More compassion, less finger wagging

Dr. Jonathan Avery, director of addiction psychiatry at Weill Cornell Medicine, is on a mission to help doctors see the human being, not the addict

12 Mar 2020 | 03:08

You’re an addiction psychiatrist. Did that job exist when you were in medical school, thinking about what to specialize in?

I think the first addiction psychiatry fellowships were in the 80s, but it’s never been a popular profession overall. There’s a lot of reasons for that. One, historically, addiction is sometimes viewed as something distinct from the medical profession; it should be taken care of in the 12-step rooms. Even methadone clinics, when they came around in the 60s and 70s, were separated from medicine proper. There’s always been a distinction in some ways between the worlds of medicine and addiction.

How does a person become an addiction specialist?

You do college, four years med school, three or four years’ residency, then it would be an additional year fellowship. You’re in your early 30s, and you have to make a decision: do I want to become a certified addiction professional or not? And by then you’ve accrued debts, and even if you’re interested, it is an extra year of training.

It’s a shame it’s so hard and such a long path to be an addiction provider. Because really, to be a doctor in general is to be an addiction doctor. You can’t avoid substance use in our patients, be it if you’re a primary care doctor, a neurologist, and certainly a psychiatrist. You really need addiction training. So the few of us addiction psychiatrists that exist now – less than 100 graduate each year in the country – our mission ends up being almost consultative to other professionals, which is to help everyone feel confident treating addiction even if they didn’t pursue that additional training.

What attracted you to this field?

My dad was a hospice physician, so for 10-plus years before residency I was very involved in that space, starting at the beginning of high school.

I was always drawn to medicine and to psychiatry, but I had some really positive experiences in medical school where I saw people with substance use disorders get better, and I became excited about the potential to be a clinician in that space. Just as I was getting excited about it, I was constantly encouraged not to pursue it. There’s this idea that one, it’s something a little distinct from medicine. Two, there’s not much we can do about it, there’s a certain helplessness. Then certainly there was this stigma that existed, even among medical professionals, to patients with substance use disorders.

Thankfully that didn’t discourage me. I was curious why, given that these patients are all around, why people weren’t more excited about this field. So I sort of took off running and some of my early research even as a trainee was thinking about why so much stigma exists in the medical community towards addiction, towards individuals with substance use disorder.

I think the hospice folks are angels, by the way. They’re so comfortable with the end-of-life realities that we in America don’t want anything to do with.

I put death and addiction as two of the things we’re very uncomfortable with, right? Just like people at the end of their life, we tend to shy away from? These are people we should be listening to, and having their stories told, and thinking about how to do it with dignity.

I was struck in my experiences with addiction folks, they could use a similar treatment and a similar thoughtfulness. I just made a video about a family in Virginia who lost a loved one [see sidebar] – the thought is that we’ve got to get these stories out. They’re rich, they can teach us – that addiction and death can’t hide in the shadows, that they’re with us all the time. No one’s immune. Death and addiction are always something that happen to other people, not to us. We have to recognize that that’s not true.

What’s a big misconception about addiction?

This idea that it’s bad people doing bad things. Even doctors don’t appreciate the degree to which it’s a brain disease. In vulnerable patients, their neural circuitry gets hijacked by substances and their ability to make good decisions for themselves deteriorates. Because of that belief, that moral failing belief, we’ve tried to punish and punish and punish folks with substance use disorders, from the legal system, to how we treat it in communities and then to the medical community. Where instead, if we treat it more like a disease, then we’re more likely to offer treatment and compassionate care and not to be so finger-waggy and punishing about it. That’s the biggest narrative shift we’d like.

Obviously addiction knows no socioeconomic or age boundaries, but is there something that at-risk people have in common, an “addiction gene,” so to speak?

I wish for any of these – from mental illness to substance use – that we could exactly pinpoint anyone’s risk. We don’t quite have that. There’s different neuroimaging stuff that we’re leaning into, but some of the more clinical history is still what we’re relying on: if you’ve had a family history of addiction, if you yourself have a history of mental health issues or trauma, if you have difficult early life experiences even if not formal trauma, all of these things can impact the development of substance use disorders down the line.

You say a person’s neural circuitry gets hijacked... how does that work?

It used to be easy to talk about the neurobiology of addiction. We used to say all roads lead to dopamine, and it was simple. Now Nora Volkow, the head of one of the big addiction organizations, she comes out with the Neurocircuitry of Addiction paper pretty much every year and it’s almost impossible to read, even for me these days. There are so many circuits and genes and ways that we think about it. How I describe it is that for certain people, they have this exaggerated response to a substance where others don’t. Some people have an opiate and they’ll be nauseous and they won’t feel good and it won’t light up their brain. Other folks get an opiate for the first time and it will be the best thing their body and brain has ever seen, and they’ll get this huge dopamine spike, the circuitry will get hijacked in a way where it motivates behavior to get more opiates, and the natural rewards of other things diminish. It’d be nice to have it be so simple that we could understand it and intervene more, but we’re not quite there yet.

