Frontiers in Psychiatric Treatment is a webinar series designed to equip psychiatrists with the latest knowledge about advances in the field through digestible, clinically relevant updates across an array of subspecialties. For our first installment on Monday, January 24, Timothy K. Brennan, MD, MPH, covered recent developments in treating addiction, with 15 minutes at the end for Q&A. Dr. Brennan is the Chief of Clinical Services for the Addiction Institute of Mount Sinai, overseeing addiction services across all campuses of the Mount Sinai Health System. He is also the Director of the Fellowship in Addiction Medicine Program at the Icahn School of Medicine at Mount Sinai.
alright on behalf of the Department of psychiatry here at the Icahn School of Medicine at Mount Sinai, welcome to the first in a series of lectures about the frontiers of psychiatric treatment. My name is Dr Tim Brennan and I am the chief of Clinical services for the addiction institute of Mount Sinai. Um it's great to connect with all of you, albeit virtually in this rather impersonal format But nevertheless welcome my plan over the next 45 minutes or so is to take us on a journey through addiction medicine. I've tried to be mindful that our audience today is a rather heterogeneous mix of professionals. We have social workers, we have lab professionals, we have psychologists, psychiatrists, other physicians and of course what I talked about here today is just my personal opinion. Uh everybody has an opinion on addiction, that's the nature of the work that we do. But you have my word that I'm going to focus as best I can on the evidence and avoid as best I can. Uh the anecdotal, I will try to leave plenty of time for questions and answers. There's a Q and a button on the zoom platform. Feel free to put a question in there. I won't see it until the end of my talk but happy to answer any questions um that get asked. Okay, so some important financial disclosures as I get started. I don't have any disclosures, I don't have any relationships with anybody in the pharmaceutical industry or in the addiction treatment industry maybe I should get some but I don't have any as of now, a free resource for all of you in case you have any questions about the field of addiction medicine, this is my mobile phone. Please feel free to call me or text me. I'm happy to connect with any of you about um our great field for patient referrals. Please use the regular Mount Sinai addiction institute numbers on the Mount Sinai addiction institute website. I'll put those numbers up at the end as well. Um Now before we begin I'd like to kind of challenge all of us because I end up getting asked about a particular question regarding addiction quite a bit. Um I'm wondering if you're game for a bit of an experiment. Um And the question I get asked a lot is about so called internet addiction or uh technology addiction or for that matter. Cellphone addiction. Um They asked me if it's real if it's bad, what on Earth is going on? So I'd like to invite us all to participate in this experiment. Please place your phone in your pocket or face down so that you cannot access it and make a promise to yourself that you will not check it for the next 45 minutes. Um This is not going to require any consent form. This is not an I. R. B. Approved project. I'm not collecting any data. This is just a fun experiment and I'm asking for 45 minutes of your time. The average lifespan by the way is about 41,440,388 minutes. So I'm just asking for 45. Um and as I'm talking, just try to keep a running tally either in your head, on your hands or maybe on a piece of paper of the number of times your brain tells you to look at your phone and then perhaps at the end of the talk, we can decide amongst ourselves if we think technology addiction is a real entity. So our plan today is to talk briefly about the neurobiological understanding of addiction, which I will attempt to do in one slide will then learn how to diagnose and talk about people suffering from the state of addiction or suffering from addiction as a disease with patient centered language. Um I would like to try as best I can to describe recent developments in treating some of the most common substance use disorders as well as described. What I think might be some of the most compelling and interesting questions facing uh those fields. And then finally, I'd like to leave us with some thoughts about where our field might be. 25 years from today. 25 years from today, of course will be year 27 of the covid era. Um Just kidding but we'll see where we are. 25 years um from today now. Um No talk about addiction of course um would be sufficient without starting off with a schematic about neurobiology. Um Some of you have probably seen this schematic uh it's used quite frequently whenever anybody talks about the neurobiology of addiction. Um and what we're talking about when we talk about neurobiology of course are three main structures in the brain. The ventral tech mental area, the nucleus incumbents in the prefrontal cortex. The neurons of the ventral segmental area contained the most important neurotransmitter uh in in addiction and perhaps in the entire central nervous system. And that of course is the pleasure uh neuro hormone dopamine that dopamine is released into the nucleus accumbens and prefrontal cortex. And the patient or mammal. I guess if we're being more accurate feels the pleasurable effects of dopamine. The dopamine that gets released when we ingest drugs or have sex or eat food or have a stimulating conversation. That dopamine is fundamentally rewarding to us. It's reinforcing to us and encodes memories and it triggers conditioning such that we want to seek that dopamine again and it's very very effective at ruining lives. Um As we continue to seek dopamine release as we begin to become addicted to the substance. We of course have more and more trouble finding that same amount of dopamine release. We develop tolerance and we need more and more of the substance in order to trigger