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Interviewer: It's a situation that no parent ever wants to deal with, but their teen has run away. Once you have located your teen and got them back home, what do you do next? How can you make sure to resolve whatever is going on and why they ran away in the first place?

To help us understand the situation and what steps to take next, we're joined by Amanda McNabb. She is the quality improvement and training manager at the Community Crisis Intervention and Support Services with Huntsman Mental Health Institute.

Amanda, it is a situation that really I think most parents fear sometimes. And when it happens, what do you tell parents, and what is the first step that they should do when they get their kid back?

Amanda: Usually, when a parent is dealing with a situation in which a teenager has run away, one of the things that we really suggest is having another support system with them. So maybe having a mediator, a family friend, somebody who can come in and help keep the emotions that are going on at a minimum so that the conversation can happen about why.

A lot of families will then just say, "Don't do it again. This isn't good. Now you're going to be in trouble." And they don't really focus on what was the reason behind the idea of running away for that teenager.

Interviewer: What are some of the common reasons that they would run away? I mean, I know that every family is different, but with all the amount of people that you interact with, there have got to be some common threads.

Amanda: Absolutely. And those common threads can run from just a teenager who doesn't like the rules in the house and wants to have some extra freedom or things like that. It may be that they're dealing with a lot of pressures and feel like between school and home and friends and everything else that's going on, they just can't handle it and need to get out of the situation.

There may be some concerns about gender identity or feeling accepted for who they are. And that may be another reason that a teenager might leave the home or leave the situation.

The teenager also could be dealing with mental health, depression, anxiety, maybe thoughts about suicide. And the idea of running away is the first step towards "What do I do with my mental health itself?"

Interviewer: So Step 1, get a mediator, get someone in between, calm down some of the, I'm sure, very high-intensity emotions that are happening in that situation. What are some strategies and next steps that we can share with parents who are trying to help identify what is going on with their teen or with their home situation and where can they go next?

Amanda: I think in the beginning, as you said, being able to calm down and really bring those emotions back down to where everybody can actually communicate with one another.

When we're in a high emotional situation, we're not often listening to the other person. We're not having a true conversation. We're always thinking about, "How am I going to respond?" Or with teenagers, it's, "Okay, how am I going to hold this person to consequences for their actions and their behavior?" And instead, we really want to focus more on, "Okay, what is going on in this situation? How can I try to see their perspective?"

With teenagers, and really adults, we each have our own perspective on the situation, which doesn't always match up with somebody else. So we want to focus in on really being able to use those reflective listening skills and those active listening skills to communicate and say, "Tell me more about what's been going on," so that we can come to a positive conclusion and hopefully make things better.

Sometimes with that piece, we really will say to families and parents, "Call the crisis line." We are here not just for suicide or major mental health concerns. We are here for crisis.

And when a family has a teenager who's run away, I define that as a crisis. That is something that is creating a lot of discord and emotional upheaval for a family. And so we're here to try to walk you through those next steps or be able to intervene and say, "Maybe we need to do a mental health assessment on the individuals involved to make sure that everybody is in a safe place to have those conversations."

Interviewer: So with a service like the crisis line with the Huntsman Mental Health Institute, for some people, this might be the first time they are reaching out to a service like this. What can they expect when they call that phone number?

Amanda: When they call, usually, you will get ahold of one of our certified crisis workers who will then just ask, "How can I help you today? What is going on that made you call in?"

And once we've started to define what's happening, what's the situation, what is the actual need in the moment, and sometimes that need is just, "I need to vent. I need to talk about what's going on," or it could be, "I have questions about what resources are available to me," then we can start to collaborate together with the caller and say, "Okay, here's what may be available. Here's what may be an option."

And it doesn't always have to be the parent. It can also be the teenager. The teenager is always welcome to give us a call or use our SafeUT app or anything like that to reach out to one of our crisis workers and say, "I'm struggling with what's going on. I need help." And hopefully, they get a warm reception and are able to feel comfortable talking about some of those issues that maybe they haven't been able to bring up with other people before.

Interviewer: Now, who is the crisis line for and does it cost anything?

Amanda: The crisis line is for anybody and everybody. It is free to the consumer. We are here 24/7. Same with our SafeUT app, which is just a texting way of getting hold of the crisis workers. And it really is for parents, teenagers, anybody who's seeking that extra help.

Interviewer: So for a parent who is dealing with a runaway and it's time to figure out what's going on and heal together, what is the number to get in contact with the crisis line?

Amanda: Parents can reach us at 1-800-273-TALK, or the national number at 988.

Interviewer: Just 988?

Amanda: That's all it is.

Interviewer: What should you do if you suspect your child is doing drugs? It's a scary moment for any parent. I mean, how do you know for sure? What's the best strategy for talking to them about it? How much can you do on your own and when should you see a professional?

I'm going to answer those questions with our expert today, Dr. Mary Steinmann. She's a psychiatrist who specializes in child and adolescent psychiatry.

Dr. Steinmann, let's start at the beginning here. We're going to cover a lot of ground today. But what is the first thing a parent should consider if they have a reason to believe that their child may be using some sort of a substance?

Dr. Steinmann: So I think there's definitely a difference between experimenting with substances and actually developing a substance use disorder. And so it can actually be fairly normative or expected behavior in children and adolescents to be curious about or experiment with substances. But we also know that using substances can really place individuals at risk of developing later substance use disorders. So it's something that we want to take very seriously and be able to help parents identify signs in their own children that may warrant additional questioning or additional evaluation or perhaps even getting additional help and support and resources.

Interviewer: Yeah. So if experimentation can be normal . . . I would imagine as a parent, as soon as I saw my kids or had the idea my kids were using drugs at all, I would be like, "Oh, they've got a problem." But you're saying that that's not always the case?