What types of addiction are you seeing?

The big epidemics we think about these days are youth vaping and the opiate epidemic, but we still see a ton of alcohol, a ton of people getting into trouble with marijuana. Here in the hospital where I work, most of the medical admissions for the consequence of substance use are alcohol-related, although most of the overdose deaths or near-deaths are from opiates.

So drinking is still the big one. What alcohol-related problems do you see?

Alcohol – less overdoses, but more presenting with the medical consequences of alcohol use, either being in withdrawal, or intoxication states, or having some organ damage – liver, brain – from drinking.

You hear marijuana’s not addictive. Do you agree?

For marijuana there’s been a lot of shifting attitudes with the shifting legislation and the shifting availability of it. It probably is less addictive than a lot of other substances, but there are folks that will use marijuana and develop a marijuana use disorder. The data varies, but maybe as high as 10 percent of people that try weed will end up with problematic use patterns of it, so it’s certainly not totally benign. I think the seductive nature of vaping, of either nicotine or marijuana, is there are ways to use it all the time. If you’re using something throughout the day, especially through these new delivery systems, it’s very hard not to develop a use disorder.

Opiate use disorder, marijuana use disorder. I’m noticing a language switch – you’re not using "addict" or "abuse." Is that deliberate?

Yeah we’ve played a lot with language in the field of addiction, and trying to figure out the least stigmatized, most thoughtful way to underscore a couple principles. One, that it’s a disease or a disorder, and two, to separate out the person from that disease or disorder. We like to say, “an individual with a substance use disorder,” as opposed to “the heroin addict.” We’ve seen, when we look at public and clinician attitudes, they really change based on how you describe folks. So if you can describe it as a person with a disease as opposed to the defining characteristic of a person, you’re more likely to offer treatment for the person with a heroin use disorder than the heroin addict. I think it’s important to draw that distinction between the person and what their disorder is.

You’ve been over-prescribed opiates yourself, specifically 180 Percocet for a broken foot when you were in medical school?

Right, it was happening to everyone, including me. I broke my foot about 15 years ago and got an enormous amount of opiates. I took one, and these others sort of float around. And that was how we got here with the opioid epidemic, with pain being the fifth vital sign. You really couldn’t go wrong giving opiates for pain.

How have things changed since then?

A lot of the effort in the opiate epidemic is to cut down on doctor over-prescribing: to limit prescriptions for acute pain to three to seven days and not a months’ worth, and to make sure we really need opiates for a given pain condition. The idea is not to be withholding or punitive again, but just to have a more nuanced understanding of who benefits from opiates. There are certain conditions we still think need opiates: severe acute pain, end of life situations. We don’t want people to totally go to the opposite direction, but we want a nuanced view of opiates and not this dramatic over-prescribing.

I read that if a patient is prescribed five days of opiates, they’re at risk of developing dependency. Is that right?

It seems that the more you take, the more likely you are to get stuck on it. That’s true for anything really, but especially for opiates, and especially for people who are vulnerable to opiates. So the more we can do to limit opiates prescribed, the better.

How does someone end up in your office? Do they call, or get assigned?

Because of the punitive nature of addiction, and its status as less than a disease, and not something we all feel comfortable addressing, a lot of people come to addiction treatment when things are rough in their life and too late. So we see a lot of people coming in due to legal consequences, or families bringing them in, or work consequences. We wish more people would present to me when they’re worried about their substance use, or they’re thinking about how to better address their mental health issues. But a lot of people come to addiction treatment when things have gone poorly in their life.

Can you give an example of how you might treat a patient?

In the world of addiction, we think of all other substances on one hand and opiate use disorder on the other hand – because it carries that risk of death, and this different profile than the other substances. We really feel like you need to be on medications for opiate use disorder. The ones that are FDA approved are buprenorphine, commonly referred to as Suboxone; methadone; long-acting injectable naltrexone, more often called Vivitrol. So if you have opiate use disorder, there needs to be a strong doctor or nurse practitioner or some prescriber involved to help you get these medications, because the outcomes are so much better when you’re on them. It decreases death and overdose, improves functional outcomes. They’re some of the most effective meds we have in medicine. So for folks with opiate use disorder we’re really playing an active role, and also getting people these naloxone rescue kits to help revive people if they’ve overdosed.

Then for all other conditions, there are meds that are helpful for alcohol and nicotine and other substances, so we might provide some med support, or treat the co-occurring mental health issues, and we often either do therapy ourselves, motivational interviewing or other types of supportive therapies. And then we work often with other support systems like 12-step support systems, and then if people are struggling out in the community, these outpatient rehabs or inpatient rehabs.

A big problem you see in our medical system is that we treat one condition at a time – the depression but not the alcoholism, say. But doctors are only human, and as you’ve said, tend to “back out of the room” when confronted with a messy situation. How can they overcome that instinct?