that same amount of dopamine release and we develop dependence which of course makes us suffer from withdrawal syndrome and we then have to seek out that substance in order to stave off the effects of withdrawal um the sort of bottom line of um of neurobiology of course though, is that it's an archetype that we can apply to our practices. You know, I'm not requiring or asking people to learn the structures in the um in the central nervous system, but allowing the patient to sort of understand um the implications of addiction from a neurobiological standpoint I think can be compelling to some folks who have a lot of self blame and a lot of guilt about their addiction. If they can understand perhaps what's causing some of these compulsive decisions they're making, they may well um be better able to contextualize their their illness going on. What's the current state of the addiction industry? Well, to be honest, the addiction industry is one of natural empathy. It's one of snake oil, it's one of corruption and it's one of compassion. Now when I talk about natural empathy, I'm talking for the moment about products or or compounds or substances like ibogaine, ayahuasca, psilocybin, kratom, I'm mindful of course about the role of these substances on the frontiers of research. In fact, there are some very well regarded entities not far from where I'm standing right now, that are rolling out psychedelic research centers and I'm very hopeful about these centers, but for now those substances reside in the realm of natural empathy. But if you were able to check your phone right now, which you're not. But if you were and you googled natural addiction treatment, you would see a whole host of entities that were offering you experiences. Oftentimes in central and south America with some of these um compounds. What I mean by snake oil to be clear are the hucksters and others that offer so called rapid acting anesthesia accompanied detoxification where the patient's actually intubated and undergoes and rapid detoxification equine therapy uh and niacin infusion centers which still exists right now. Uh this is outright snake oil. These uh these treatment modalities have not been proven at all. Uh in in my mind reside in the realm of snake oil. When I talk about corruption. Of course I'm talking unfortunately about the churn of addiction patients that unsavory actors um tend to exploit by way of their insurance benefits. These are operators of so called sober homes. Um fortunately a lot of them have been shut down in new york, but they still exist particularly in florida and in southern California. And these are centers that basically uh patient broker, They ask for referrals, they get patients, they keep the patients and essentially exploit their Medicaid benefits. And then the patients discharged at the end of the treatment with no regard to their actual sobriety. Um but of course, what I mean by compassion, I think I hope is the care that most of us provide, that's the care hopefully that we embody here at the addiction institute of Mount Sinai, that's the evidence based care that resides in peer review. And hopefully that's the care that we're going to bring forth as we move forward as a field. A few words about the language of addiction, many of you might know this. Um but if you don't, the language is incredibly powerful and has changed quite a bit in our field. Um we no longer use certain words and thankfully we've taken quite a bit bit of a leap forward um in recent years to kind of de stigmatized are shared vernacular. Um so some important pearls for all of us don't use the word addict. Just strike it from your memory, strike it from your vocabulary and do not use it, ban it addict. We're getting rid of that word. I recommend that you use person with substance use disorder instead. Likewise don't use the term substance abuser or alcoholic patients themselves might refer to themselves as addicts or substance abuser or alcoholic, but we're not supposed to refer to them that way as professionals. Um Likewise, medication assisted treatment should be struck from the record and replaced with just medication for opioid use disorder or more simply medication. The term medication assisted treatment implies that medication is somehow supplemental or optional or a temporary remedy for somebody's opioid use disorder. But we now know definitively that medication is the gold standard for opioid use disorder. So as you kind of move forward in your professional lives, remember we're no longer using the word addict, We're no longer using the word substance abuser. And we're no longer using the word alcohol, diagnosing substance use disorders. I'm afraid. I don't have any fancy advances to tell you about unless you've been living under a rock as a mental health provider. You now know that we use the D. S. M. Five uh substance use disorder terminology. They combined the previous um diagnoses of abuse independence Into 11 combined criteria. Um I've presented the 11 criteria for you hear of a alcohol use disorder. But you can replace the word alcohol with the substance of your choosing in order to decide how to um diagnose somebody with a say opioid use disorder or cocaine use disorder. Um These are 11 criteria. The item in bold is craving or a strong desire or urge to use that is new to the D. S. M. Five. It was not in previous uh additions and it replaced what used to be legal problems associated with the substance. It's very hard to do research across uh national boundaries or for that matter even state boundaries these days when we talk about legal problems because things are so heterogeneous for us when it comes to substances so craving or strong desire or urge to use. Is there uh there are modifying criteria For these use disorders. If you have 2-3 of those 11 you have a mild use disorder. 