MSU Opioid Addiction Lecture at GRCC

MSU Opioid Addiction Lecture at GRCC


>>Okay, if I could have
everyone’s attention, please, we can get started
this evening. I’d like to welcome
everyone to GRCC, Grand Rapids
Community College. This is our
fourth year hosting Michigan State University
College of Human Medicine’s Your Health
Lecture Series. And I’d like to thank
everyone for taking time out of your busy schedules
to come out this evening. My name is
Paul Krieger, professor of Biology
here at GRCC. I’m a proud
alumnus of GRJC, and the coordinator
of tonight’s event. Our sponsors for this free
public event are GRCC, MSU’s College of Human
Medicine, and Spectrum Health. Let’s please give them just a
nice round of applause, please. (applause) In the words of our new college
president, Dr. Bill Pink, we strive to remain relevant
and responsive at GRCC by offering an accessible
and affordable education to a wide variety
of students. Whether it’s for a
transfer student or for a student enrolled in
one of our degree programs, GRCC is a great place to
start your college education. You’re sitting in the
Science Auditorium of the Calkins Science Center at
Grand Rapids Community College. And it is home of the
Biological Sciences department as well as the Physical
Sciences department. For more information about
our wonderful programs, you can check out our
website at grcc.edu. Now, I would like to
introduce Mark Brieve, Director of Community
Engagement and Outreach at MSU’s College
of Human Medicine, who will introduce our
speaker for this evening.>>All right,
thank you, Paul. And as Paul said, this
is the fourth year we’ve done
this talk. And we do a number of these Your
Health Lecture Series events around the state, and what I
really enjoy about this one in particular is I can walk from
my office to get over here, where, when I go
to Marquette, it’s a seven-hour
ride in the car, so I do
appreciate that. Certainly as Paul said,
this couldn’t be possible without our sponsors– Grand
Rapids Community College, Michigan State University
College of Human Medicine, and Spectrum Health. And without
further ado, I’m gonna introduce our
speaker Dr. Cara Poland. She’s a board-certified
physician, specializing in
addiction medicine with the Spectrum
Health Addiction
Rehabilitation Program. She’s the Medical Director
for Substance Use and Pregnancy
Clinic, and also Assistant
Professor at Michigan State University
College of Human Medicine. Dr. Poland earned
her medical degree from Wayne State University
School of Medicine in Detroit. And she completed her
internal medicine residency at St. Joseph Mercy
Hospital in Ann Arbor and her addiction
medicine fellowship at Boston University
in Massachusetts. Dr. Poland’s clinical interests
include safe opioid prescribing, medication-assisted treatment
of substance use disorders, and treatment of females
with substance use disorders. Please welcome
Dr. Poland. (applause)>>Thank you, so… for those of you guys who
have seen me lecture, the first bit of slides
will look pretty familiar. And then, I actually updated
all my slides for this, so I’m pretty
excited. So I do not have any
financial disclosures. I don’t think I need
to do that, though, because this isn’t
a CME event. So we’ll go on. So here are just some
measurable objectives for you, so we’re going to talk a
little bit about how addiction is a chronic
disease, discuss the current epidemiology
from a national perspective, and then, come right down
to Kent County statistics, understand some
of the barriers to accessing
medication-assisted treatment, and understand how
treatment works in a bio-psycho-social model
of disease care. So I am also,
in full disclosure, President of the Michigan
Society of Addiction Medicine, which is a chapter of the American Society
for Addiction Medicine. And this is our
definition of addiction, so if we’ll notice the
definition of addiction has a lot of commonalities
with other diseases like, say,
diabetes. It’s a
chronic disease. It involves
the brain, like something maybe
like Alzheimer’s disease. There’s different
circuitry involved and there’s characteristic signs
and symptoms and manifestations that can lead us to an
appropriate diagnosis. So it’s good to remember that
this is, in fact, a disease. The United States is pretty
unique in considering substance use a
moral failing. We don’t see that in
other areas of the world. And so, I always like to
kind of point that out. So these are some of the
characteristic signs and symptoms
of addiction, and you’ll see I have
so cleverly highlighted the A, B, C, D, Es
of addiction for you. And so, what we know
is all diseases have kind of characteristic
signs and symptoms and that’s what we
use to determine what is the disease and
how do we diagnose it. So there’s actually a diagnostic
and statistic manual for all psychiatric illnesses,
and addiction falls into that. And so, there’s a list
of 12 criteria that we use to diagnosed a
substance use disorder, including the
severity of it. So you can have a
substance-specific use disorder like an opioid
use disorder, and then we characterize
it as mild, moderate,
or severe. So we’re gonna talk a little
bit about neurobiology. I’m not a very
smart person, so I got to make
it really simple. So we’re not gonna talk in
like real high-tech words. So we got this area
of the brain here, and we call that
the “brain stem,” and that’s– a lot of people
call it the “primitive” area of the brain or the
“reptilian” brain. So we’ve got this area
of the brain right here, and what this area
of the brain does, this is part of kind of the
primitive areas of the brain and it’s very
subconscious. So we don’t really think
about what’s happening here. And what this area of the
brain does is it sends this chemical called
“dopamine” out. And dopamine is
like the gas tank. So the gas is provided by
this area of the brain and it sends messages to the
other areas of the brain, and this is called the
“ventral tegmental area” for those of you that
like big, scary words. So the gas tank
releases dopamine, and what does
dopamine do? Dopamine is what makes
things feel good. So dopamine is what
makes it– that– you know, I don’t
always have room for those last few
carrots on my plate, but I always have room
for dessert, right? Like, there’s no question
with my five-year-old that he will always be
able to eat ice cream, but he’s not– but he’s so
full from his dinner, right? And that’s because
when we eat ice cream, it actually releases dopamine,
which makes us feel good. And that’s why there’s
something special and different about dinner made
by mom and dad than dinner made
at a restaurant. The same food can
taste different, based on how our emotions
interpret what that means, and that’s because of this
fun dopamine chemical. This is also the thing
that makes things like sex pleasurable. We’re gonna
go there. So if we really think
about what we’re doing in the course of
having intercourse, if you just think about it from
like a physical standpoint, it’s kind
of gross. It is, okay! Like, it’s just
kind of gross. Why do we do it
over and over again? And why is there like a
billion dollars of money spent on preventing
pregnancy? Because it’s
kind of gross, and the only thing that should
come from it is pregnancy. So if you don’t want to be
pregnant, why are we doing it? Dopamine. Because it
feels good. So we don’t
think about that!