Dr. Steinmann: That's right. It's definitely concerning behavior. It's not something that parents need to be complacent with. I think it's important to actually dissuade substance use and to talk to kids about the dangers of substance use and the potential consequences of substance use, because there are a lot of them.

Kids don't tend to think about long-term risks very much. Their brains aren't hardwired to think about long-term consequences until, honestly, sometimes their 20s. And so that's where I think it's helpful for parents to kind of take a role of, "These are the rules in our house. This is what our views are. These are what our values are. Here's what's acceptable and unacceptable behavior for our house. But I am also here and open to answer questions or listen to what you have to say. Or if you find yourself in trouble, intentionally or unintentionally, I am here for you."

Interviewer: So I'm a little confused. If you suspect that your child is using a substance and maybe . . . I don't know. Do parents generally have a good idea if it's early on? When you said, "Don't be complacent," do you just kind of sit back until you start seeing a problem develop, or do you jump right in as soon as there's some sort of substance use and say, "I understand this is just a natural thing. If you ever want to talk about it, we should"? I mean, I don't quite understand that differentiation.

Dr. Steinmann: I think a lot of the differentiation depends on families, right? So there are some families where even alcohol use or smoking is not a practice in the home, and so there might be a different baseline for a family addressing substance use and experimentation and how they approach that topic in their children, versus maybe a family where there is recreational alcohol use, or occasional nicotine use, or what have you. And so there are some baseline cultural differences that I think go into play.

We certainly want to educate our kids up front about what the dangers are, and say, even if you're comfortable as a parent, "This is kind of my own experience with using substances," talking about responsible use, if that is a value in your home. And in other homes, that might not be acceptable at all.

But kind of laying down, "This is what our family values here, our baseline. I understand you may be tempted to experiment with things. Here are my concerns about that."

And then also knowing your child and knowing their baseline and being able to identify if they're starting to behave differently, if they're starting to hang out with a different peer group, knowing what their peer group is and who their friends are. Having those consistent expectations is really important, but then also providing that guidance, that education, "This is what we value in our family."

That may be no substance use whatsoever. That may be, "This is the concern I have about you using substances right now as an adolescent." And that's the stance I tend to take as a child and adolescent psychiatrist. It's, "I'm concerned about the effect that any substance has on your developing brain. I understand you might be tempted to use. I discourage that, but I am also here if you have questions," and not to shut down that conversation prematurely.

If curiosity develops, if they're like, "Well, I see you drink all the time. Why can't I?" being prepared to kind of have those discussions so that then that increases your chances of having your child actually be honest with you if and when they start down that path, and being available to support and guide and eventually seek help, if needed.

Interviewer: So it sounds like if you suspect your child is using substances, and maybe they're just at the point where they're just kind of experimenting, that's a great invitation to have a conversation at that point?

Dr. Steinmann: Exactly. And even before use. I think sometimes we overestimate the age at which kids may actually be exposed to substances in schools, but we may be having these conversations too late sometimes and setting those expectations too late sometimes.

And so being aware that a lot of times, by middle school, kids are already exposed to peer groups or other folks who use, and maybe thinking about this for themselves. We may be wanting to even have those conversations earlier, depending on the environments in which our kids socialize.

Interviewer: And it sounds like a parent's kind of mindset is super important for this first conversation from the standpoint that I think . . . Well, first of all, what are some of the reactions that you see parents have when they find out their kids are using drugs? I can imagine there could be some anger that is probably born out of fear, because drugs can be detrimental to somebody's life. There's probably the thought that only bad kids do drugs. Are there some other reactions you see? Or what do you see?

Dr. Steinmann: Fear is a big one. And I love what you just said as far as anger often being born out of fear. Anger is a very reactive emotion. We all get angry over a lot of things. But if we dig deep, a lot of times it does come from that fear, either because we're terrified of . . . We just want the best for our child. We want them to grow up to be the best version of themselves that they can be, and there are serious consequences to problematic and ongoing substance use. There can be dangers to even intermittent substance use. And so fear is a very, very common and normal response to parents.

Also, that anger component of fear or fear that gets manifested as anger tends to be the emotion that then puts our kids on the defensive and shuts them down.

And so even though it's a completely valid emotion and an understandable one as a knee-jerk response on the parents' end, it may be the one that we want to kind of work on our own response to continue to invite that conversation instead of making the child feel that they're a bad kid because they thought of going to a party with their friends or even tried to ask a question or to get clarification for themselves or to seek help. Very often it's that fear of anger and punishment that keeps kids from seeking help.

Other common responses I get are often, "Only bad kids do that." And I think probably what parents often mean by that is the behavior is certainly concerning and undesirable, but that doesn't mean our child is a bad kid. There's a difference between the behavior and who someone is as a person, and sometimes kids can overly internalize that.

And so, if a parent's response is, "Well, only bad kids do that," or, "My kid possibly can't do that," that's a form of denial that probably needs to be addressed, especially if you're starting to see telltale signs of substance use or behavior changes. And we can talk about that in a little bit.

Or it can be, "Well, why are you judging my friends? They're not bad people. I know who they are. You don't," which can also raise defensiveness and unwillingness on the part of the child to engage more in that conversation.

Interviewer: Let's say a parent has suspected that their child is using a substance. They've had the conversation, they followed your advice, but then they start noticing, like you mentioned, some personality changes or they start becoming more concerned that it is escalating to a different level. Is that the point that you would get your child help, or is there another intervention that a parent would do first?

Dr. Steinmann: I think there are a couple different routes to go. So we have that conversation. Maybe we were lucky enough to have that conversation upfront before use even started, and the conversation had exactly the effect that we intended to have, which is to deter use. That's kind of the best possible scenario. "Hey, let's talk about the dangers of this." The kid acknowledges, "Yep, that's not a behavior that is good for me," and we move on.