4-5, a moderate use disorder and six or more a severe use disorder. There was, as I understand it, a bit of controversy regarding mild substance use disorders. The word mild is a term that of course might imply to some patients that it's not that bad. So it feels a little strange to diagnose somebody with, say, a mild cocaine use disorder or a mild opioid use disorder. But nevertheless, these are the modifiers that we have. Um, of course, also when one enters into remission from a substance use disorder, uh, there's both early and extended remission early conveys about three months of abstinence extended. Remission conveys a year or more the word remission for most. Everybody has connotations of cancer. Uh, and my understanding is that was a deliberate inclusion to medicalize the disease of addiction and you all should feel very free in using those terms with patients to sort of underline the medical nature of their disease. Um, so moving on now to kind of the meat of our, our talk here today, I'd like to tell us all about some recent developments in addiction and I'm gonna try as best I can to go from amphetamines to zolpidem. I won't go in that order, but I'm gonna try to include what I think are some of the most resonant and important uh, substances that folks are struggling with today. So, first off, of course tobacco and nicotine. Um, I, I get asked to talk a lot about the opioid crisis. Um It tends to be in most of the headlines. It's in most of the newspaper articles about addiction and to be frank most of the people with money in the in the government are in the N. G. O. Space have money to combat the opioid crisis. But I always feel this need as a addiction medicine physician to kind of sheepishly point out that America has a much bigger problem with tobacco and nicotine than we have with opioids. And that might be a provocative statement. But what I mean is that tobacco is killing a lot more people than opioids and there's no forecasts of the opioid crisis. That suggests it's going to kill anywhere near as many people annually as tobacco. Um Some epidemiological um pearls for you regarding tobacco. It starts off with some good news, smoking rates are declining across all age groups and have been declining for several years. If you look at the smoking rates in the seventies and eighties and nineties you'll see a gradual decline that continues into 2022. Uh That's great news, fewer and fewer people are smoking fewer and fewer people are commencing combustible cigarettes meaning a cigarette that's that's lit on fire with a match or a lighter. Um At the same time we've seen a dramatic increase in so called vaping devices. We all know those as as electronic cigarettes which have gone through a number of iterations as a product. Um, and they've really gained significant market share, particularly among young people. Uh, now there's a very fast moving ongoing debate in policy circles regarding the exact regulatory framework that should govern so called vaping devices. Some people want them regulated by the Food and Drug Administration. Other folks want there to be nothing to do with FDA instead want them marketed as tobacco products outside of the FDA is purview and it really depends on how we conceive of this device. Do we think of a vaping device as a quick device or do we think of a vaping device as a use device? What I mean by that is there's kind of an inherent tension in the way that we think about vaping devices. I personally think that the, the creator of the electronic cigarette deserves to be considered for the Nobel prize in medicine, because if enough people switch over from combustible cigarettes to electronic cigarettes, we are going to save millions and millions of lives and perhaps trillions in healthcare spend. So that is a Nobel prize. If I ever heard one. However, if we think of vaping devices as use devices, there is a dramatic increase in the last several years of adolescent nicotine use almost exclusively through electronic cigarettes. So perhaps the same creator of electronic cigarettes that might be speaking in Stockholm to accept their Nobel might also be considered guilty of creating the most sort of incredible and severe adolescent nicotine use disorder epidemic in human history. So it was very scary as we looked at the sort of dramatic rise of pediatric vaping from 2017 into 2018 and 19. Uh, and you, all those of you who are parents are around youngsters probably know what I'm talking about. But there were these devices popping up all over America across all adolescents, demographics and part of the reason they were so attractive is because they had flavoring in them that was probably deliberately marketed to Children. I'm talking about bubblegum flavoring creme brulee mango uh, flavors like that, those flavor profiles tend not to appeal to a pallet of a, of a middle aged person. Um, so there was significant reform in that space and those devices which were ubiquitous, were quickly pulled from America's storefronts and nowadays it's much, much harder to find. Um, flavoring. Now, flavoring is still available in devices that can't be refilled or recharged as I understand it. So kids are still able to find some flavoring in the one off electronic cigarette category. But what we saw as a dramatic increase in 2017, 2018, 2019 has in fact plateau toad in the last year or so, probably because of some of this regulatory reform as far as accessing these things. So scary. News that's gotten a little bit better in the last year or so, of course when we talk about best practices and clinical management of tobacco use disorders or for that matter, vaping use disorders. We're talking about nicotine replacement therapy. It should be offered at every clinical encounter. It's underutilized. It is available all over America, all over the pharmacy. Um, counseling patients to switch from combustible cigarettes onto a Vape device is simply good advice. The amount of carcinogens in a combustible cigarette is extraordinary. It seems like vaping devices are dramatically safer compared to combustible cigarettes. So recommend that people switch. Uh, that does not mean that they will be successful at coming off of vaporizing devices but