which I know you’re in favor of. You’ve mentioned it in your books. Harm reduction, including naloxone, but also possibly including clean needle and syringe exchanges, supervised injection or supervised consumption sites where a person can go safely, use drugs under supervision. If they have an overdose they can be revived with a variety of methods, including naloxone. Another important thing, I actually interviewed someone on a supervised consumption site in Canada and they talked about how not only do they provide all these services, but they form relationships with the people that come in.
[00:13:41.500] – Lloyd Sederer, M.D.
[00:13:42.040] – Mark Leeds, D.O.
And, that seems to be the most important part of it.
[00:13:45.300] – Lloyd Sederer, M.D.
That will help somebody get into recovery, get into treatment, stay with the 12 steps. It’s always relationships.
Harm Reduction and Risk Reduction Strategies.
While naloxone, available as Narcan nasal spray, is a major form of harm reduction that can help to people alive through active opioid addiction, there are other ways to provide harm reduction which are currently being used in other countries. Needle exchange programs do exist in the US, but they are very limited. For example, in Florida, where I live and practice medicine, we have only one such program in the entire state. For heroin users in Miami, the “IDEA Exchange” program protects them from the dangers of dirty needles, including an increased risk of HIV and Hepatitis. For users elsewhere in the state asking “where can I get clean needles near me?”, they are not going to be able to find such a program in their area. In another episode, I interviewed Stephen Finley, who manages SafePoint, a supervised consumption site in British Columbia, Canada. Stephen Finlay is the manager of addiction services in the Surrey region for Lookout Housing and Health Society. British Columbia has allowed a variety of harm reduction strategies to be implemented, and they are proving to be successful. In this segment, I ask Dr. Sederer, as a public health expert, what are the chances of such programs coming to the U.S.?
[00:13:54.820] – Mark Leeds, D.O.
What do you think about that as far as the lack in the US of those? In Philadelphia, there was a case where someone was trying to open up a supervised injection site and the government was blocking, the federal government was blocking the opening of the site. Do you think that there’s any hope that we’re going to be like in British Columbia where they have all these different forms of harm reduction? Do you think that will come to the US?
[00:14:16.360] – Lloyd Sederer, M.D.
I don’t think it’s imminent. This country has certain fixed views, convictions about certain things, like opening a site for people to shoot up down the block. Moreover, the elected officials are really scared because, in a way, it’s condoning the purchase of an illegal substance, because at these sites, a person has to bring their own stuff, their own drug, their own needles, so, which are illegal. So, the DA’s and others oppose it vigorously because they don’t want to be at risk for a federal suit.
[00:14:59.470] – Mark Leeds, D.O.
And, even in Canada and apparently Switzerland, they actually have medical heroin, prescription heroin. And, and I brought up, on this other interview, we talked about it and I said, well, that probably would help us a lot here, in getting people on Suboxone, because now that these contaminants in the heroin on the streets, whether it’s fentanyl or some analogue to fentanyl or even some other kind of drug that’s opioid-like that stays in the system for a long time, I’ve heard that maybe it’s sequestered in the fat cells, but for whatever reason, they go twenty-four hours, like you would normally expect. They take the first Suboxone and they go into precipitate withdrawal, and sometimes even wait two, three, four or five days and they still can’t start the Suboxone. And, it would be really helpful if we could put them on something known like a known opioid with a short half life and transition them. But we really can’t do that. We can’t use oxycodone. We can’t use anything but those three MAT drugs.
[00:15:53.130] – Lloyd Sederer, M.D.
The closest thing is methadone. But also, it’s methadone in the US, puts many people off. A daily observed treatment, you have to go wait in line for a drink while somebody observes, from little plastic cup. And everyday, go everyday. It takes a year or two before you’re given a few days supply, especially with someone who may be working or trying to work. All those barriers, all those demands, put people off.
[00:16:24.730] – Mark Leeds, D.O.
There’s a program, I think it started in 2015 at Yale, E.R. initiated buprenorphine treatment. And, it was very successful. And there’s actually, I think, two programs in within a short distance from where I am, but I don’t think there’s a lot of these programs around the country and I don’t think they’re advertised in any way, that there’s not any easy way for people to find them. Where someone goes to the E.R., the E.R. doctor gives the patient their first dose of Suboxone or buprenorphine, and then they’re referred to a local clinic and they’re able to continue treatment in most cases. I think that these programs are usually funded. So if a person can’t afford it, all the treatment is covered from therapy, to doctors visits, to medication. And it seems like a really successful model.