(chuckling) We just think about the
fact that it feels good and we do
it again. And this area sends
a message up here, and this area is part of what
we call the “cerebral cortex.” That’s the part of the,
like, thinking– the more thinking
part of the brain, the more conscious
efforts go there. And so, I call this
the “GO Center.” This is the area
of the brain that gets the message
of the dopamine, the dopamine is good, and
it says, “You know what? “Dopamine felt good– we should
do whatever that was again!” And so, it sends
a message… Nooo… I messed– no–
oh, no– we’re good. So it sends a
message– sorry– so it sends a message up
to the front of the brain and it says, “We are
gonna do that again.” So we’re gonna do
a little experiment. It’s kind of right after dinner,
so this might not work so good. Doesn’t it look
fantastic? Aren’t you
just aching– don’t you wish that
out on that table, they had a whole big
bowl of carrots? Yeah, just ready
to munch on? Feel different now? Probably some
more people wish there was one
of these out there. Anybody in the room
lactose intolerant? Okay. What did that
made you think? (gagging) “No, thank you,”
right? You’ll go for the
carrot over that, right? Because you have
like this think that makes you have a
different reaction to this. This doesn’t make your
brain release dopamine. It makes your brain release
the like “stop” chemical, makes your brain say like,
“Let’s not go there.” Is that how you kind
of feel right now? Okay, I get into
nodding head, I could take that
as a good sign. So I’m on to
something, right? So different people
react differently to different
stimulus. So I tell people–
I’m sure my husband loves that thousands of people
know this about him in Grand Rapids alone. So after we had our daughter,
10 days postpartum, my husband went to see the
urologist and had a vasectomy. (scattered laughing) We were done. He came home from
said vasectomy and the doctor had given
him 10 tablets of Norco. So we’ve got a 10-day-old
baby, like, “Whatever, “go lay on
the couch.” I don’t even know
what’s going on, I’m so sleep-deprived
at this point. And so, my husband comes
to me and he’s like, “I don’t feel
very good.” Apparently– I don’t know,
maybe some of the men in the audience can help me,
but apparently throwing up after having a vasectomy is
not a pleasurable experience. I don’t know– so my
husband, needless to say, gets nauseous when
he consumes opioids. So he’s protected from an
opioid use disorder, right? Because his brain does what the
lactose intolerant brains do when they see this. It says, “Oh, don’t
even think about that “because that is gonna
make me feel crappy.” There’s more serotonin, the
happy chemical from the brain, in your gut than there
is in your brain. There’s more opiate
receptors in your gut than there are
in the brain. So we know that they
have this connection and that the body likes
to reuse the same thing over and
over again. It’s not
very smart… or maybe it is
really smart, but it does reuse
the same thing. So those people
that saw this, when you first saw it, and
you’re not lactose intolerant, something happened. You probably had a
little bit more saliva go into
your mouth. If you haven’t eaten dinner,
it’s now 7:15, you probably start to
feel a little bit hungry. The more I’ve left this up,
the hungrier you’ve gotten. You might not have been
hungry before you saw this. Why is that? Because your brain is
reacting unconsciously. You’re not
thinking about it. You’re not saying,
“Gee… I…” This isn’t real. This isn’t a
giant ice cream, so why are you producing
saliva to eat my ice cream? It’s a picture. Because your brain
isn’t that smart. Your brain just sees it
and it says, “Yum,” and it says, “If
I’m gonna eat that, “I need to produce saliva,” and
so your body produces saliva. This is what happens
to my patients when they think about or
when they see substances. So imagine how hard it
would be if you had, say, an alcohol use disorder and
you’re driving down 131… and you saw the
“Beer City USA” sign. What’s that
gonna do to you? And what do you have
to do to prevent it from doing
that to you? It’s gonna make you
think about using. It’s gonna make you
think about alcohol. It might not come all the
way to the conscious part of your brain because, just like
you know that that’s a picture, nobody’s fooled
by my trick, right? I’m not a very
good magician. My patients aren’t
fooled by the billboard, but they still
react to it. And I’ll bet you that at
least a couple of you guys in the next couple days
are gonna have ice cream. You can blame
it on me. So it’s our affective
response to the images that cause our body to
unconsciously respond to different
stimuli. And we don’t always
have control over it. So then, we’ve got– we
went from here to here, and now we’re going
to the frontal cortex, and this is the
CEO of the brain. This is the part that
says, “You know… “as much as
you want to, “you cannot just have ice cream
for dinner every day.” Now, I know that. I’m sure most
of you know that. But my 5-year-old, if
I gave him the choice to have ice cream
every day for dinner, he would have ice cream
every day for dinner… because he doesn’t have
a full frontal lobe. In fact, your frontal lobe
isn’t actually fully developed until at least
your mid-20s. They say
25 to 28. So some of you all don’t have
a fully functional frontal lobe, I’m just saying. And the frontal
lobe is the CEO and that’s the conscious
decision-making part of
our brain. That’s the part of
the brain that we use when we’re
thinking. That’s the part of
the brain that we use when we’re making decisions
between good and bad. That’s the part of the
brain that says, “Okay, “you have to have
something good for you “before you have that
ice cream sundae, “and you can’t have
eight scoops of ice cream.” That’s the part of the brain
that helps us put that stop, puts that brake on these
unconscious area of the brain, and says, “You know, maybe
that’s not a great decision.” Now, that area of the brain is
a little bit malleable, right? And so, the more we get
these dopamine releases, the more of this area
the brain says, “That was a good thing–
we should do more of it.” And the more it sends that
message to the front that says, “Oh, we should
do that again! “That felt really good–
I liked that,” the more this area the brain–
the harder it is to say, “No, that wasn’t
a good thing to do.” And so, it can become
harder and harder to make the right decision
if your body’s getting– er, if your brain is
getting overwhelmed by these
unconscious parts. And so, this is
where addiction lies. And so, in order to
change that messaging, this area the brain has
to kind of grow stronger and learn
some new tools. And so, it’s not just about
one thing or one decision. It’s about a series of things
that have happened to somebody. And you know, his guy