they will have at least harm reduced themselves. Of course we have to FDA approved pharma co therapies for tobacco use disorder. Those are varenicline and buPROPion. Hopefully most of you are prescribing them in your clinics, those of you who are practicing clinicians. And then sort of the phrase that I find myself using a lot. It has been well known for decades now that smokers die on average 10 years earlier than nonsmokers. So I would suggest you simply commit that to memory. It's hard to talk to a 20 year old who's smoking one pack per day of cigarettes about the sort of uh, perhaps chance that they might Get a lung cancer diagnosis as a 50 year old, but everybody understands what it means to die 10 years earlier uh, than another group and that's the data when we look at tobacco use disorder. Moving forward, I think the most interesting issue facing the field today is whether or not the vaping industry will gain any traction, regain any traction regarding flavoring. Uh These companies saw a massive rise and then plateau and then decrease in their market share from 2000 and 17 to 2000 and 22. So they are angry. They have plenty of lobbyists on K. Street in in D. C. And I will be curious to see kind of what happens regarding the flavoring saga. Likewise will this massive cohort of adolescents who commenced vaping devices beginning around 2000 and 17? Will they eventually switch over to combustible tobacco use at any scale? Uh If so, that will be very concerning because we will essentially erased all of the gains that we've made in tobacco cessation efforts over the last three decades or so going on Now of course to alcohol, America's other major major problem, Alcohol is responsible for about 95,000 deaths annually. Now, if I were giving this talk two years ago, I would tell you that alcohol still is killing more people than opioids. But the most recent data suggests that alcohol is actually killing less people than opioids. Opioids have surpassed alcohol um in the last year or so. But nevertheless, America has a very um strong problem with alcohol and there are some very worrisome signs uh in the last year or so a year and a half that there has been a dramatic increase in home consumption of alcohol during the pandemic um, sales of alcohol increased dramatically during the so called stay at home orders. And it seems like the work from home movement has interrupted a lot of social moors and other kind of cues that we get about when and how to consume alcohol. Such that people who perhaps otherwise would have abstained from alcohol into the afternoon and early evening because they were in professional settings now might be, you know, pouring themselves a drink at at two or three PM because they're sitting at home and they're not responsible for driving and they're not sort of accountable to anybody in a professional setting. So those of us in the field are a bit worried about what this might mean when things continue to normalize as a society where we'll find ourselves with alcohol use disorder rates. Best practices of course in treating alcohol use disorder involved one of three FDA approved pharmaceutical therapies, we have naltrexone, it's available in a once daily oral formulation or a once monthly intra muscular injection. We have Diesel forum, which is an aversive therapy that causes the patient to get sick when they ingest diesel from and then try to drink alcohol. And then we have a camper state. Um which is a glutamate modulator uh that helps the patient decrease the amount that they're drinking it is reasonable for patients to be on multiple pharma co therapies for alcohol use disorder. Um but I would encourage you to stick with the FDA approved pharma co therapies. There is data out there about other therapies. I've deliberately withheld them from this slide because while there might be some compelling data speaking to efficacy, there is equally compelling data speaking to non efficacy regarding some of those other substances. One of the things that I think are the kind of um most interesting issues going forward when we talk about alcohol use disorder in America is will regulators do anything to curb the so called taste good alcohol movement. What I'm talking about and and I'm an abstain. Er but what I'm talking about are the kind of like um flavor profiles and types of drinks that have now increased dramatically where alcohol is sold products like the one on the left hand side of your screen, which has flavors. Like, first of all, it's a so called hard seltzer and there's flavors like mango, tangerine and watermelon. My understanding, having not tried this product is that it doesn't necessarily taste like alcohol, which perhaps the is was enough of a reason for folks not to consume quite as much in anyone's setting. My understanding is that the company that makes this product has dramatic market share among young drinkers and I'm curious to see if regulators might do anything to uh to kind of weigh in there. It stands to reason that the way that the alcohol industry is evolving. We may arrive at the point where alcohol literally does not taste like anything but can still be consumed in the same way that one might consume a non alcoholic product. I'm enjoying a Schweppes seltzer, It's orange flavored, it has this essence of orange but it tastes like nothing else. Imagine if that were available in an alcohol form where you literally tasted none of the alcohol. Ah another question that I have is, will the so called non alcoholic beer movement catch on. Um for those abstainers in the audience, you may have noticed that there are products out there that now are specifically marketed to folks who don't drink alcohol. I'm talking about non alcoholic beers and other spirits and stuff. Um If you look at some of the advertising they're deliberately going for, I think wellness aficionados, folks who participate in exercise and sports and things like that. Um, curious to see if they gain any traction. Um No, check back in 25 years and we'll see where we are