[00:17:05.080] – Lloyd Sederer, M.D.
It’s a great model. But, that transition from receiving it right away in the E.D., and the time to appointment at one of those clinics, and the very limited access of prescribers, doctors and advanced practice nurses who have the DEA approval to prescribe, it is very low. We did a study about that in New York in terms of trying to not only understand the presence of those prescribers, or those who are permitted to prescribe because they have the waiver, and those permitted to prescribe who actually prescribed. And only a small portion of those who are allowed to prescribe, prescribe. And, one of the things I did a little over a year and a half ago before I left, being the chief medical officer for mental health the state of New York, is I set as a standard requirement, licensing requirement for mental health clinics, to dispense naloxone, or to show somebody where they can get it for free, and to prescribe buprenorphine, which was never done. And, the reason we did it, I did it, was we actually looked at Medicaid recipients or a predominance of public health patients, and what percentage of them in their entire medical records, which we have as a state agency, either was diagnosed with an opioid use disorder or had taken opioids, had been prescribed in the registry in the past year. And about a little over 30 percent, one in three were in need of buprenorphine. So, we made it a standard and now we’re trying to make it happen, and scale it up. And it’s very slowed down by COVID as you can imagine.
[00:19:04.980] – Mark Leeds, D.O.
There is a program in Bangor, Maine. There’s an article from two years ago, that they had spent a lot of time working on this program, getting it up and running. And it was very difficult, where they were determined to make one day access available for buprenorphine, that if a patient showed up for help, that they were almost guaranteed that they could start treatment that same day if needed.
[00:19:24.780] – Lloyd Sederer, M.D.
Right. Right. When I was in New York City in 2002, I was a mental health commissioner in the Bloomberg administration. And I worked at, one of my main campaigns was to introduce buprenorphine to people with opioid disorders in New York City. And it was extremely hard to get people to do it. And, one of the things that happened, as an unintended consequence, is that the black market started to sell it on the street when, at first when buprenorphine came out, I asked police chief, is this stuff being peddled on the streets? And he said, no, we don’t, we haven’t seen any instances, but a year or two later, it was sold on the street by drug peddlers. And, people bought it as a type of insurance policy, that if they couldn’t get access to the dealer or the dealers didn’t have drugs or the price was too excessive, or even if they wanted to reduce their dose to spend less money, they buy buprenorphine on the street. And, in some ways, that’s pretty smart, if you know you’re addicted and you know you may be cut off and how horrible the withdrawal will be, I think it should be accessible to people who are addicted and not all of these conditions and difficulties to get it. Buprenorphine is a life saver. And the point that you made earlier about at least a year of treatment is really important because some people think, well, a few months of this, six months of this. But, it’s a year and a half that enables people to get off of it and stay off of opioids. So there’s something about the longer term treatment that’s different.
Why is mental health so important, especially with respect to addiction?
Dr. Sederer speaks about the importance of identifying and treating coexisting mental health conditions when treating a person for addiction. We also discuss comprehensive psychiatry and what happens when seeing a psychiatrist. Psychiatric counseling is important and it helps patients, but the economic reality of our medical education system places an unreasonable financial burden on doctors, causing psychiatric services to be lacking when it comes to the amount of time a psychiatrist is able to spend with each patient.
[00:21:16.110] – Mark Leeds, D.O.
The coming off of it is a difficulty. I think a lot of people are afraid of that, sometimes even afraid of getting started. I’ve had patients that have come off of buprenorphine and had a lot of difficulty and issues with long term effects of feeling, some depression, some opiate withdrawal symptoms of chills and aches. Some people have come off of it with very little problem, you know, a week or two or a month and a half. And that’s an issue, one patient recently, and I’m wondering what to make of this. This patient, the family was concerned about a history of bipolar disorder. And, I know you talk a lot about that of comorbidities or coexisting conditions. The patient was started on a combination of an antidepressant and also Abilify, which is for bipolar, and then came off buprenorphine and was very successful, had very little withdrawal, like a week or two, was doing well and very happy. And, she felt good as far as not having the blocking of the opiate receptors, I guess, for long term use, that’s one issue is you block the natural endorphin system to some degree and don’t get the runner’s high and those kinds of feelings. But in this case, I was thinking, was Abilify some kind of, maybe a wonder drug as far as helping people transition off, or is it just that she did better because the bipolar was treated a bit. It’s hard to say, it’s just one case. It’s anecdotal, but it would be nice if there was some more research done in that area of helping people transition off of buprenorphine.