Maybe experimentation happened, and then I think it's important to have the conversation potentially of, "What was that like for you?"

Understand what drives a behavior. We don't tend, as human beings, to engage in behaviors that don't work for us, especially in the short term in teenagers.

And so some may admit, "Hey, I've been really stressed out and I tried alcohol," for example, "and it helped me to feel better." Wow. As a parent, I would want to know, "Well, what's been stressing you out? Is there something else that's healthier that we can kind of engage in? Because, once again, I have my concerns about kind of going this route to address stress and manage stress. Are there different things that we can work together on to help you out with?" and seeing if we can get to the underlying driver of that behavior.

If the behavior continues despite, "Hey, we have a house rule we don't smoke, we don't engage in underage drinking, we don't engage in any forms of substance use" . . . which again is my stance, really, as a physician, because I'm concerned about that brain development . . . and the use continues, then we might need to consider additional types of interventions and understanding what's underlying that continued substance use.

I'm also going to be keeping a close eye on function. Function is really, in psychiatry and in medicine and mental health, what we look for to really start to make that distinction of, "What's the difference between substance use and a substance use disorder?"

And when we say the word "disorder," what we really mean is there is some impairment in academic functioning, in relationships, and that could be friends, family, etc. Are we engaging in additional risk-taking behaviors? Are we putting ourselves in safety risk by result of use? Are there legal consequences? Are we carrying vape to school, for example? All of those things would be red flags for more serious problematic use and possible disorder that might warrant additional treatment.

Interviewer: When a child is using a substance, is there generally some other underlying cause? Is it really truly just kind of a symptom of something else going on? I mean, either experimentation out of curiosity or an underlying condition, or are there other reasons?

Dr. Steinmann: It can be all of the above, honestly. What can start as experimentation can then kind of just spiral out into use for other reasons.

Some people may never engage in use but may find themselves starting with symptoms of anxiety or depression and then are just trying to find a way out of feeling that way. And they may have tried other things or talking to friends or things like that, or hear that, "Well, taking this has helped for me. Maybe it would help you too." And so it can sometimes be a chicken-and-the-egg type of scenario, honestly.

Interviewer: All right. Sounds like we have two steps so far. A parent suspects their child is using a substance, they have a conversation because it's just experimentation. Then that behavior continues, they have another conversation again asking this time, "Is there something else going on?" or, "Why are you using it?" or, "How does it make you feel?" reiterating the rules or the policies in the household. What would be the third step if it continues on past that point?

Dr. Steinmann: I would say then it's probably time to get some external support and some help. And honestly, it's never too early to get external help and support. Again, if this is just a conversation that, for any reason, a parent might struggle to have with their child or not know how to approach it, it is perfectly fine to seek out professional help to help learn how to have that conversation.

And there are a lot of other internet resources that are available if you don't have the ability to talk to somebody.

But I would seriously then consider looking at other resources, including a therapist or a primary care physician.

Not all cases of substance use disorder have to go directly to a psychiatrist, just like not all cases of depression and anxiety need to go to a psychiatrist. Sometimes talking with external supports, such as your child's pediatrician or primary care provider, someone that has an established relationship with them and knows them, can be a good middle-ground next step to get additional support before jumping into subspecialty options, although those are definitely certainly available.

Interviewer: Is there a negative message given to a child when you say . . . because there's a certain weight to saying, "All right. We've got to go to the psychiatrist now." You know what I'm saying? For this problem. That comes with a whole bunch of other stigmas.

Dr. Steinmann: It can. And unfortunately, getting mental health care and having mental illness needs is still really stigmatized in our society. I think that's why I generally recommend starting out with primary care if someone is having questions.

Now, granted, there are times where you would want to bypass primary care. For example, if your child has been absolutely refusing to go to school or you're noticing that they're skipping school a lot or they're getting suspended or even expelled for issues related to substance use, or you're concerned that there's an imminent safety risk, such as heavy use or heavy binge use or physical consequences from that, or you suspect a really severe underlying driver for substance use, including depression or anxiety, perhaps even things like suicidal thoughts, or if you suspect another serious mental illness, those would be things that would be quite appropriate to go up to a higher, more specialized level of care.

It can take a while to access the mental health system as well, and you don't want to get stuck in the lurch while your child is really struggling, especially if their imminent safety is on the line.

Interviewer: When you talk about substances, drug use, what does that entail for you as a physician and a psychiatrist?

Dr. Steinmann: That's a great question. I think a lot of times, when we talk about substance use, our minds automatically go to the hard stuff like heroin or cocaine or methamphetamine. We also think about alcohol and nicotine and marijuana, which are a little more readily available.

But there are also, especially with teenagers . . . Think about access and what you're more likely to be able to get a hold of or afford. Or what are the underlying concerns that might be problematic in teenagers, such as anxiety or depression?

This is another great example of a misperception, actually. Sometimes we think, "Well, my child is very high functioning and they do great in school. They can't possibly have issues with substance use." But I work with a lot of teenagers and young adults who may have some mild ADHD or anxiety who are very high performers and may feel compelled to be even higher performing. And so they may actually get wrapped up in overuse or misuse of cognitive enhancers, like caffeine or prescription stimulant medication.

And so having an idea of kind of the breadth of things that can be misused or abused is important.

It's scary and it can be overwhelming to think about, but it's important to, again, think about those underlying drivers of behavior and the type of direction that might lead even into substances we might not typically think about as being abusable.

Interviewer: And some of these ways of talking to the children about substance abuse might be kind of against a particular parent's parenting philosophy. We are all raised in our own ways by our own parents, and a lot of times, that's the way we raise our children. Is this evidence-backed stuff? Should somebody just go ahead and use their instincts instead going into this conversation? What are your thoughts on that?