moving on from alcohol to cannabis. It's impossible to drive across America these days and not be confronted with the heterogeneous um market of cannabis. It is illegal in some states and it is legal in other states. It is used by about 18% of Americans. Uh though three and 10 cannabis users are thought to have a cannabis use disorder. Um We are now at all time. Highs among, pardon the pun among american college students regarding their cannabis consumption, 44% of american college students used cannabis during the last year. I find that to be an extraordinarily high number. Um, importantly at the moment, there are no FDA approved pharma co therapies for cannabis use disorder. There are many of prescribers that are using off label FDA uh medications, but none are FDA approved motivational interviewing and cognitive behavioral therapy are the most successful talk therapy interventions of course, group therapy for those that are willing to um go through with it. Importantly, the cannabis that's available for consumption and recreational use these days is dramatically stronger in THC component then the cannabis that was used for recreational consumption In the late 60s and early 70's. So if you talk to a 70 year old who grew up in that movement, they may describe using cannabis as a adolescent or young adult and thinking that it really wasn't that big of a deal. uh if those same people smoked the marijuana that's available for recreational consumption today, they might experience 10 times the intoxication that they were enjoying as a 22 year old. Uh, and so we're talking about kind of a similar product but a very dramatically different strength. Uh and so always important, I think to contextualize the strength of cannabis when we talk about it as a use disorder. Um, what I think is the most important or interesting ongoing issue regarding cannabis is the widespread confusion between so called medical cannabis or medical marijuana and recreational cannabis to say nothing of cannabidiol. Uh most people, if you were to interview them on the street corner would mix up these terms very easily. And in fact, the cannabis lobby, I would argue has deliberately conflated some of these terms in order to get there. Um their legislative agenda passed. And so this is a very fast moving topic. Um what's true today will not be true probably in the next legislative session. And it seems like more and more states are grappling with this in some way. Uh and then of course, overhanging the entire cannabis industry is the illegality of cannabis regarding the federal law. And so we get into these rather strange situations where cannabis is both legal and illegal to consume at the same time. Um and we'll have to see kind of um where things go. I think it's fair to say that the cannabis legalization issue is trending nonpartisan. Um though it was originally perhaps a bit of a partisan issue, I think it's trending nonpartisan. I'm sure this portion of the talk will be dramatically different in 25 years if we were to reconvene. Um moving on from cannabis to sedatives. Sedatives when I what I mean by sedatives are not just benzodiazepine, benzodiazepines, but so called Z type drugs like zolpidem and select open and also a sedative hypnotics, drugs like GHB and Gbl, I would argue perhaps That they might be categorized as America's silent epidemic. Um there are a lot of benzodiazepine prescriptions floating around our pharmacy stores and our medicine cabinets. Um about 4% of Americans have endorsed lifetime nonmedical misuse of a sedative. That's not somebody who says that they had a prescription for clonazePAM, That's somebody who used somebody else's clean as open for non medical reasons. I find that number to be fairly high. Um Not so psychiatrist to be clear are actually not prescribing benzodiazepines at any increased rate. The prescriptions from psychiatrists or mental health providers have largely been steady for more than 10 years. But non psychiatric prescribers have seen dramatic increases in the rates in which they're prescribing Benzodiazepines. So I reviewed a study of about 386,000 ambulatory visits in the United States and they saw the non psychiatric providers were had increased their benzodiazepine prescriptions from 3.8% of all ambulatory visits To nearly 7.4% of all ambulatory visits, which is rather alarming. And of course perhaps America's will definitely America's most popular. Benzodiazepine. Alprazolam saw 17 million prescriptions go out the door for Alprazolam in 2019 and it now resides at number 41 on America's most popular and most commonly prescribed medications. It is the most commonly prescribed benzodiazepine best practices in the clinical management of sedative use disorders I think involves judicious prescribing with patient engagement about the possible possibility that they might develop sedative dependence. I've had to treat patients who alleged that they were never told that benzodiazepines uh could be habit forming and so feel free to have those open and honest and clear conversations with patients at the treatment outset about not just the ability to develop dependence, but also the finite limits on your prescribing duration and perhaps a plan for tapering them down after the treatment is complete. We know now definitively that long and slow outpatient benzodiazepine tapers are much more successful than quick inpatient benzodiazepine tapers. So please feel free to engage in the more longer term paper then in having patients come into the hospital going on from sedatives to prescription stimulants. Crystal methamphetamine and cocaine. Five million Americans used cocaine in 2025 million Americans. Misused a prescription stimulant in 2020 meaning taking somebody else's dextre amphetamine, for example, in 2.5 million Americans used crystal methamphetamine in 2020. These are high rates. And so while a lot of attention has been paid to the opioid crisis, we see amphetamine use continuing to rise. Uh there are of course no FDA approved pharma co therapies