[00:22:42.720] – Lloyd Sederer, M.D.
Indeed, and your point about the fact that when someone has a drug dependence, frequently, they have a mental health disorder as well, and, to succeed, for that person to succeed, both disorders have to be detected and treated, in order for somebody to stand a chance. And in this case, this patient was treated for depression. And Abilify seems to be sort of add on drug for many conditions, not a good enough response with depression. People with a very troublesome impulsivity and self destructiveness, even some kids with ADHD, it sort of seems to quiet the nervous system. But it is an antipsychotic and it has a lot of side effects. And that’s a concern, particularly with kids.
[00:23:37.820] – Mark Leeds, D.O.
Yeah, definitely not something that’s going to be right for everybody. As far as psychiatry, in my experience, I took a month of a psychiatry rotation and I was really excited to learn about psychoanalysis and what psychiatrists do, and to be honest, in the area that I did it in Miami, a psychiatrist, in my experience and a lot of cases would see a patient for a few minutes, figure out what medications to give them. There wasn’t a lot of talking, I don’t think any psychoanalysis, but I know that that does occur. I know there’s an organization, is that BPSI? There’s an organization that teaches, I think, psychiatrists and other practitioners how to do psychoanalysis. And also, as far as MacLane, I had actually met someone that was a 12 step liaison at one of the signature programs there, and they mentioned that at that program, the residents of the rehab, if they’re there for 30 days, every single day, they see a psychiatrist. And my thought was, if a psychiatrist is only handling medications. What do they need to see them for every day? But, do they actually get psychoanalysis, and therapy, CBT? Does a psychiatrist do those sort of things?
[00:24:45.640] – Lloyd Sederer, M.D.
Yes, but not that many psychiatrists provide any type of therapy, cognitive therapy, analytically oriented therapy. And, in some ways we’ve, as a field, been driven to do that. One, the supply of doctors who can prescribe is very limited. But second, it’s an economic issue. So, if you are a doctor who spends forty five or fifty minutes talking with the patient, prescribing medication, maybe, if you work hard you may see ten patients a day and you’ll make, a thousand dollars or twelve hundred dollars. It’s not bad. But, if you have four patients an hour whom you prescribed medications to, and each one of those visits is close to what’s paid for a forty five minute session, essentially you’re quadrupling your income. And many young doctors, as you know, leave training with enormous debt, often two hundred thousand dollars or more. And many of them are living in cities that are very hard to afford living in. And, so there’s the rent, they want a car, they have kids, they have to pay tuition. So, these doctors essentially can’t afford to do what many people in our field like to do, which is to talk to people. They’re driven to this by the economics.
[00:26:21.390] – Mark Leeds, D.O.
I can say in my experience that having the opportunity to spend an hour with a patient is definitely rewarding, it’s definitely helpful for the patient. I feel like I’ve done more than just rushing into a room and out again. And you don’t make as much money doing it, but you definitely feel better about helping your patients, having more time to spend with them.
[00:26:40.600] – Lloyd Sederer, M.D.
Yes, absolutely. And some people even change their field. There might have been a GI doctor, or pulmonologist. And they go back into training for psych residency because they want the opportunity to spend time with patients, talk to patients, not have eight patients in eight waiting rooms, and they want that experience of being able to form a therapeutic relationship and help somebody change the course of their life.
The Sinclair Method: Using naltrexone to treat alcohol use disorder.
Naltrexone is a medication approved for treating both opioid use disorder and alcohol use disorder. It is an opioid receptor blocker that can be taken as a tablet or a monthly injection (Vivitrol). We briefly discuss TSM, an effective treatment for alcoholism that is gaining traction in the US.
[00:27:13.680] – Mark Leeds, D.O.
I was wondering, are you familiar with the Sinclair method for treating alcoholism? It’s using Naltrexone, but it’s using Naltrexone, but the person continues to drink a small amount with the medication.
[00:27:25.740] – Lloyd Sederer, M.D.
I’ve heard of it, but I don’t know beans about it. Well, tell us more.
[00:27:30.240] – Mark Leeds, D.O.
They take the naltrexone, a 50 milligram tablet, one hour before they’re planning to have a drink, and then they restrict their drinking to half a drink or one drink or maybe at most two drinks, for example, a glass of wine. And then they stop. And, apparently the naltrexone, by blocking cravings, would help them to not drink anymore. And also, they call it pharmacological extinction of the craving over time. You know, you’re kind of doing the end part of Pavlov’s experiment where the dogs aren’t getting the reward anymore, by blocking the opioid system. But the key part of it is, that they have to continue drinking a small amount, but they don’t do it every day. They’re not supposed to take naltrexone every day, only on the day they’re going to have a drink. And then they’re instructed for the rest of their lives, if they ever plan to have a drink, always take your naltrexone one hour before.