isn’t fully developed until you’re at least 25
and, just for the record, the average age of first
use of an illicit substance is 12 years old. I don’t know about
anybody else in the room, but I wasn’t very far off
from playing with baby dolls, personally, when I
was 12 years old, and I certainly wasn’t
thinking about the consequences of my actions now
that I’m in my 30s. Right? I’m gonna a bet,
even though you guys– a lot of you’re a
lot younger than me, you weren’t
thinking about today when you were
12 years old, right? Because
we weren’t. We literally didn’t have
the frontal lobe to do it. We couldn’t. Right, we don’t have
that impulse control until we get
a little older. Now, you can kind
of think through the consequences
of your actions. If you don’t study for
that exam on Tuesday, what’s gonna
happen, right? And that can sometimes be
the reason that you study for that exam, because now
you guys have the capacity to think through
some of that. When you were 12, it
was harder to do that because your brain just
didn’t work like that. So this dopamine thing
is just fascinating. It’s just
amazing. So if we circum– so
we usually circumcise– if we’re going to circumcise a
baby, we usually circumcise them in the first
few days of life. And this is where you cut off
the foreskin on the male penis. So… yes, I’m going
to pick on the men again. I like to
pick on men. So let me just
think about this. When we circumcise
a baby boy, what we do is we take
them into a procedure room and we numb up their penis,
and then we cut that skin off. And when we take
them back to the mom– this is usually done while
mom’s still in the hospital, baby’s less than, you know,
two days old, right? And we give the
baby sugar water… if they
start crying. And they
stop crying. Because their brains haven’t
seen high doses of sugar, right? Because for the vast
majority of women who don’t have diabetes
during pregnancy or that’s
uncontrolled, their baby’s only seen
a slower level of– controlled
level of sugar. And so, this is the
first time their brain has seen that amount of sugar,
so what does that area do? It’s like, “Oh, cool, I’m
gonna release some dopamine. “I’m gonna increase the normal
rate of dopamine by 200% “and that’s gonna
feel fantastic.” That’s part of like survival
because we want baby to eat because breast milk
is very sugar-laden, and so we want
baby to get that. But then, now… I’m just guessing that if
we were to do a circumcision on any one of the
men in this room and I were to offer
them some sugar water, how about a lollipop,
for pain control, they would probably not
be very happy with me. May have some choice
words for me, right? And that would kind
of be appropriate. I’m gonna give you
guys that much. Because now, your brains
have all seen a lot of sugar and had those
spikes. And as your brain
sees that sugar, it starts to release
less dopamine. It starts to not
respond in the same way because it gets kind of
what we call “sensitized.” It starts to say,
“Sugar’s just there. “It’s just
something we have,” and now, our new set point
for feeling really great when we have
sugar is higher than it was when
we were first born. And this also happens
with illicit substances, substances
of misuse. We’ve got– we
know that there– we have identified over
1 billion– with a B– chemicals. Right, so we know the
chemical structure of over 1 billion
chemicals. That’s crazy. That’s like
substances, right? Only about 200 of them affect
that area of the brain. So we only know about
200 different things that can do this
with dopamine. Pretty amazing,
right? And so, we have the brain
sensitized to sugar, and I can say,
like, my children.. they’re poor children,
my poor kids. So we do piano. And my son practices piano
for about 45 minutes a day. He’s five
and a half. I am a
cruel mother. And at the end of his piano
practicing, he gets a Skittle. (audience laughing) And we talk about this Skittle
the whole practice. “Are you gonna pick
a purple Skittle? “Are you gonna pick
a blue Skittle?” Right now, we have like
Tropical Fruit Skittles that come in like
a pink package. His favorite color is pink,
so that was very exciting when we got to pick out the
pink package of Skittles. So we talk about the
Skittle for 45 minutes, and it is rewarding enough
to that kid’s brain– one Skittle– that he will
practice piano for 45 minutes. Now, not that he doesn’t
like practicing piano– you know, we try to
make it fun, right? But you try to get me to do
something for 45 minutes and talk about a Skittle,
and I would be like, “Yeah, right– where’s
the rest of the bag?” So we see that the brain
kind of changes its response as we get older. So this is the control brain
and this is that frontal lobe, that front area
of the brain, and this is somebody
who used cocaine. And this is an older study,
so it talks about abuse. We do not use
that word anymore. We use
“disorder.” This is an individual with
a cocaine use disorder and this is a control study,
control patient. And so, if we look at
these colors, as we go up, it shows that the closer to red
it is on the rainbow scale, the more sugar that’s being
consumed by the brain and the more work that
the brain is doing. So you can see that there are
actually physical changes in the brain, resulting in less
work being done by the brain in somebody who uses, compared
to somebody who doesn’t. Right, so their brain
literally is disrupted. It’s not functioning
the way it should be. Just like in diabetes,
the pancreas is not releasing insulin the
way it should release insulin. So the brain is just
not able to function. So I can’t expect my patients
to do the same things that I can expect somebody
without a substance use disorder to do. What’s really amazing
is that, over time, within the absence
of cocaine, this brain will start to
look more like this brain. And it’s pretty remarkable,
there are some studies that have been done that
where it actually looks at on the order of
days, weeks, months that the brain actually
regains function. Pretty
amazing stuff. Yeah, we can skip that one,
skip that, skip that. Okay, so addiction is
a biologic disease resulting in characteristic
signs and symptoms. And we know– we have
identified some of the biology. We’ve defined the
signs and symptoms, so we can diagnose it and
that leads us to treatment. So what we’re going to
talk about a little bit is the epidemiology
next. You’ll see that this is
one of my new slides, that this goes all
the way through 2014, which is our most
recent national data. And if we look
at the dash line is drug overdoses
involving opioids, and we look at
the solid line and that’s all
drug overdose deaths. And gee, those look like
they’re quite similar. So the CDC has declared the
opioid crisis an epidemic. Interestingly,
this is the first and so far only
man-made epidemic. Every other epidemic