for amphetamine use disorder, contingency management, motivational interviewing uh cognitive behavioral therapy and group therapy are the mainstays of treatment For amphetamine use disorder. Perhaps what I think the most interesting ongoing issue facing amphetamines is that one in 20 us Children are currently on a prescription stimulant. I trained in pediatrics before I trained in addiction medicine. I find that number staggering. And I'm curious if that implies that one in 20 US Children has a mental health disorder known as A. D. H. D. I know what I kind of personally think. I'm curious to hear what maybe some of you think, but these are the rates of prescription right now in America. Moving on from uh amphetamines to lesser talked about drug. But I want you to be aware of synthetic katha nils. You may have seen these maybe four or five years ago, they gained significant traction in and around Brooklyn. Uh these are human made stimulants that mimic the mechanism of action of Catherine in itself, which is found in the cotton plant. For those of you who have spent any time in East Africa. You know exactly what I'm talking about. Very widely used substance. I'm talking about caught in East Africa. Um, but it's been sort of marketed here uh, in a synthetic way and is frequently labeled as substances like bath salts or plant food or jewelry cleaner. And it says clearly on the packet, not for human consumption, but it's definitely sold for human consumption. Typically at bodegas and in stores like this, it has an unclear exact mechanism of action, but it's thought to be around 10 times stronger than cocaine. The New York City Department of Health did a number of very provocative but very effective advertisements about the dangers of so called bath salts. A couple of years ago, there were, there was a bit of an epidemic going on. But I think thanks to that advertisement and some crackdown from law enforcement, we saw the rates of emergency room visits um really declined significantly. And then of course the final substance that we'll talk about today. Opioids America right now, I would argue is in its third wave of of the opioid uh relationship. The image on your left, of course is a is Parag Warrick. Uh this was a serum that we could give to youngsters to try to help with colic. America had a problem with opioids after the civil War. That's when hypodermic needles were invented. And then thanks to the pre coarser agency of FDA, we saw opioids disappear from chemist shops throughout America. But then in the Vietnam era, american G. I. S were using heroin at very high rates because it was freely available in Southeast Asia. And so a lot of them came home with very severe opioid use disorders. In fact, many of them were the original patients in the methadone maintenance movement. Uh and thankfully with the proliferation of methadone clinics, we saw a gradual decrease in opioid use disorder. And then of course the third wave the image on the right now iconic of two people slumped over in their driver's seat with the youngsters face blurred out in the back. Um this is of course a uniquely american epidemic. I've shown the americans the share of population of America and the pleasing mount Sinai color palette on the left and you'll note that while we represent a rather small amount of world population we guzzle down an extraordinarily outsized amount of the global opioid supply. I'm not sure what it means about americans in their quest for opioids or thirst for opioids. But this is what the data is. Um You've seen a number of graphics about the opioid crisis. I'll present you with only this one. Uh This shows the real exponential increase of deaths related to synthetic opioids other than methadone. That's the really steep sort of royal blue line. Um And that's of course primarily driven by fentaNYL and fentaNYL analogs which are adulterating the opioid supply best practices and clinical management of opioid use disorder. To be very clear include buprenorphine. naloxone which can now be prescribed without the need for a waiver course. So please notify the D. E. A. That you want to prescribe buprenorphine and you will be able to prescribe buprenorphine up to a certain threshold. Likewise, naloxone rescue kits are now available throughout the country and there are a number of so called opioid overdose prevention programs. When naloxone is introduced into a community deaths go down from opioid overdose. So naloxone is fundamentally uh something that works when we talk about combating opioid deaths. And then of course fentaNYL test strips which allow somebody to test the heroin. Perhaps that they fought and make sure that it doesn't contain fentaNYL. A brief word for you if I could about so called safe injection sites and feel free to ask any questions about these. But these have gotten a lot of attention in the media in the last a year or so. And of course there are now two as I understand it, so called safe injection or safe consumption sites operating in new york city. Um the concept of a safe consumption site is based around the idea that folks are using their substances in very unsafe manners, in unsafe places, perhaps the restroom of a fast food restaurant. Um and that's very dangerous. And so allowing folks the dignity to use their substances in a safe and humane space with accompanying nursing uh, availability allows us to decrease harm. Um that being said, I find safe consumption sites kind of sad if I'm being honest. Um and I'm troubled that there are perhaps going to be more safe consumption sites popping up all over the place and less treatment centers. Um I was rounding on somebody this morning who is staying here in the hospital because we need to find this person a buprenorphine prescriber and I find it scandalous that we have a place for this person to use heroin, but we don't have a place for this person to go get buprenorphine in their community. So I would suggest that safe consumption sites represent the absolute floor, maybe even the basement of what