[00:28:20.210] – Lloyd Sederer, M.D.
Yes. It’s a way of diminishing a person’s response. So, it takes away the reward of the drink because their pleasure centers are blocked. So they may have, in the past, the more they drank, the more their pleasure sensors were activated, whereas here they have a minimal response and it doesn’t get better because the drug puts a cap on that. And, that is a type of extinction as well.
[00:28:54.360] – Mark Leeds, D.O.
You’ve published, I think, 13 books total? And, you wrote a book two years ago, which is really great, I think also any doctor who treats addiction or any patient or family member should read this book.
[00:29:06.150] – Lloyd Sederer, M.D.
Can I show a picture of it?
[00:29:07.710] – Mark Leeds, D.O.
Oh, yeah, that would be great, if you could show the book.
[00:29:10.630] – Lloyd Sederer, M.D.
So here’s the book. It’s easy to recognize. It has a great cover, with all the pills.
[00:29:16.680] – Mark Leeds, D.O.
The Addiction Solution.
The Addiction Solution: How to stop drugs.
In addition to “Ink-Stained for Life” and 11 other published books, Dr. Sederer has written a book specifically on the topic of addiction and addiction treatment, “The Addiction Solution.” Here, we discuss this book and how different types of addictions and different types of substance abuse affect the brain and how specific therapies can target specific regions of the brain. We also talk about the stages of addiction that start with the stage where a person is not ready to give up drugs or alcohol. It is at this stage where harm reduction can be most effective. While addressing addiction’s effects on the reward center is important, therapies can also target the prefrontal cortex as well as other regions of the brain. Specifically, we discuss cognitive behavioral therapy (CBT), contingency management, and spiritual peer support programs.
[00:29:18.990] – Lloyd Sederer, M.D.
The Addiction Solution. Yes.
[00:29:19.510] – Mark Leeds, D.O.
And, I actually ordered, I the originally ordered the audio book, which is excellent. I could listen to it in the car driving. And, I liked it so much, I wanted to be able to take notes and highlight things. So, then I got the Kindle version and, I think that’s important. You want to be able to look at it and be able to reference back to things, but both versions are excellent.
[00:29:38.550] – Lloyd Sederer, M.D.
Well, thank you. Thank you very much. The premise of that book, what got me to write the book, is my view fundamentally about substances. About drugs that change how we feel and think. And that is that, people use drugs because they serve them. They are useful to them. I’ve come to believe that that’s where, we as clinicians need to meet people, understanding that they’re doing this for a purpose. We’re given to exhort people. “Don’t you know, this stuff is going to kill you? It’s ruining your family. You lost your job.” That doesn’t work at all, because they’re having the experience of either pleasure from it, dramatic, and immediate reduction in pain, physical pain, mental pain. And, also drugs transport us, many of them, out of the everyday grind. So, there’s a purpose being served and that’s what needs to be appreciated. That’s where the connection, I think, starts with a patient. That, “I understand we’re doing this because it serves you and you’re going to keep doing it until you find other ways that serve you in the same ways.”
[00:30:58.350] – Mark Leeds, D.O.
And that’s where harm reduction comes in. You talk about the stages of a person being ready and when their in that first stage, where they’re not ready at all and you want to meet them where they are, at least you can put them in a safe place of: “here’s, something that can save your life. We’re going to keep that on hand, the naloxone. And if possible, here’s a safe place where you can go use the drugs that we know you’re not going to quit yet and form relationships with people that may help you when you’re ready to quit.”
It’s so important that relationships, family, friends who care about you, not friends and family, who tear you down, make you feel better about yourself, but those that you care about and they care about you, AA meetings. These are support systems, and fundamental to a person tolerating the kind of demands that getting off drugs requires.
[00:31:54.500] – Mark Leeds, D.O.
People should know that you don’t have to be drug free to go to a meeting, that you’re definitely welcome to go to an AA meeting, NA meeting, sit in the room and listen. And, you could have used drugs that day. You might not even be planning to quit yet, but you are definitely welcome to go and sit there quietly and hear what they have to say and talk to people afterwards.
[00:32:14.510] – Lloyd Sederer, M.D.