that has been declared has been an infectious disease
vector of some sort… that has been officially
declared by the CDC. Some people will call it
an “obesity epidemic,” but that is not officially
declared by the CDC. That’s usually a question,
so check that one off. So this is
overdose by drug. Again, national
statistics, and you can see that fentanyl
and fentanyl analogues is this one that has just
gone out of control. Heroin is this one that
kind of mimics that. Prescription
opioids are this nicely steadily
increasing one here. Then, this is cocaine,
methamphetamine, and methadone. And what I’d like to
point out about fentanyl and fentanyl analogues is
that we cannot separate out prescription grade,
pharmaceutical grade fentanyl from illicitly
produced fentanyl, so those end up being
lumped together and a lot of this may be
illicitly produced as well. And so,
what we know is that when we don’t
know what we’re getting, we’re more likely to
overdose than when we do. However, we can see very
clearly that we are prescribing more and more
prescription opioids and more and more people
are overdosing and dying from their
prescription opioids. This looks at us
here in the Midwest in terms of death rates
from natural and semi-synthetic
opioids. So there were
2,302 deaths in 2015. And we are kind of maybe
doing a little better than some of the other areas,
and this is age-adjusted. Lighter one is 2014,
darker one’s 2015. So we see the biggest
increases in the South and in the
Northeast, and this is the Kentucky that
you’re always hearing about in this type of thing, and
this is Massachusetts. So this is now comparing the
United States to Michigan. We are doing a nice
job of outpacing the rest of the United States
in terms of people dying. I’m not sure that’s quite
a good thing, right? So we’re actually ranked
number 18 for overdosed deaths in the nation. This is the state
of Michigan, county map from the Office of
Recovery Oriented Services, 2013 to 2015. It’s not publicly
available, so if anybody wants any
of these next three slides, you’ll have to
just let me know. And the hash-marked
counties are ones where fewer
than 7 people died and, by national law, we
can’t report those statistics because it’d be too easy
to kind of figure out who that
individual was. So we can see kind
of our area here– Kent County, Muskegon,
Ionia, Ottawa. So this is kind of our–
essentially our catch– Allegan– our essential
catchment area. And we are kind
of in the middle, but are surrounded
here in Kent County, but are kind of pretty
well surrounded by areas that are suffering
quite significantly. Some of the thought around
why we might be different is multi-fold. Our community mental health,
which is Network 180, has a ton of resources
in Kent County. We’re one of the most
resource-rich counties in our state in terms
of substance use treatment
opportunities. We also have a group called
“Grand Rapids Red Project.” Full disclosure– I’m
past Board President– and that is our
local needle exchange and naloxone rescue kit
provider in the community. And what we know from
data from Massachusetts is that the more naloxone
in the community, the lower the
death rate. So we think that
that may, in part, be related to
those factors, so we have more
access to treatment and more
safety net areas. We have the ability
to provide people with multi-modal
therapy, so we can better
match the individual to the best
treatment for them. So heroin use
is increasing amongst almost all
demographic groups. And the overdose deaths
are climbing. There’s been a 286% increase
from 2002 to 2013, so over 10 years. At the same time,
we have seen an increase in heroin addiction
but it does not– that somewhat parallels that,
but has not gone up as high, as well as that,
and that gap is likely due to
prescription opioids. Heroine mortality rates–
so we’re doing pretty well with killing people, compared
to the previous slide. We also think
that maybe in part because we have more
treatment opportunities, and so one thing
that sometimes happens is that people go into an
abstinence-based program, so they’re not getting a
medication-assisted treatment. And when they leave that
abstinence-based program, they’re at a higher
risk of overdose death because their brain has kind
of recalibrated a little bit, not completely,
but a little bit, to not needing
as much– um, to not being as
tolerant to as much opioid. So the same amount of
opioid can lead to death. There’s also hypotheses
that our dealers in our county are just giving
more potent drug, and so people don’t realize
what they’re taking. So this is total drug
poisoning mortality rates. And then, this one
is heroin-specific. So you can see that those
kind of parallel each other. So this is an
interesting slide. It’s kind of busy, so I’m
just gonna cut to the chase. So this is death–
medical examiner death from the state
of Michigan. It’s a little bit older–
2009 to 2012. This is the most
recent data. And the important thing
right here is this 59%. We’re just gonna
focus on that. And what that
bar is saying– so this is– the red is
total drug poisonings. The blue is drug
poisoning deaths, who filled a prescription
within 364 days of their death, and the green is people
who filled prescription within 30 days
of their death. So this 59% means that of
these 669 people who died of an overdose… that on their
medical examiner data for the state
of Michigan, it attributed their
death to an overdose, to complications of
an opioid overdose. 59% of those people filled a
prescription within 30 days of their death for the
drug that killed them. So 59% of people who filled
a prescription for the drug that killed them in
a Michigan pharmacy, written by a
Michigan prescriber within 30 days
of their death. That’s just scary. So it’s not just
those illicit opioids. It’s also the
prescription ones. And this is likely
very much underreported because we do not do chemical
analysis on every death. So if somebody
has maybe COPD, chronic obstructive
pulmonary disease, and has breathing issues,
their respiratory drive in the brain instead of being
set by the amount of oxygen, switches over to being set by
the amount of carbon dioxide in their brain, and that causes
them to not be as responsive to the amount of
oxygen in their body. And so, when we give
people opioids– again, opioids in the gut,
opioids in the brain, it’s in multiple
areas of the brain, it actually hits that
respiratory center, that breathing center,
and it slows it down. So these people
die of an over– they actually die
of an overdose, but because they
have end-stage COPD, no autopsy is done because they
just assume that the patient died of
their COPD. So we’re actually vastly
underreporting this. Michigan
mortality by age. This would be
for Michigan prescription drug-related
mortality by age. This would be the
35 to 54-year-olds. This would be the