Dr. Steinmann: I think that parents are the experts on their children, and so using your instinct can be a very powerful tool.

If you are noticing that your child is not acting like themselves, I do think it's important to ask more questions and probe. And again, by asking, you're kind of almost opening the door to, "I'm interested, I'm curious about you. I care about you."

Sometimes the hardest thing we can do, as parents, is to open the door to conversations that we might not be comfortable having, but by doing that, we're actually modeling for our kids that it's okay to talk about these things, that maybe their assumption that we're going to blow our stack or over-assume might be unfounded, that we want to be and try to be safe people to talk to because we have their well-being at hand.

I liken it in some ways to talking about suicide, for example, and suicide prevention. There's significant data that shows that simply asking about suicide does not increase the risk of suicidal behavior. And I think the same is very true for substance use.

Just because you're asking doesn't mean that you are giving permission or suggesting that they should engage in that behavior. All asking does is signaling your child that, "Hey, I'm aware that this is a problem and I want to be a person that you can rely on and trust to talk to about it."

Interviewer: For a parent listening to this interview that wants to go on to get some more information, what are some good reliable sources that they could go to online to get some help framing this or figuring out the approach or whether or not they should be concerned at this point? What do you recommend?

Dr. Steinmann: For reputable sources on the internet . . . because you're right, there are a lot out there and it can be really overwhelming to kind of weed through and find the best sort of reputable information. I really like the Substance Use Resource Center through the American Academy of Child and Adolescent Psychiatry. The Substance Abuse and Mental Health Administration, or SAMHSA, also has a lot of good resources.

And something that I found fairly recently as a resource, that I thought was very parent-friendly type of language, is through the Child Mind Institute. And they have various questions about how to talk to your teen about substance use for parents who may not be sure on how to start that conversation.

Interviewer: We know here in the United States, the opioid crisis and the addiction to those drugs is a real concern. But when it comes to the medical side of things, what is opioid addiction?

Joining us today is Dr. Elizabeth Howell. She is an Associate Professor of Psychiatry and the Director of Addiction Psychiatry and Addiction Medicine Fellowship at University of Utah Health and Huntsman Mental Health Institute. Now, Dr. Howell, just to kind of start out, like, when it comes to your perspective, what is opioid addiction?

Dr. Howell: Well, everybody has their own thoughts about it. But if you want to look at the official definition, we would look at something called the DSM, the "Diagnostic and Statistical Manual 5th Edition" of the American Psychiatric Association, and they have 11 criteria. And if you have two or more of those criteria, you have either mild, moderate, or severe opioid use disorder or other use disorders. But I think a simpler way to think about it, because I don't think the general public goes around memorizing the DSM-5, is to think of it as loss of consistent control over use of a substance, continued use in the face of adverse consequences, compulsivity or craving. And then the other part can be denial, and it doesn't mean that you don't know there's a problem, but you're not in touch with how many ways the use of the drug is affecting your life.

Interviewer: So those are behavioral things that we're looking for.

Dr. Howell: Right.

Interviewer: But when it comes to, say, biologically, physiologically, I guess, what is going on when we get into this? Because I've heard that it's not actually the drugs that are causing the addiction.

Dr. Howell: Right. The addiction is actually in the brain. And, you know, there is no addiction without a brain, so we don't know in the field if there's something different about people who get addicted before they ever use or if the drugs cause the brain to change or both. And that's a big mystery. There's actually a really neat study that we're part of at HMHI, called the ABCD Study, that may shed some light on that. But for now, we don't have the answer to that. So what we do know, though, is once people have started using regularly is that the brain is different and it doesn't react the way that the brain of someone who doesn't use drugs reacts.

So, for example, people tell me all the time, "I don't understand why they don't just quit using because I can have a drink and then stop." But the point is that that person's brain is very different than the person's brain who is unable to stop when they start. And there are a lot of different brain changes that happen, and it's interesting because you can actually track some of these brain changes to specific behaviors. So, for example, you know, being out of touch with the consequences of your actions, or not having strong feelings about anything except drugs, those can all be traced to different parts of the brain. So it is behavioral, but behavior comes from the brain and addiction and drug use change how the brain reacts to normal things in our lives.

Interviewer: When we say that the brain is different, I guess, does that mean that there are certain people that are more susceptible to addiction? Does that mean that, you know, is it nature? Is it nurture? Or are certain people just born that way? Do people, you know, grow up leading towards addiction?

Dr. Howell: It's really both. About 40% to 60% of the risk is genetic. That's only 40% to 60%. Some of the other risk comes from life experiences or, you know, where you grow up. If you grow up in a family where everybody else is drinking, of course some of that is genetic, but it is also environment and you are exposed to that. But also, trauma is a huge risk factor for addiction. Trauma, traumatic experiences in childhood, especially, can change the brain in a way that you're much more susceptible to either wanting to use, or when you do use, losing control over your use.

Interviewer: Thinking of those patients, you know, or maybe a loved one is listening right now and they have someone in mind, what kind of treatments are available? Because, I guess, one of the things I want to ask first before you get fully into the treatments is, is there a cure for opioid addiction?

Dr. Howell: There's no cure, as I think of a cure. There is treatment. And this is very similar to other illnesses that we treat in medicine. So, for example, if you have high blood pressure, there's probably no cure. You can definitely treat it. You can do things. You can lose weight. You can exercise. But even people who are very thin and very athletic can have high blood pressure. It's a medical condition. You can do everything you possibly can with your life and you could still be suffering from addiction. You might try everything. You still have, for whatever reason, a very high risk of continuing to be unable to control your use, having craving, etc.

But the treatment that we have tries to at least arrest the process. So for opioid use disorder, one of the most effective treatments we have is medication for opioid use disorder, and this can be kind of controversial for some people, but methadone, buprenorphine, naltrexone, are all different medications that they work in different ways a little bit, but they do help people stabilize so that then they can get their lives back together, and then the behavioral treatments can work a lot better when your life is more stable.