Yes, that’s, I think, a really good policy. I spent some time with a leadership group in AA a couple of years ago and what I discovered is that their numbers of attendees, it’s pretty hard to collect because they’re essentially independent entities with important privacy protections, but they have not, the number of people using 12 step programs, has not increased in two decades. Whereas we know that just population growth alone, no less, this storm of addictions that we’re going through now, the numbers are greater, but they’re not drawing more people.
[00:33:03.350] – Mark Leeds, D.O.
And, that’s another interesting thing that you go into in your book, which I think is really interesting and critical for people understand, is that there’s a lot of different kinds of therapy, and you even diagram the brain and talk about what kinds of therapy will work on different parts of the brain. And, for example, the meetings, the spiritual support, that works on the prefrontal cortex, the newer part of the brain that we have, and other animals don’t have so well developed. And, the part of our brain that makes us different, maybe from a rat that keeps running back for more cocaine, that we can actually think things through and maybe stop ourselves. And, then you also talk about the reward center and different parts of the reward center and different kinds of therapy that work on those areas. It’s really important that people know that there’s a lot of different things they can do. Not just meetings, not just MAT medications.
[00:33:52.710] – Mark Leeds, D.O.
I try to emphasize by that tour of the brain, that graphic. Maybe you can put that up, or your producers can put that up, because there are four key areas, as you were mentioning, that allow us to intervene. And, addiction dependence is really a tough thing to quit. And, so if you enable these four different areas to quiet down, or to act more strongly, you’ve given the person comprehensive treatment. You’ve touched on their motivation. You’ve touched on their pleasure center. You’ve touched on their reasoning and judgment and also their hippocampus and amygdala, the memory centers, which are really important and responsive to CBT, cognitive behavioral therapy. And this is the example that you mentioned before, Pavlov’s dogs. He taught the dogs to salivate to the bell rather than the food, and essentially demonstrated that we can change what people respond to. And one of the biggest problems with recovery, or remaining drug free, are cues which are bound in the hippocampus and very salient, very powerful. So, someone may see a drug deal going down. A friend may call them who is high. Prince dies. And, those cues are what trigger a relapse, someone may be not using for 10 years. And then there’s this convergence of events, and maybe they’re fighting with their partner, and a cue comes along and boom, the next day they’re using as if those 10 years didn’t mean anything.
[00:35:47.060] – Mark Leeds, D.O.
Have you heard of prescription digital therapeutics? Using an app on your phone to provide CBT and other forms of therapy?
[00:35:55.190] – Lloyd Sederer, M.D.
Yeah. For those people who can stay with it, it works. But, the retention rate is actually very low. Even if you get a prompt on your phone, it’s time for the session or whatnot. It doesn’t seem to hold people, maybe for a few sessions. But, retention is important and this is a chronic disease, a chronic relapsing disease. So, care needs to be ongoing. Not all the time, but regularly. And, someone needs to have the kind of care that they go to.
[00:36:28.040] – Mark Leeds, D.O.
One interesting thing about one of the apps I looked at, it provides another kind of reinforcement, which I don’t think is CBT, and you do mention it in the book. On certain parts of the app when you get to certain points, they have you spin a wheel on the screen, and it’s kind of like gambling. Spin the wheel and you might win an Amazon gift card.
[00:36:44.440] – Lloyd Sederer, M.D.
[00:36:46.310] – Mark Leeds, D.O.
Although I don’t know if that’s different. There’s that were you spin the wheel like you’re gambling and you get the gift card, and they say that lights up parts of the brain where you’re getting that thrill of gambling. But then you also mentioned the treatment of actually paying somebody for being abstinent.
[00:37:01.520] – Lloyd Sederer, M.D.
This is called contingency management and it works. The problem is that a lot of regulators are, I think, myopic about this because they are morally opposed to paying someone to do what he or she should be doing. And, New York City, when I was there, the mayor wanted to have a program where mothers were paid to take their kids, poor mothers, single mothers, paid to take their kids to the pediatrician. And, the program was going to cost fifty million dollars. And the city council said we’re not going to pay mothers to do what they’re supposed to do. So we toss in $50 million. But it’s still never got off the ground because there was, you know, people were still being stigmatized because they were being paid to do the right thing. But it works.
The future of addiction treatment will be making what we already have more available.
In this section, we start out by discussing harm reduction again and the importance of making harm reduction strategies, such as naloxone spray, available to anyone who needs it and as often as they need it. We also talk about making treatment more affordable and more accessible. Part of the issue is the high cost of drugs, such as naloxone and Suboxone.