we can do for folks that struggle with opioid use disorder, but they are not a treatment. They are not a ceiling. We have to do better for folks with opioid use disorder. Um I'll be curious to see if any of you have any questions or comments about safe consumption sites. Um I think they represent one of the most interesting issues. I'm not sure if they're here to stay. We'll see where things go moving forward. Um And then this question of fentaNYL um fentaNYL is all over America now and it's essentially poisoning the heroin supply. Um I'm curious if the cartels who manufacture heroin and fentaNYL for that matter are going to actually fix the fentaNYL problem for us. Ah Drug cartels follow business principles just like any other business and it makes absolutely no sense to kill off your customer. And so I'm imagining that because fentaNYL is a tricky substance, it's a very strong substance and because it is very easy to um produce and smuggle. I think they're actually just screwing up the chemistry regarding the dozing and myself and others are wondering if perhaps in a few years they will get it right in that they will allow somebody to consume fentaNYL but not accidentally die from a fentaNYL overdose. We shall see going forward. So my plea to all of you before I wrap up is to consider treating addiction in whatever type of mental health field you practice in. Um this is the sad reality of american treatment rates regarding addiction compared to depression, hypertension and diabetes. Most people with addiction don't get treated for addiction. And I personally find that sad. Likewise, we are a small workforce in addiction and so we're here for you for referrals. But I would encourage you to treat patients right where you're encountering them. If you do want support from Mount Sinai, the number for Mount Sinai West addiction institute and Mount Sinai Beth Israel's addiction institute is listed here for you. Um Where might addiction be in January of 2047, Where might I be in January 2047? I don't know. But my imagined utopia is that in January of 2047 methadone is no longer available for opioid use disorder. And there are no opioid treatment programs because patients can go to the pharmacy and get buprenorphine products just like everybody else that goes to the pharmacy for any problem that they have. Um I hope that cannabis is federally regulated to guarantee quality control of the THC CBD ratios. People should know what it is they're consuming if they want to consume cannabis. Uh, perhaps the temperance movement in alcohol has gained cultural exceptions beyond religious and recovery circles. It's awkward to tell people that you don't drink most of them follow up with a question about if you're um in recovery from an alcohol use disorder. Maybe that movement will increase going forward And not drinking will just be considered culturally acceptable. Uh tobacco consumption rates, hopefully in 2047 will be at all time lows with hopefully a commensurate rise in people using Vape devices which we know are dramatically safer. And perhaps hopefully people who choose to still inject opioids in 2047 will know exactly what they are injecting and will not be at risk of accidental opioid overdose. So, our experiment has concluded, concluded, maybe some of you were brave enough to write down how many times you went to your cell phone and perhaps you're ready to answer to yourself Whether or not mobile phones are actually addictive. Thank you for participating in that and thank you for listening to me. I've left you with a painting of my favorite artist Winslow homer. This is called Northeaster. Uh and it was painted in 1895. Here are my references and I will stop sharing and open things up for questions. So one person was brave enough to state that four times to their phone and that yes, it was addictive. You know, there are treatment centers in South Korea and Japan for so called internet addiction. Um, I'm curious to see kind of where things go moving forward in America. Um, another question could better screening for personality disorders, help in treating substance use disorders. Probably presumably um, one of the big challenges of addiction is that most patients are not getting cared for right. Most people don't actually come to see me or to see you all, they go to see their primary care doctor. And the primary care visit, depending on the dataset you look at is most likely to be less than seven minutes in duration. So how does the physician, how does she deal with like your hypertension? You're hyper lipid e mia some um, you know, routine need for a screening exam and also perhaps some substance use disorder. So we've seen um rollout of mandatory addiction screening across primary care settings. Um, I think more screening is always a good thing and presumably personality disorders are, are problematic when they're not diagnosed. So, so yes, I would, I would agree with you other questions. Feel free to ask them in the question and answer session a question about a vaccine for addiction. Um, you know, this has been spoken about. There was a fair amount of research done regarding a so called cocaine addiction vaccine. I'll be honest, I'm kind of cynical about how that might work. The idea that you could somehow vaccinate somebody against um a use disorder um is hard for me to conceive of that being said. I think, you know, there are clearly Jenna typical differences across substance use disorders. And so one of the most disappointing things about our field is how little we have to offer in regards to pharma co therapy or tailored treatment. If you go to a tumor board meeting, they're talking about cellular differences in people's tumor and their tailoring their treatment with that amount of specificity. Uh If you go to an addiction treatment center to be honest, whether you say you've got a cannabis problem or a cocaine problem, you're probably gonna get put in the same type of group therapy environment. So we have to do better than that as a field. And I think some