21 to 34-year-olds. So we are losing our most
productive and active members of society to
this epidemic.>>(indistinct).>>Oh, you’re not
in that age group. Yeah, you are. But a lot of the
people that are– there’s a significant portion
of the 55-plus age group that’s retired–
not you, Dr. Weston. You’re not allowed to, until
I’m no longer MISAM President. (laughing)
And then, 16 to 20 tend to not be working as much
as that 21 to 54 age group. So if we look at the treat–
so this is talking about a treatment gap, so what we see
in our fine state of Michigan, so convenient being
in Michigan– it’s easy to, like, pick
out like which one of these is North Dakota. (laughing)
So… yeah, how many of you guys
were actually able to find North Dakota
when I said that? Just saying. So Michigan– if
we look at Michigan, we’re actually in the second
highest rate of dependence… so having a
substance use disorder for the
different scales. We’re in the
second highest rate of having a
substance use disorder, but see those tiny
little dot here? That’s our
treatment capacity. So we’ve got a lot of people,
but not a lot of treatment. That’s not good– that’s
a disconnect, right? We need more
people treating, so that we can address
the community that we have. So there’s a lot
of access barriers. We’re going to talk a
little bit about barriers to treatment next– so there’s
lot of access barriers. There’s not
enough providers. There’s limited
numbers of providers. There’s limitations on
the numbers of individuals we can treat. There’s limitations on
the number of individuals a social worker
can treat. There’s limitation on
the number of individuals a physician
can treat. So there’s all
these limitations, which result in
waiting lists. One of our Spectrum
Health Clinics is closed to
new patients because they are at
capacity for social workers. They have
capacity. They could treat
more people. They feel like
they could, but that number makes
it so that they can’t. And this is not
unique to that clinic. This is something that happens
in all different care settings, and methadone clinics,
and buprenorphine clinics, kind of in all of the
substance use treatment licensed programs. There’s coverage
limitations by insurers. There’s utilization
management processes, so there’s these people
that sit somewhere that aren’t seeing the
patients, that are saying, “You know, I don’t know
about that, Dr. Poland. “That Suboxone stuff–”
which is the trade name for buprenorphine,
naloxone– “costs us about $700
a month to pay for. “I don’t know if that’s a
good choice for this person. “It’s kind of
expensive.” We’ve got some program
personnel barriers. We’ve got a lot of
people still in treatment that are providing
treatment that don’t believe
that medication has a place to treat,
when what we know and the evidence very clearly
shows that medications improve outcomes,
overall. In fact, just the fact
that somebody comes in and sees
a doctor… improves their outcome over
somebody who doesn’t come in and see a doctor, somebody who comes in
and sees a social worker or a different
provider. And that’s, you know, just
the placebo doctor effect. There’s still this belief
that medication substitute one
substance for another– this was founded in a lot of
the AA and NA literature. There’s belief that alternatives
are better than medications, and there’s a significant
number of people that do not support
medication-assisted treatment. Medical staff barriers–
a lot of treatment programs lack access to qualified
healthcare providers who can prescribe or who have
the capacity to prescribe. So with buprenorphine products,
we’re limited as providers in terms of how– the
number of individuals we can have on
that medication. It is the
only medication that has any sort of
random arbitrary limit. Technically, if I
wanted to prescribe some like crazy chemotherapy
medication, I could do it. I just would have no idea
how to give it to somebody. So it’s probably not a
very safe thing to do, but nobody puts a limit
on whether or not I can technically
write a prescription for any other medication other
than this buprenorphine– write a
prescription. Know, and with methadone,
it’s also slightly different, in that you cannot write a
prescription for methadone for the treatment
of addiction. So that’s why we have
methadone clinics, where they
dispense methadone. So the patient never leaves
the methadone clinic with a prescription. They never go to the
pharmacy for that medication. They go to the methadone clinic
and they get dosed daily at the methadone clinic,
and then as they progress, and are doing well, they get
what they call “take-homes,” and they get doses that
they take home with them, but those are
all given to them and dispensed at
the methadone clinic. There’s funding
barriers. A lot of states
will not reimburse for physician
services. Funders won’t pay for
the laboratory tests. They won’t pay
for the medication. The patients can’t
afford the medication. There’s regulatory barriers–
I touched on that a little bit. So there’s all sorts of
kind of rules and regulations around what can
and can’t be done. These vary state-by-state, so
just because I can do it here, doesn’t mean I
can do it in Ohio. Just because they
can do it in Indiana, doesn’t mean that
I can do it here. So it’s hard to
necessarily find that. We sometimes find
that to be difficult in the Upper Peninsula,
specifically, because we have
some border regions that will not fill prescriptions
from outside of the state for medication-assisted
treatment. The pharmacies
are just refusing. And a pharmacist
can refuse– it is within their
scope of practice to refuse to fill
up medication. So we experience that
right here in Michigan. So how do
we treat it? We have three
FDA-approved medications. I always tell people, “I am
just not the smartest person, “so don’t make things
too complicated for me. “I can handle
three medications. “If we throw alcohol in there,
that makes it up to five, “and then we can
get really back down “because five is
just way too many.” I am not in a methadone
treatment program, so I cannot utilize methadone
for the treatment of addiction without violating the
Harrison Act of 1914. I try not to
break laws. And then, disulfiram or Antabuse
for alcohol use disorder is just kind of a cruddy drug
that doesn’t work very well, so now we’re
down to three. So anyone can be an addiction
doctor is what that means. And studies, again, show that
medications are effective in treatment. So we’ve got three
FDA-approved medications. They all have different
ways that they act. Only 30% of treatment
programs nationally currently
offer medication, and that results in less
than half of eligible patients receiving
medications. And what all these medications
essentially try to do is stabilize those
brain structures, so that the patient can focus