[00:37:59.240] – Mark Leeds, D.O.
I think we need to look more closely at things that work, even if we don’t agree with them. In British Columbia, Canada, there are areas where they have Dilaudid dispensing machines on the streets, biometric machines where you can get Dilaudid, which is intended to be crushed up and injected. And, it sounds crazy and I’m sure that will never happen in the US., But things like that are saving lives and keeping people from getting HIV, hepatitis, and maybe preventing them from getting endocarditis, heart valve infections. There are things that we might not agree with. Even MAT, a lot of people are against it. In fact, even Naloxone, there are stories of sheriff’s departments where the sheriff says, we’re only going to give one or two doses of naloxone and stop if that person keeps relapsing, and they really need to get it as many times as they need it, even if it’s 10, 20, 30 times, or more.
[00:38:52.170] – Lloyd Sederer, M.D.
Yes. And, what’s also under that reluctance is the cost. Because, those sheriff’s departments, police departments, have to pay for the naloxone. And now with fentanyl, a single dose often doesn’t do it. Two doses and then two more doses four hours later. So, the cost of administering, in some ways bankrupts these first responders. And, that’s why it needs to be essentially covered, made possible free, particularly to first responders. So, that’s not a factor. But it is a factor and needs to be fixed.
[00:39:33.210] – Mark Leeds, D.O.
And when it comes to drug costs, that was an issue with buprenorphine for a long time until, I think it was last year, the Indian company, Dr. Reddy fought Indivior, the maker of Suboxone, in court, and they finally were able to sell the generic Suboxone films, the buprenorphine/naloxone films, and now Indivior is being disciplined for restricting access to buprenorphine. I think part of that might have been that there was talk in the company about getting people hooked, which was a terrible thing to talk about, because people don’t really get addicted to buprenorphine, they become physically dependent on it. But, a lot of issues with drug costs. There’s actually a quote, and I don’t remember where I saw it. I actually think it might have been Timothy Leary talking about LSD, where he made a comment saying, the drug is cheaper than water. And I think that’s probably true of every drug. I think every drug is cheaper than water when it’s made to scale. And it’s not that the drug cost too much, it’s just that they’re charging too much.
[00:40:32.490] – Lloyd Sederer, M.D.
That’s right. The profit margins.
[00:40:35.520] – Mark Leeds, D.O.
Naloxone costs, I think, one hundred fifty dollars for two doses at most pharmacies. And, it probably only cost pennies to make a nasal spray.
[00:40:43.740] – Lloyd Sederer, M.D.
That’s right. Especially when it’s made in huge volumes like you were suggesting.
[00:40:49.020] – Mark Leeds, D.O.
There’s no reason why we can’t all have access to it for free, maybe paid for by the government, or very low cost, maybe walk into a pharmacy and buy it for two to five dollars for a package or something.
[00:41:00.750] – Lloyd Sederer, M.D.
It’s not just the profit motive, but also, many people think that this is bad behavior, taking drugs. They don’t see it as a psychological, sociological, neurological disorder. They see it as somebody being bad or weak, and damaging their family, exploiting, stealing. And so, these are not people that they want to help. These are people that they want to be mad at, which, of course, doesn’t work. It just drives people away.
The super powers of a person in recovery from addiction.
While we should make addiction treatment available to all people suffering in active addiction because they are human beings, it is also important to note that addiction disproportionately affects high functioning people with a high level of intelligence and creativity. By helping them to overcome their addiction, they have the potential to do incredible things with their lives, including helping many other people.
[00:41:42.120] – Mark Leeds, D.O.
Speaking of that, with people who are addicted, at least the patients that I’ve seen, tend to be people that have huge potential, they’re not like your average person. The person who is susceptible to addiction is often very intelligent, very creative. Because, I think addiction uses those abilities against them and it’s harder for them to break free of it. For example, I had a patient, which is a funny story, who’s a very intelligent, high functioning guy that was using heroin, and his father came in with him. And, I was telling him that usually people who are addicted are very intelligent, creative, high functioning people. They get caught in addiction. And, he said to his father, he said, “Do you hear that, Dad? That’s what I was trying to tell you.” And the father just looked at me and said, “I never had a problem with addiction.” And like, we just made our point. You know, you clearly are not in that category because it never affected you. And I’ve also compared it to, you know if you remember the old Superman movie with Christopher Reeve where they put the chain with kryptonite around his neck, that imagine if Superman wasn’t wearing a Superman costume, and he was laying there, helpless with the kryptonite. If you saw him in a dark alley, you’d say, oh, look, it’s a junkie. You know, he’s probably high something, and not realizing he’s Superman. And, I kind of see my patients that way. If you can take away this kryptonite, take away the active addiction, that these people are really capable of incredible things. They deserve to get naloxone if they need it a million times or get their MAT drugs.