So, really, treatment has to be a combination of things, and it doesn't happen overnight. There isn't a magic medicine, a magic bullet as people call it, to treat any kind of addiction, especially opioid addiction. And the medications only work when you're taking them. Once you stop taking them, your brain is still different and you can start having craving years after you ever used an opioid. And that's the disease if we want to call it a disease, or that's the difference in the brain is that the brain is always going to be seeking the drug even when the other parts of the brain know that it's destroying someone's life.

And I hear this from patients all the time. "I know this is killing me. I don't want to use, but I can't stop." And that's the terrible conundrum that people have when they're in the middle of their addiction and they want to stop. So our treatments are really to help them be able to stop safely and then try to get their lives back together and hopefully heal up some of the brain changes that have happened over the course of their addiction so that they can live a life without being addicted.

Interviewer: So now that we know a little bit more about opioid use disorder and how some of the physiological things that actually comes with this type of addiction, if there is a listener that either themselves or someone in their lives, you know, might be going through this kind of struggle, where do they start to get this treatment, to get this kind of, you know, get on the road to recovery or, I guess, remission if this is a disease?

Dr. Howell: You know, sometimes you can go to your primary care doc or provider and get some help. There are more and more primary care providers who are prescribing medication for opioid use disorder. But then there are others who don't or they don't feel comfortable with it, or they don't know that much about it. And so, then, you would go preferably to an addiction specialist of some kind. The fellowships that I run, the Addiction Medicine and Addiction Psychiatry Fellowships train physicians who finished a residency in a primary specialty to be addiction specialists and to be able to treat regular opioid use disorder and other addictions, but also how to be specialists for people who have really complicated problems, because often we see the patients who've been through many different kinds of treatment and nothing has really taken hold for them and we need to get a little bit more sophisticated or refined about how we're treating their specific addiction. And the medication is only part of it. By no means is it the only thing that you have to do. You can't just throw a medicine at somebody and expect that their opioid use disorder is going to be just fine. It doesn't work that way.

So what you would do is if you, you know, you could start with your primary care provider. If they are not knowledgeable or comfortable, then, you know, one of the things that you can do is you can call, actually, our University HMHI crisis line and they can often help people get connected to treatment because you may need to go in the hospital. It may be that severe. And yet you may just need outpatient treatment, and they can help people sort that out and figure out what's needed.

We also have a recovery clinic over at HMHI, and it's staffed by addiction psychiatrists and addiction medicine specialists and therapists and other staff. And our trainees also work there, and they can help with evaluations and recommendations for treatment. And if you can get treatment at HMHI, fine. If not, if your insurance doesn't cover it there, then we can help send, you know, refer you out to wherever you can get the treatment with your insurance coverage.

Interviewer: And for a listener who might not be in the state of Utah, I assume that there are similar crisis lines in other places of the world?

Dr. Howell: Right. Yeah. So if you're not in Utah, it varies drastically around the country, but there's generally a community crisis line. And the other thing is that there is a 1-800 number through the Substance Abuse and Mental Health Services Administration. But there is a website, and I think it's called "Find Treatment Now" that you can look up and find all kinds of treatment options within your ZIP code and within a certain range from your home.

Interviewer: And for listeners who might be interested in, say, those different resources, they'll be linked in the episode description, if you want to click on your app or on the website. Now, Dr. Howell, I guess the one last thing I kind of want to ask to kind of wrap this up is, what kind of hope do family members and people suffering from this disorder, you know, have when they get into treatment?

Dr. Howell: You know, most people come in to treatment and their families are pretty hopeless feeling. And I'm not trying to sugarcoat addiction. It is a disease that can be fatal, but it's not uniformly fatal. Even without treatment, a lot of people get better over time. But especially with treatment, it can accelerate that process.

There's two things that, I think, are important for opioid use disorder. One is if you are someone with opioid use disorder or you care about somebody who has opioid use disorder, you should definitely get a naloxone overdose reversal kit because the one thing I can't do is help somebody who's dead. And if you die of an opioid overdose when we could have prevented that with naloxone, it's really tragic and unnecessary. So once again, this depends on your community. In Utah, we have utahnaloxone.org and they can facilitate you finding a place that you can get a free naloxone kit to have on hand. And clearly, if you're the person overdosing, you're not going to be able to give yourself naloxone, so it's helpful to have it and for everybody in the family to know how to use it, where it is, etc. I have one in my bathroom. I have a sticker on my door at the house that says, "I have naloxone." And pretty much any addiction provider I know carries some of it around because we never know we could just be walking down the street and come upon somebody who needs to have an overdose reversal. So I would look into that and that's the first thing.

But the second thing is that there is hope for recovery, and I'm always meeting people who are in recovery, who've had severe addictions. I was in another part of the state recently and I was working with a guy on a community event, and he said, "I'm so-and-so and I used to be a heroin addict and, you know, I was . . ." and he told me all about the things in his life that were tragically going wrong. And he made a big change in his life and got into recovery. And I don't know all the specifics, but it's five years later, he's not been using for a while. He's taking care of his children. He's got his own business and he's really successful and he's very happy. So that's what I see can happen. And if you only see the tragic part, you see people in the emergency room or in the hospital with all their complications or you see people who are destroying things in their lives, you feel hopeless. But you never really get to see all the people that do well. And that's one of the nice things about our addiction care system that we have is that we get to see people on both sides, and we're not trying to sugarcoat the tragedies that can happen, but we definitely know people can get better and live productive lives.

Interviewer: What is the fine line between a few drinks to relax or blow off steam and a potential alcohol abuse problem?