on the thought processes, focus on that CEO
of the brain, try to develop that frontal lobe
a little bit more. I’m gonna skip
over a lot of this. Okay, so those
receiving medications as part of their treatment
are 75% less likely to die because of addiction than
those not receiving medication. It is
cost-effective. We save money. For every $1 invested
in addiction, we save $4 to $7 in
drug-related criminal activity, and we save
up to 12– when we include
healthcare costs, savings exceed a
12-to-1 ratio, so every $1 we spend
treating addiction, our community
saves $12, overall. So addiction
in isolation. So there’s this fantastic
1970s and ’80s experiment– it was published in 1981
by a guy named Bruce Alexander out of Vancouver, which
continues to be, to this day, one of the most forward-thinking
addiction treatment areas in the world. So what he noted– and this is where kind of the
“War on Drugs” stuff started. Anybody involved in
D.A.R.E. programs in school might remember that kind
of “Just Say No” mentality we had back in
the olden days. A lot of you are probably
not even remembering that, because I’m old. So in the 1970s and ’80s,
they did these experiments, where they put
a rat in a cage and they gave the rat the choice
between cocaine and water. And the rats used cocaine
until they overdosed and died. And so, we said, “Well,
exposure to cocaine “will automatically lead
you to using cocaine “to the exclusion of anything
else until you die.” Makes sense. Then, this guy came
around and he said, “Well, you know, you’re
isolating those rats “and we know that rats are
kind of social creatures. “They like to be around other
people, animals, things.” So he built
rat park. It had toys, food,
tunnels, friends. It was rat paradise–
it was wonderful. And what he found
was that rats alone– he put some rats in their
little cages in isolation and they drank
the drugged water, and the rats in the park
kind of tried the drug water, but they didn’t really
continue to use it. And if you Google search
“rat park cartoon,” these are
blatantly stolen. And you can kind of go
through the whole experiment if you’re
interested. So the rats in the park
tried the drug water, but the vast majority of them
didn’t continue to use it. Why were they different
than those rats alone and drinking the
drugged water? So what he said was
there must be something about that
social atmosphere that makes those rats
immune to addiction. It must be something about
maybe not being exposed to excessive carbohydrates
that makes people have less type-2
diabetes, right? So it’s an exposure
thing maybe. So we had this thing
called the Vietnam War. And in the Vietnam War, about
20% of soldiers used heroin while on duty, so
there’s this huge concern that we were gonna have all
these heroin-using people coming back
after the war, and we were gonna have this
huge addiction epidemic, and it was gonna be
terrible and awful and all these people
are gonna die, and heroin was gonna like be
the scourge of the universe– didn’t happen till
many years later– but at that time, we thought
that’s what was gonna happen with these soldiers
that came back, and what we found was that
a lot of them reintegrated back into the community
and stopped using heroin with no treatment. Because home was rat park
compared to the Vietnam War. That was like
isolation in a cage. It sucked! Right? So… 95% of the soldiers discontinued
after returning home. Now, that rate of
use is still higher than the general
population. And so, meanwhile,
back in rat park in Bruce Alexander’s lab–
so he took some of these rats and he put them alone
in the cage for 57 days, then put them
back in rat park, and they went
through withdrawal, but they didn’t
use as much. Now, their overall rate
still stayed above the ones– the rats were
always in rat park, but it was still less
than the isolated rats. So people who are prescribed
short-term monitored amounts of opioids for injuries
do not necessarily become addicted
to heroin. It is not just the exposure
that automatically results in a substance
use disorder. So are there social markers
that increase risk and what makes a
person feel isolated? So we have a culture–
one postulated theory is that we have a culture
that’s more connected than ever,
electronically. There’s Facebook and Snapchat
and all that kind of stuff, like we’ve got all these things
that we use to communicate with each other, and that
has been at the expense of developing
human relations. I call them
“3-D encounters.” You cannot see 3-D through
the computer screen. It is a 2-D
media, right? You cannot get– you do
not get a feel of depth. You do not get that
tactile expression. We are, like rats,
social creatures. So is the rise of addiction a
symptom of the Information Age? Humans have a need to bond
and form connections. What we know, what studies
show is that in a neighborhood in the 1950s, ’60s, and ’70s,
on average, people got together with their neighbors
10 times a calendar year. Today,
it is two. So for too long, we’ve
talked exclusively about individual
recovery from addiction. We need now to talk
about social recovery, how we all recover together
from the sickness of isolation that’s sinking us
like a thick fog. That is from the gentleman who
did the rat park experiments. And so, one of the things that
I think will hopefully help us solve this crisis is to increase
the community-mindedness, increase the opportunities
for our young people, our kiddos, our kids in
elementary, middle school, to have safer
communities, where there’s more
interconnectedness on a very
personal level. Michigan State University
is a community-based campus. We’re all over the state,
and part of these lectures is to encourage the beginning
of these conversations to hopefully build
safer communities, and looking at the
resources that we have to be able
to do that. I end all of my lectures
to all the people who’ve lost their
lives to addiction and those that try to
prevent further losses. I lost my younger brother
to the disease of addiction. He had an
alcohol use disorder and committed suicide
about five years ago. It’ll be five years
on December 23rd. And so, this is also very
near and dear to my heart. And so, thank you for
joining me tonight and hopefully joining me in
the fight against addiction. Thank you. (applause)>>We have time for a
question and answer session, so if people would like to
ask Dr. Poland any questions, I could bring the
microphone around. You just
hand it.>>Okay, so I told my mom that
I was going to event tonight, and then, she
told me something I don’t know how
long ago she saw it. It was basically
about when mothers, when they’re using opioids
when they’re pregnant, and like, they give birth,
the child is addicted. Is it true that there’s
like hospital cuddlers? Like she talked about it
where they cuddle the–>>Hospital cuddler, oh yeah.