[00:43:09.240] – Lloyd Sederer, M.D.
That’s a lovely analogy of some guy lying in an alley, being wiped out by kryptonite and, who can be helped to stand up and contribute to society again, just like Superman.
[00:43:24.990] – Mark Leeds, D.O.
Doctors will get hooked and they have an incredible potential to help a lot of people if they can overcome their addiction. And, not just doctors. There’s the politicians, there’s artists, and people that have a huge potential to not only help themselves, they help a lot of other people. If we can just help them get past this active addiction, you just never know who that is lying on the side of the road, who needs our help or what they’re capable of if we can help them get past this.
[00:43:50.350] – Lloyd Sederer, M.D.
Yes, yes. Naloxone is a little bit like the CPR that people learned if someone passed out on the streets, especially when it didn’t require mouth to mouth. And a lot of people were saved by that, by random passers by, not by doctors who were there, or nurses. And in a way, that’s where naloxone needs to be in terms of its standing in our country, other countries. This is the way to revive somebody, keep them alive.
Public Health and Funding for Addiction Treatment.
Many people who need addiction treatment do not have access to care. There are programs around the country, often referred to as “pilot programs” that provide funded care to their communities. The problem is that there are too few of these programs, they are hard to find, and they do not have enough capacity to handle the needs of their communities. Even with the passing of laws in favor of improved addiction treatment and the promises of more funding, change has been slow in light of the ongoing opioid crisis.
[00:44:28.320] – Mark Leeds, D.O.
Would you accept a position in national public health, helping the country, if you were asked by the new president coming in? Is there a place for that, for what you did for the state of New York, and the city of New York City, at the national level in the US?
[00:44:43.650] – Lloyd Sederer, M.D.
Well, of course, it depends on who the president is. But I think I’m done with government service and it’s been a really good run for New York City and New York State. And the other thing, that even during those years that gave me pause about working for the federal government was that, there’s a different horizon for change in cities, and states, and across the country. So in cities, you can do things and you can realize gains, make changes that appear within a year or two. At the state, it’s three to five, and nationally it’s five to 10. And, I’m too impatient, I think, for that kind of work.
[00:45:32.400] – Mark Leeds, D.O.
There was a law passed in 2018, just two years ago, I think it was the Opioid Emergency Response Act of 2018 or something like that. And, I actually interviewed somebody on the podcast about it. He was recommending that doctors, or the heads of medical facilities start applying for grants for funding, That this is going to be a great program to make a lot of changes. And, I don’t know how much effect that that law has had, but at least I haven’t seen myself, you know, a lot of programs coming up. Maybe they’re out there, maybe they’re hard for people to find. But, have you seen that that law has made any positive changes?
[00:46:12.290] – Lloyd Sederer, M.D.
I don’t know about other states, but those grants are rendered state by state and New York State received, first 30 million dollars, and then I think another 15, I’m not sure. And, it was through the state agency for substance abuse, called Oasis, in New York. And they distributed that money to increase access to enable clinics to hire more doctors, to pay for naloxone so that it would be free and accessible. And that’s visible. Whether it’s going to make a population level change remains to be seen. But that’s where it has to start. The money needs to go and be spent responsibly by some regulatory body that will ensure that the right things are purchased for the money.
Ink-Stained for Life.
In Dr. Sederer’s new book, “Ink-Stained for Life,” he tells stories of his childhood, growing up in New York in the 1950s. There are many great life lessons to be learned and interesting connections made between the past and present. You may discover, while reading this book, that you see parts of your own childhood and life in these stories. As I say in the interview, I highly recommend this book, which you can purchase here.
[00:47:12.560] – Mark Leeds, D.O.
Dr. Sederer, I definitely want to highly recommend listeners get “Ink-Stained for Life,” your new book.
[00:47:17.930] – Lloyd Sederer, M.D.
I have a picture of that too.
[00:47:20.270] – Mark Leeds, D.O.
Oh, great. Yeah. So there’s a hardcover book. I would definitely recommend that.
[00:47:25.580] – Lloyd Sederer, M.D.
It’s available in paperback too.
[00:47:28.800] – Mark Leeds, D.O.