Dr. Troy Madsen is an emergency room doctor at University of Utah Health. Dr. Madsen, I hear that doctors have a series of questions that they ask patients, and it's pretty accurate at indicating if somebody has a potential alcohol use problem.

Troy: We do have a screening tool we use. We all learn this in medical school, and it is something that we will then use in our practice, is a quick screen to say, "Does this individual potentially have an alcohol use disorder that we should look into further and ask some more questions and see, 'Well, how much are you drinking? Do you need some help?'"

This is a tool that's called the CAGE questionnaire. So the first C, the C stands for cut down. Have you ever felt you need to cut down on your drinking? The A is annoyed. Have people annoyed you by criticizing your drinking? So, for each of these, you get a point if you answer yes. G is for guilty, G of CAGE. Have you ever felt guilty about drinking? And E is for an eye-opener. Have you ever felt you need a drink first thing in the morning or an eye-opener to steady your nerves or get rid of a hangover?

Now, if you answer yes to two of those questions, so if you have a score of 2 or higher, it has a 93% sensitivity for identifying excessive drinking and a 91% sensitivity for identifying alcoholism. That means it's a pretty good tool for potentially identifying individuals who may be needing some help, again, just answering yes to two of the four CAGE questions.

Interviewer: When you say over 90% accuracy that that person may have a drinking problem, this is research supported?

Troy: It is. Multiple studies. This CAGE questionnaire has been around for many, many years, decades. They've got studies going back into the '80s on this. So it's something that's been studied over many, many years, many, many people.

If you're answering yes to two or more of these . . . let's say you've had people tell you, "You really should cut down," and let's say people are critical of you, you get annoyed by it, if you've got two of those four, that's potentially a sign that maybe you need some help. Maybe you do have an alcohol use disorder.

Interviewer: What if you just have one? Is that supported by the research? Does that necessarily mean anything?

Troy: So that's considered a negative screen. So, if you just had one . . . let's say you felt guilty about your drinking, so you got the one point there, but you didn't answer yes to any of those others. It's like, "Well, no one has ever told me I should cut down. I've never really felt annoyed. I don't really need an eye-opener in the morning to take care of a hangover," so if you just get the one, technically, that doesn't get you a point.

Obviously, there are a whole lot of other variables that play into this, like who you are hanging out with. If you're hanging out with people who are drinking a lot, they're probably not criticizing your drinking and you're probably not getting annoyed by it. So it's one of those tools where it's not a perfect tool.

The advantage of this tool is just something quick that we can do as healthcare providers. It's a quick screen. Just talking through those questions took us maybe 30 seconds. And if you're getting a score of 2 or higher, it doesn't mean you have an alcohol use disorder. It just means, "Let's do some additional screening to see if that's potentially an issue."

Interviewer: It's pretty amazing how accurate the CAGE questionnaire is, but is that where doctors stop, or are there some additional questions that a doctor might ask, or is there an additional resource that a patient could go to on their own to find out a little bit more information?

Troy: There's something called the AUDIT questionnaire, and if you search for that, you can find it online, but that goes through in more detail about getting into exactly how many drinks you have per week, how many you have at once, and getting into the whole binge drinking thing.

And some of those CAGE questions, it kind of goes through some of those again as part of it, but it's a 10-question questionnaire and that really then breaks things down by a score to say "Are you a medium risk? Are you a high risk? Are you at a point where addiction is likely?"

So it's an additional questionnaire. We don't need to go through all the questions on it, but I think that can be helpful as the next step to potentially see, "Is there an issue that I should get some help for, or where are things right now?"

Interviewer: And if somebody has taken the test and they're thinking, "Wow, maybe I should look at getting some help or I would like to get some help," what would the next step be? Because that seems like it could be intimidating.

Troy: If you're looking for inpatient treatment where you need inpatient detoxification and you need medically-assisted treatment to be able to just reduce your drinking or cut off from drinking, it's something you can talk to your doctor about. I think, regardless, I'd talk to your doctor, but they can help set those things up for you. There are many community resources available for that as well.

In some people, it's just the sort of thing where they just reach a point and they just say, "I need help, and I need it now, and I need to make this happen, and I don't have time to wait on that." We see those individuals in the ER on a regular basis. You can come in. We can talk to you about options. In some cases, we admit people to the hospital for this if they are in withdrawal and they have severe symptoms. I'd say I admit people for this . . . it's a weekly thing for me where I'm admitting patients for this.

So, with any substance use disorder, I think the important thing is just reaching out for the help. And I think that's the hardest part, taking that initial step, but if you can reach out to family and say, "Hey, I've got an issue. I need help," I think that's . . . it's a huge thing just to be able to do that. Then you take it from there and you'll get the help you need as long as you just keep pushing forward.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: I'm sorry, give me a second here. I've got all these reminders coming up telling me I need to eat a salad.

Mitch: A salad.

Scot: What?

Mitch: Note to self: Eat salad.

Scot: Yeah.

Mitch: Okay. All right.

Scot: Because if I don't remind myself to eat, I don't. So I go, "Hey, Siri, set a reminder at 4:00 to eat a salad." And then at 4:00, I get a reminder that says, "Eat a salad," and I have to dismiss it so I can see all of my screen. If I want to set a reminder to eat a salad, there's nothing wrong with that.

Troy: It's a little odd, but that's all right. It's all right, Scot.

Scot: Providing information, inspiration, and motivation to better understand and engage in your health so you feel better today and in the future. The podcast is called "Who Cares About Men's Health." My name is Scot Singpiel. My role here is I own the microphones. I'm also the manager of thescoperadio.com, and I care about men's health.

Troy: And I'm Dr. Troy Madsen. I'm an emergency physician at the University of Utah, and I care about men's health.