of the work with um with genotyping will go a long way towards towards helping with that. Likewise, there's a question about deep brain stimulation in addiction. Absolutely. You know there has been some early research in that. I think the concept that patients are going to participate in any sort of um neurosurgery at any sort of scale is unlikely to me. But I'd be very curious to see where the kind of transcranial uh world is regarding addiction in five or 10 years from now. Um Very intriguing research out and data on treatment of other mental health problems. I think it stands to reason that um addiction could be uh in play for for them question about three and 10 cannabis users meeting criteria for cannabis use disorder and what the rate is for alcohol use disorder among people who consume alcohol. I do not know that. Uh So I apologize. I don't know that data off hand. One question um that's come up about a buprenorphine prescribing. So uh when buprenorphine came to the market in America the D. E. A. Not the FDA. But the D. E. A. Required a mandatory prescriber. Of course that you could take in a number from a number of different vendors. Uh And unfortunately that led to not that many physicians being being licensed to prescribe buprenorphine at the end of the outgoing administer at the end of President trump's administration, they took off the need for a D. E. A. buprenorphine waiver. My understanding is that they took it off in a manner that was not consistent with the way things are supposed to be removed from the federal registrar. And so the biden administration reinstated the need for the waiver and then they took it off via a different mechanism. So right now you no longer have to take a course. You do have to notify the FDA that you are going to be prescribing buprenorphine. That seems bizarre to me. But that is the current state of affairs. So everybody is welcome to prescribe buprenorphine. It's a real shame that there are not more buprenorphine prescribers because patients are often times kind of fleeced for their prescription as you go north up the Hudson it becomes harder and harder to find a buprenorphine provider that doesn't just accept cash only, which I think is is rather um outrageous, there's a question um about what are indicators that a person needs specialized addiction treatment for their substance use problems. Um That's a great question, I would say if they failed primary care treatment of their substance use problem. Um As a rule we don't say no to patients here at the patient referrals here at the addiction institute. Um but we are oftentimes overloaded with patients. And so just as we wouldn't send every diabetic to an endocrinologist, we can't send every addiction patient to an addiction treatment center. Likewise, it's not feasible for a lot of patients to travel to come and see us. So I would say if you've tried to treat somebody and whatever practice you're at and they have failed uh then that would might be a reason to refer them. Of course if somebody needs hospitalization. Uh We're fortunate enough to operate a number of inpatient detoxification and rehabilitation units here at Mount Sinai and happy to take any and all patient referrals for that. One of the challenges of addiction pharma co therapy is that it's not prescribed. So medications like naltrexone and acamprosate and isil from are not prescribed by internal medicine and family medicine doctors at any scale. And and that's really sad. I've gotten a number of referrals from internist and the sole reason for the referral is like needs diesel from or needs naltrexone. Um and I always try to encourage them to just be brave enough to prescribe it in there in their clinic time for a couple more questions. Um long acting injectables. Um You know, I find that to be very intriguing. So right now we have a long acting injectable form of naltrexone that lasts for about 29 or 30 days. The downside being, if the patient doesn't show up for their next injection, they have gone from being um unable to uh to inject heroin successfully because the mu opioid receptor is blocked too. Now suddenly having those receptors be open and perhaps their tolerance is much lower than it used to be. So, once monthly injectable naltrexone kind of scares me because each month I'm worried if the patient is going to show up. Um but super long acting formulations, I would maybe change the game quite a bit. What if I could give somebody a shot once a year and they wouldn't be able to uh inject any opioids. That's very intriguing. I think the the drug courts that are out there would find that um very intriguing um as well as far as what training might be out there. Um uh for buprenorphine, the american Society of addiction Medicine and the american Academy of addiction psychiatry are the two main vendors that offer a lot of buprenorphine coursework. Um and I would encourage you to check that out. Uh And then finally, one last question. Um my thoughts on legalizing all substances. Um You know, there's a lot of fanfare that gets made about what Portugal did and and what Scandinavia did. Um Those are very homogeneous electorates for one America is nothing like those places. And so, um, I think it's unrealistic politically. Uh likewise, I think personally that America doesn't need necessarily more than three or four or 17 legal intoxicants. I think the sheer illegality of substances is enough to dissuade a lot of um substance initiates um, talking about young people that being said, I think putting people away for drug related crimes into prisons is a complete waste of our resources and and totally unethical. So I am for decriminalizing substances. I'm not for legalizing substances. I think that's all of our time. Friends. So thank you so much for coming to the lecture. Look forward to seeing everybody in the next series of Frontiers and psychiatric treatment on behalf of the Department of psychiatry at the Icahn School of Medicine at Mount Sinai. Thank you so much and have a great rest of your day.