So, you can get the book as a coffee table book. The Kindle, I highly recommend the Kindle because you can click on a word and get the definition right away, because you introduce a lot of great vocabulary. There’s “haberdasher,” there’s “quotidian,” just some really great words. I really enjoyed just clicking on the words to see what they mean.
[00:47:51.170] – Lloyd Sederer, M.D.
I love those words because the haberdasher was my grandfather, and that’s someone who sells or makes men’s clothing. And that’s what he was, a salesman in the Lower East Side men’s store. And they were known these men were known as haberdashers. So, it’s not like it’s a fancy word for me. It’s a word that I heard when I was three years old, and five years old. Quotidian, I love because it’s a nice way of saying “every day” without saying it.
[00:48:31.880] – Mark Leeds, D.O.
There’s a lot of great stories in there. And for me, you know, being Jewish, but not observant really of my religion, but wondering where I stand in the world being Jewish. There was a great connection there, of reading your experience. A lot of great stories about living in New York, and seeing how my parents might have grown up, because it was around that same time period. There’s just so many great stories about things that have contributed, working on the farm and how that led to, in the future, your public health career, and learning how to work together with other people. And, you know, the your experience with with the fireworks, that was interesting.
[00:49:12.260] – Lloyd Sederer, M.D.
I had a business selling illegal fireworks as a kid. But, what what I’m also trying to show there is the arc of our lives, how this thing or that thing heralds who we become. The experience of cleaning the chicken coops, experience with working the family business. These are all etched into us, and they do shape our decisions, including going to medical school, or being an attorney, or being an artist. It doesn’t matter. They’re etched in during those early years and you can see an arc develop.
[00:49:54.080] – Mark Leeds, D.O.
You also talk about the experience of being a smart person, but then meeting an actual genius and how that feels, or being well off, but then meeting people who are actually rich. And, I know that can sometimes make a person feel bad or even inhibit them from going further in something.
[00:50:09.830] – Lloyd Sederer, M.D.
[00:50:12.500] – Mark Leeds, D.O.
For example, with me, I used to love playing piano and my parents sent me to music camp. And when I actually met real musical geniuses, it made me feel like, what’s the point of going any further?
[00:50:21.860] – Lloyd Sederer, M.D.
Yeah, yeah. That can be discouraging. I went to a really good exam school in New York City, called Bronx High School of Science, and that’s when I met some classmates who were truly geniuses. They were operating at a totally different level, and I would never get there. We would get a calculus problem and I’d labor on it, and this guy next to me, he would figure it out in twenty five seconds and it might take me an hour. And you knew that there are people who really are operating in that zone. Robert Ström, people never remember him, was one of the kids in my class and he was on the sixty four thousand dollar question, which many of your viewers may not recall, never saw. But, it was a quiz show where a contestant could win up to sixty four thousand dollars in a progression of getting the correct answers to questions. And Robert Strummer’s was on that show, and he won sixty four thousand dollars.
[00:51:28.250] – Mark Leeds, D.O.
Oh, that’s incredible.
[00:51:29.720] – Lloyd Sederer, M.D.
And he was like 15 years old. It’s a little daunting, but each of us, I think, needs to strive to be as good as we can with our own native abilities complemented by hard work and not to try to be somebody else, but to be as much of ourselves as we can be, contributed as much as we can.
[00:51:57.080] – Mark Leeds, D.O.
That was another lesson you brought up, about hard work, that if you find what you love doing, it doesn’t feel like work. Which I relate to with my blogging, that at first I was afraid to write. I don’t want people to read what I write and tear it apart and point out what I wrote, what was wrong. But, once you find that that one thing or those things that you really enjoy, it doesn’t feel like work anymore,
[00:52:19.080] – Lloyd Sederer, M.D.
Right. And as you describe describing, many people discover that they love to write, because they’re not trying to be scholarly. They’re not submitting this for a grade, but they’re talking like we’re talking to one another in everyday English about something they know a lot about. And then the words flow. And that’s a beautiful thing.
[00:52:44.400] – Mark Leeds, D.O.
And if someone is sensitive about grammar, they’ve got some great grammar checkers now.
[00:52:51.720] – Mark Leeds, D.O.
Sorry to keep you for so long, and I really appreciate you coming on the podcast with me.
[00:52:56.400] – Lloyd Sederer, M.D.
I’m very grateful to join you, and recognize the kind of work that you’re doing. This country, needs a lot more Mark Leeds’s.
[00:53:07.830] – Mark Leeds, D.O.
Thank you. I appreciate that.