Scot: So today, we're going to talk about something that can contribute to negative health outcomes. Now, on the podcast, we talk about the core four plus one more. Try to make it simple because sometimes I think people make health more complicated than it needs to be.

The core four is to be healthy now and in the future you worry about your nutrition, you worry about getting some activity, your sleep, your mental and emotional health, and plus one more is genetics because you can't outrun those genes. Sometimes you're just genetically predispositioned to head down a particular health path, although there are lifestyle things you can do to counter that. That's important to say.

And one of the other things we talk about too is we talk about addictive behaviors. And one I would imagine that many men at one point in their lives, whether they're younger or right now, have struggled with is maybe perhaps drinking too much.

There are some situations where somebody realizes they might be drinking too much and they want to do something about it. Then there are some situations where you're like, "Oh, no, I'm fine. I need to blow off some steam. I like to unwind." And maybe you don't realize there's a problem yet.

So we're hoping just to talk in a very non-threatening way about this because that really kind of changed my perception on how much is too much for alcohol.

Dr. Madsen, you're telling me about a screen that you do in the emergency room. And when we talk about alcoholism, we're not talking about the obvious . . . back in my day, we used to call them winos or the obvious person [slurs speech], like that all the time, the obvious.

Was that totally politically incorrect? I'm sorry, if it was.

Troy: It was, but . . .

Scot: We're talking about people that have three, four drinks a night. They otherwise live what would appear to be just a regular existence, but maybe that's a little too much alcohol. So tell me more about CAGE and what that indicates because that was eye opening for me.

Troy: It is. Yeah, it's sometimes surprising. It's one of those things too . . . I think, like you said, as I went into medicine and medical school, sure, you say, "Well, yeah, clearly this guy is an alcoholic. You can see it." But then you are sometimes surprised as you go through some of these questionnaires and some of these things that look at alcohol use disorder at people who are very, very high functioning who may have an alcohol use disorder. And in many of those cases, we see these individuals in the ER coming to get help, or maybe you're doing a screening tool and something comes up on that.

But we do have a screening tool we use. We all learn this in medical school. And it is something that we will then use in our practice, is a quick screen to say, "Does this individual potentially have an alcohol use disorder that we should look into further and ask some more questions and see, 'Well, how much are you drinking? Do you need some help?'"

This is a tool. It's called the CAGE questionnaire. And each letter in this, it's an acronym, stands for the question in the questionnaire. So the first C, the C stands for cut down. Have you ever felt you need to cut down on your drinking? The A is annoyed. Have people annoyed you by criticizing your drinking? So for each of these, you get a point if you answer yes. G is for guilty, G of CAGE. Have you ever felt guilty about drinking? And E is for eye opener. Have you ever felt you need a drink first thing in the morning, or an eye opener, to steady your nerves or get rid of a hangover?

Now, if you answer yes to two of those questions, so if you have a score of two or higher, it has a 93% sensitivity for identifying excessive drinking and a 91% sensitivity for identifying alcoholism.

Scot: Wow.

Troy: It's a pretty good tool for potentially identifying individuals who may be needing some help, again, just answering yes to two of the four CAGE questions.

Scot: That is fascinating. And this is research-supported? When you say over 90% accuracy that that person may have a drinking problem, this is research-supported?

Troy: It is, multiple studies. This CAGE questionnaire has been around for many, many years, decades. And so it's something where it's been studied. Then they've looked at individuals who are testing positive on this. They've got studies going back into the '80s on this. So it's something that has been studied over many, many years and many, many people.

If you're answering yes to two or more of these . . . let's say you've had people tell you, "You really should cut down," and let's say people are critical of you, you get annoyed by it, if you've got two of those four, that's potentially a sign that maybe you need to look into . . . maybe you need some help. Maybe you do have an alcohol use disorder.

Scot: What if you just have one? Is that supported by the research? Does that necessarily mean anything?

Troy: So that's considered a negative screen. If you just had one, let's say you felt guilty about your drinking, so you got the one point there, but you didn't answer yes to any of those others, like, "Well, no one has ever told me I should cut down. I've never really felt annoyed. I don't really need an eye opener in the morning to take care of a hangover," if you just get the one, technically, that doesn't get you a point.

Obviously, there are a whole lot of other variables that play into this, like who you are hanging out with. If you're hanging out with people who are drinking a lot, they're probably not criticizing your drinking and you're probably not getting annoyed by it.

Scot: There's two of the four right there.

Troy: Yeah. So it's like, "Yeah, you're covered there." It's one of those tools where it's not a perfect tool.

The advantage of this tool is just something quick that we can do as healthcare providers. It's a quick screen. Just talking through those questions took us maybe 30 seconds. And if you're getting a score of two or higher, it doesn't mean you have an alcohol use disorder. It just means "Let's do some additional screening to see if that's potentially an issue."

Scot: And just very briefly, because I'm curious, why do you do this? If somebody comes into the ER, why are you concerned if they might have an alcohol use disorder?

Troy: That's a great question. I'm concerned, number one, because if the patient is under my care, and they do have an alcohol use disorder, and they're not drinking alcohol, and let's say they're there for a prolonged period of time or they're admitted to the hospital, they can go into alcohol withdrawal. And if they have alcohol dependence, physical dependence on alcohol, they can have life-threatening symptoms.

I mean, alcohol withdrawal, it's not something you want to mess around with. People die from that. So I want to know, number one, is there potentially an issue there? And number two, if there is, let's make sure we treat it. Let's make sure they get the medication they need to prevent that.

Alcohol is an interesting thing. Every year, about a week after New Year's, I'll see someone come in the ER, maybe just a few days after New Year's, who their New Year's resolution was to stop drinking. They stopped cold turkey, and I see them a few days later with severe alcohol withdrawal, sometimes to the point where it's life-threatening.