The struggle with doctors and interacting with individuals with substance use disorders is I think they feel they don’t get a lot of wins. Part of that is that often, especially if people are working in acute care settings, they don’t have exposure to people in recovery, or families or more rounded narratives. For the prevention of doctor burn-out, we want them to get this rounded narrative about individuals with substance use disorders, this understanding that people do recover from this. In fact, there may be more people in recovery than with active substance use disorders in the United States. But physicians are often interacting with people who are actively using, and so lose track of the fact that many recover.

Also in terms of preventing physician burnout, we’re really encouraging medical schools and residency programs to ramp up their addiction training, so when doctors are out in field they’ll have the skills, know how to prescribe meds or do the therapies, or know how to refer people to therapy when they’re encountering substance use disorders, as well as carrying that hope, having seen people in recovery, that that’s a place their patient can get to in the future.

We’re also helping doctors think about themselves. As you’re alluding to, we think we’re special, but we tend not to be. We tend to be like everyone else and prone to the same biases. We’re probably more at risk than our age-matched peers to develop our own substance use disorders and have substance use in our family. There’s a mix of things we’re bringing to the table when we encounter this patient who’s struggling with a substance use disorder.

And one of the common complaints is that if I step up and I address it and I think about the complexity, that it will cost me more time. I tend to balk at that because what we see in the medical world, in the hospital setting especially, is that people are coming back and back to the hospital and using more resources and time for not having their substance use disorder addressed. You can keep giving meds for a person’s hypertension, but if it’s all from their alcohol use, if you’re not getting the underlying cause you’re going to end up spending more time with the patient trying to manage something. Similar for mental health issues: people just want to address the psychiatric issue, but that’s not going to get better either unless the substance use is addressed.

I think it’s more fantasy than reality that avoiding it, one’s going to save one's self time. I think addressing it head-on would end up improving health outcomes, provider burn-out and all sorts of other things.

How do you personally recharge?

Like every 40-year-old in New York, I meditate and exercise. I’ve got two kids and a family. But what keeps me energized at work is not only those things I have outside of work and basic self-care, but it really is what I’m passionate about. I feel like the potential for change is there. And once you’re in addiction long enough, you don’t think you’re going to save the day on any given day, you’re just in it with the patient: meeting them where they’re at, riding through the ups and downs. Sometimes doctors like to come in and give that med that’s going to change everything in a second, and that’s not the experience of working with someone with substance use or mental health issues. Nothing’s resolved in a day – or decades. I would get burned out if I came in each day thinking I was going to save the day. But rather, I’m here to just meet patients where they’re at, make sure they’re aware of their options, help them on their life course, with the feeling we’re in it together. It’s not me versus them, doctor versus patient, that we’re so different, or all the other ways we distance ourselves from our patients’ experience. If I feel just in it with them, and we’re all doing the best we can, then I tend not to burn myself out.

You’ve used storytelling, specifically video, to broadcast patients’ stories. Why is that important?

I’m going into schools and businesses and work. I go all over the place and talk about substance use disorders in a lot of different settings. It’s fine if I come in and provide information, but everyone’s like eh, who cares? It’s just a doctor doing what doctors do. So I think the best way to communicate information is to have people in recovery, have family members there. I like to go into the banks, the law firms, whatever, and have somebody in that community in recovery go with me. If I go to school to talk about youth vaping, I like to have someone that’s quit vaping as a teenager. The idea is that there’s more rounded narratives that will help us inform our decision-making and not just fearmongering or doctors finger-wagging. I can’t do my work without the recovery community. I can’t do my work without family members, because otherwise it’s just not going to be so effective.

Is there somewhere in the world that treats addiction better than we do?

I’m thinking about Portugal, or other places in Europe where it’s not criminalized the way it is here. I think that sets the tone so early here in the United States. I remember in high school, this was years ago, but we had the police come in and do prevention and say, if you’re doing drugs you’re going to get arrested. They’d come in with their police dogs and try to scare us, as part of substance use prevention.

DARE, I’m realizing, was taught by cops.

DARE, exactly. It’s somewhat the same spirit, I think, in the States now. I hear there are a lot of people doing different things, myself included, but still, people are in general scared to come forward because of punishment. Even how schools handle youth vaping, it’s basically just: suspend the person. It’s never like, this guy’s dealing with a health thing, let me get them care. It’s just, “ah, bad kid doing things at school.” And I don’t think that’s helpful for anyone. One of the things I like in recovery is we’re not bad people becoming good, but we’re sick people becoming well.

Portugal, which has decriminalized it and lowered barriers to treatment, is one good model. But I think others are trying. European countries offer free treatment, which is definitely better than the tens of thousands one has to spend for in-patient addiction treatment here.

In the world of addiction, we think of all other substances on one hand and opiate use disorder on the other hand – because it carries that risk of death.
I think the seductive nature of vaping, of either nicotine or marijuana, is there are ways to use it all the time. If you’re using something throughout the day, especially through these new delivery systems, it’s very hard not to develop a use disorder.