>>Cuddle the baby when it’s born and like
that helps them most because the baby is close
and it’s building a bond.>>So babies are
not addicted. I’m just gonna
start there. So babies can be
physiologically dependent, but the diagnosis
of addiction requires you to have some
behaviors and processes, and babies just
can’t do that. They don’t have the
brain capacity to do that. So we do have babies that are
born physiologically dependent on opioids, and
if that happens, because they will not
have opioid from mom coming into them
after they’re born, they will have what we call
“neonatal abstinence syndrome,” which is
baby withdrawal. And what we try to do
first is we try to just, like anything else,
if your blood pressure is starting to rise,
but we’ll tell you to make some
lifestyle changes, maybe cut out
some of the salt, do some exercise,
and things like that. In the same way, when a baby’s
going through withdrawal, we have a kind of
a scoring system. It’s called the
“Finnegan scoring system,” and we will look at
what the baby’s doing and we’ll start with
non-pharmacologic, non-medication ways to
manage that withdrawal, decreasing the
amount of stimulus, keep the room, kind
of the lights dim, the sound low,
making it nice and calm, so that we can all
be in Zen period, keeping them kind
of wrapped up, putting them into a
kangaroo bouncer if we can. But certainly cuddling them
and that physical connection is very important. There is an imprinting
process in humans, just like in
other animals. And a lot of that is
about kind of having that skin-to-skin contact,
so when babies are born, they can only see
about 20 centimeters, which is about, in a
normal-sized adult– which I’m not– the distance
between the baby’s head and the mom’s face. So babies can’t make
out colors very well. So they can see the
eyebrows and the hairline and things like that,
and so that helps develop that sense of connectedness
and calm the babies. If we do need to
give babies medication to treat their withdrawal,
we will give them medication. We’re not in the business of
making uncomfortable babies.>>Thank you.
>>No problem. Larry, you’re loud–
just yell.>>Any other questions?
>>Yes. He’s loud– he’ll– yeah.
>>Okay.>>A year or two years ago,
we were going back and forth through Michigan.
>>Yes.>>Is there’s actually any
movement on that, and also knowing the
average (indistinct).>>So there’s movement
at the state level. Some of it is related to the
Michigan Prescription Opioid and Opioid
Abuse Committee. Unfortunately, that
committee does not have an addiction specialist
on it– that is a gap. Apparently, it would take
an act of legislature to change that. So everyone go home and
write your County Legislature and ask for them to
have that changed. So they have been advocating
for some changes. There was a 13-bill
package that came out from the Lieutenant
Governor’s office. Lieutenant Governor Calley
is a strong proponent of equal opportunity
for all individuals regardless of
mental health concerns, and that goes for everything
from developmental delay, to addiction, to other
behavioral health issues. So he’s put forth that,
and that’s working its way through the
legislature. And currently, the one
that’s being debated is on requiring
physicians to access a prescription database that lets us know a little
bit more information about scheduled
medications. And then, there’s also the
House of Representatives has the
C.A.R.E.S. Committee, and that is led by the
Speaker of the House. They’re a representative
from both Grand Rapids and one from Allegan County are
both members of that committee. And so, they are actively
working on writing some legislature around some
of this substance use stuff. Of those 13 bills that the
Lieutenant Governor’s office put out that are active
in legislature right now, two of them are around education
within primary schools.>>Any other
questions?>>I do a lot of
advocacy stuff. Yes?>>Hey, can you
pass that down?>>Okay, hello, just as a
grassroot nonprofit organization here in
West Michigan, what could we do for
our local community, what model
could we follow, or what services could we offer
to promote health and wellness centered around
this issue?>>Can I ask what
organization you’re with? Or are you just
saying in general?>>Yeah, I would prefer to
just leave it in that family of nonprofit grassroot
community outreach.>>Mmm-hmm. So I mean, depending
on what area that is, there’s the opportunity
to provide education for the population
that you’re serving. There’s the opportunity to
provide access to care by partnering with the various
treatment programs in the area. Often, that’s done
through Network 180, certainly for
the Medicaid and the otherwise underserved
population, uninsured, and uninsured
population. There’s opportunities
to help provide some of these
community messaging. We do have another kind
of grassroots organization that’s been growing in
Grand Rapids called “FAN,” which stands for
“Families Against Narcotics.” It’s a Michigan
organization. Their meetings are the
first Tuesday of the month, I believe–
is that right? Yeah, the first Tuesday of
the month at St. James Church. And so, they– and you can
search them on the Internet to make sure that I’m
100% accurate in that. But they’re the
first Tuesday night, and they kind of promote
coalitions and working together. There’s the Kent County
Health Department in partnership with
Grand Rapids Red Project, who received a grant from
Steelcase Foundation here locally, has an
opioid task force, specifically
around overdose. That’s another way
to get involved, really making
connections. You know, Grand Rapids Pride
is a big partner for Grand Rapids
Red Project, and kind of partnering
with others. So there’s GRAAHI. There’s lots of kind of
seemingly unrelated partnerships that happen, and the more
that those partnerships happen and the more people hear
the same messaging coming from various
organizations and various groups, the better
we’re able to turn that message from necessarily
being grassroots to being kind of a
mainstream message. And it’s a bit of
an uphill battle. There’s still a ton of
stigma around addiction. If you notice, like, where
did I spend most of my time? Talking about
the brain. Pointing out that this is
a disease of the brain, this is a malfunctioning
brain that we can fix, that we can change
to help them, to help these individuals
lead the life– what we talk about in our
clinic is that we want to help these individuals lead the
life that they want to lead. That might not be the life
that I think they should lead. And that’s a pretty
distinct distinction, right? So we want to help people live
the life that they want to lead. And I can’t help people live
the life that they want to lead without the help of all of
the nonprofit organizations. We partner with Feeding America
of West Michigan. We have a
food bank. Again, full disclosure,
my husband and I fund it, but we’re able to provide
our patients with food because a lot of these folks
have unstable living situations. So I, as a parent,
will definitely say that if I’m standing there
and I’ve got $3 to my name because I’m on a fixed income
from Social Security of $750 because I am disabled due to
my mental health conditions, or physical
conditions, and I have $3
to my name, am I gonna pick up my
$1 copay prescription or am I gonna pick up
a box of spaghetti to feed
my child? I’m gonna pick up
that box of spaghetti. So that’s why I’ve chosen to
partner with Feeding America, in order to be able to
provide food to my patients, so they don’t have
to make that decision. And we need to be looking
at all of those things, all of those things
that people need in order to be able to
focus on their healthcare. Because without
that support, without knowing where you’re
going to sleep every night, without knowing that you’re
not going to be hungry– one in six children in Kent
County is hungry every day. That breaks my
heart every day. And until we
solve that, we can’t solve
other problems because if their brain
is developed without fuel, what do you think happens
as they get older? So it’s not just about
treating substance use. It’s about building a
healthier, safer community… The rat park of
Grand Rapids. Yes, young man.>>Um, I’ve seen
several studies– I think we’re good–
I have a loud voice. All right, all right. I’ve seen several studies
that show a direct correlation in states that have
legalized medical marijuana and legalized
recreational marijuana and decreased rates
of opioid overdoses. So from your perspective,
do you see medical marijuana as a reliable
treatment method for opioid use
disorder?>>We can talk
more about that. That’s a pretty
long question. Suffice to say, those studies
are pretty poorly done. There is no such thing
as “medical marijuana.” So there’s this body in the
United States called the “FDA.” And what they do is
they approve medications and they approve– and
they kind of keep us safe. They’re the ones
that regulate, like if there’s a
salmonella outbreak, they’re the ones
that track it down and figure out what jar of
peanut butter it started with, so to speak– not to
pick on peanut butter. But they’re the ones that
kind of do that stuff as well. And so, when a new
medication comes out, when I prescribe
somebody a medication, doesn’t matter
what it is, I prescribe them
a dose, a route, a frequency, and
a quantity, right? When somebody writes
for medical marijuana, they’re prescribing
a gram of plant. Now, let’s talk
about aspirin. Everybody’s heard of aspirin,
I’m gonna start with, correct? Okay, so if you go
to your doctor, your doctor
might suggest, especially maybe if you’re a
wiser person in our audience that you take a baby aspirin
for cardio protection. And they prescribe
81 milligrams. 81 milligram
baby aspirin. They don’t tell you to go
find a local willow tree, cut a one-inch by
two-inch rectangle out of the
willow tree, weigh it, so that it
is 2 grams, dry it. I don’t know what
other processes, maybe spray some
pesticide on it, and then
chew on that. But you know where
aspirin comes from? Comes from the bark
of a willow tree. So when somebody is written a
prescription for marijuana, we have no idea how much active
ingredient we’re giving them. As the years
have gone by, we’ve seen an increase in
the amount of the chemicals in the
marijuana, we’ve seen an increase
in the active ingredients, we’ve also seen a
parallel increase in kind of the two
major active ingredients, one of which results in
increased risk of psychosis with intoxication
from marijuana, and in especially
vulnerable populations– are you young men in your
early 20s in this room? I know, I’m just picking on
the guys all night tonight, but it can precipitate
schizophrenia in somebody who has vulnerable
genetics for schizophrenia. So there are
a lot of risks. And we do actually have
pharmaceutical grade marijuana. It’s called
“Marinol.” So we actually have
that available. It just doesn’t
get people high. So those studies were
actually pretty poorly done. And we can talk about
the specifics of that, if you’re interested,
later. But that’s kinda my–
so that’s one end. That’s part of my
spiel on marijuana. So I call it
“voter-approved marijuana” because that’s
what it is. And then, the
other end is– so we’ve got two
different questions. “Are there medicinal
properties of marijuana?” Which we know
the answer to. We have purified it,
we have tested it, and we have Marinol…
pharmaceutical-grade marijuana. And then, we have the question
of, “Do we legalize marijuana “in the same way that we have
legalized tobacco and alcohol?” And at what age,
and what routes, and what regulations,
blah-blah-blah? And I feel that those are
two separate questions that have, in the common world,
been muddied into one. And I think they need
to be separated out. Is that fair?
>>Thank you.>>No problem. I went over. You guys
indulged me. I can stick around
for a few more minutes. I have cards if people
want them, too.>>All right,
thank you. (applause)

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