So you can really see the dramatic effects of people who may have an alcohol use disorder, the impact it has on their body, and that's why I want to know, "Do they have an issue?" so I can make sure I treat that and prevent it.

Scot: If somebody has an alcohol use disorder, now that's going to be that obvious alcoholic, right? Like, it's going to be very obvious. Or is it not necessarily as many drinks as I might think that it would take to form an alcohol use disorder?

Troy: Yeah, it's really not. Over my career, I'm kind of at a point where you don't get surprised by a lot. But I think early on I was sometimes surprised by some individuals who would come in the ER looking for help and wanting to get help, and recognizing they had an alcohol use disorder. These are CEOs of companies. These are even local celebrities or very high-profile individuals who are very high functioning. I mean, they're very successful in their career. They do very well, but they do have an alcohol use disorder.

And it's not the stereotypical image, like you said, of someone who's out and publicly intoxicated and tripping over themselves. It's not that image. It's something where it affects people in all walks of life, and people who are extremely successful, to maybe that stereotypical image of someone who does clearly have an issue. So, yeah, it's not always obvious.

Scot: So the CAGE is just a quick screen that you use to determine if somebody might have alcohol use disorder. If you're answering yes to two or more of those questions, it might be worth a little bit more investigation into your life or just an honest look.

I believe at some point in my life, in my younger years, I was running around with some people who drank a lot and I probably, by definition, was an alcoholic. I think if somebody would have called me on it, I probably would have dismissed it or would have gotten annoyed by it. This group always used to say, "You know what? We blow off steam, we party hard, but we go slay the dragons the next day. We get up and go do our jobs and we function, so that's not a problem." But actually, in retrospect of what I've learned, that could possibly be a problem.

Troy: And that's a challenge, like you said there, because I think that's what a lot of us will think is that, "Hey, it's not affecting my life. I get my job done. I get my work done. Work hard, play hard," whatever the mantra may be. Again, the people I've seen that have surprised me are very, very successful, but clearly they have an alcohol use disorder.

Scot: All right. And to look at it a different way, according to the National Institute on Alcohol Abuse and Alcoholism . . . Now Dr. Madsen, Troy, talked about some attitudinal things that he asks questions, the CAGE test. This is actually, according to them, their drink guidelines. If you're drinking more than this amount, then you are beyond the moderate or low risk range. And for men, they say no more than four drinks in a day, or no more than 14 drinks per week.

So if you're sitting down in any given day, like on a Saturday, and you're drinking more than four drinks, that is considered beyond moderate or low risk. Or if you are having more than 14 drinks per week . . . like, if you sit down and you have a couple of beers every day, according to them that's low or moderate risk. But if you go to three beers every day, then that's not.

Their guidelines are based on the standard drink sizes. Do you know what these are, by the way, Troy?

Troy: I usually have to look it up. But yeah, it's basically 12 ounces of beer, it's 8 to 9 ounces of malt liquor, 5 ounces of wine, or 1.5 ounce of 80 hard proof liquor. So that's what is considered one drink.

Scot: Yep. So if you have a mixed drink and you do a double, if you do three ounces of liquor, you're done for the day to be considered moderate or low risk range. If you're over that and you do that more than a couple of times a week, that four drinks per day, then they're considering that that's beyond moderate or low risk range.

Troy: But to clarify this, Scot, you're saying four drinks per day. But that's once a week if you're having more than four drinks. And then they're saying 2 drinks a day, 14 total in a week.

Scot: Yeah. So they're saying no more than 14 drinks per week, but they're saying in any given day, you could have 4.

Troy: Sure. So you could come home and you could have 3 evenings a week where you have 4 drinks, for a total of 12, and there you're not over the 14. So I guess it's kind of how they're defining it.

But even there it's interesting. I think you said maybe it sounds like a lot, 14 drinks in a week, but if a person is coming home, and let's say in the evening their usual routine is to sit down and have a couple of beers or whatever, right there, if they're having 2 beers a day, they're right at that 14 mark. And then if you have one evening a week, you go out and you have 4 drinks, right there you're over the 14.

So you can see how it doesn't . . . it sounds like a lot, but when you think day to day, if that's part of your routine, you can get over that 14 number fairly easily.

Scot: There are two considerations when it comes to alcohol use. One is the physical impacts it has on your body. Troy talked about alcohol withdrawals, which could be potentially deadly. What are some other physical problems that drinking can bring about that you've seen?

Troy: Well, there are certainly the immediate impacts, just intoxication. It increases your risk of accidents and injuries. Just affects your judgment. That's definitely a component of a lot of injuries we see in the ER. It seems like that magnifies your risk. If you're on a motor vehicle, if you're on an ATV, you're around fires, anything like that, you're increasing your risk of being injured in those sorts of things.

Then there are just the obvious physical effects. And sometimes these aren't immediate, but just the cumulative effects of individuals who it affects their liver. And then with the liver effects, you can have liver failure, which is a devastating thing. That's just awful to have. It's not something that is easily treated and sometimes requires a transplant. And even there, it requires being able to get a transplant. Unfortunately, people do die on the transplant list while awaiting that after they've had an alcohol use disorder and have had effects from that.

That can also lead to gastrointestinal bleeding, so bleeding in the stomach. We have people who have liver disease that then that makes them more likely to have bleeding. They can have severe bleeding, life-threatening bleeding. So it definitely has impacts there.

It also increases your risk of cancer. We've had studies come out showing that moderate drinking can improve or reduce your risk of heart disease. But then I think further studies that have come out in the last 10 years have shown that potentially the impact of alcohol use on cancer, and here we're even talking moderate alcohol use or potentially even just a drink a day, potentially the increased risk of cancer may outweigh the reduced risk of heart disease.

The instructions that have been given through the internal medicine physicians and family physicians is that if someone is drinking in moderation, not a big deal, but it's not something where you would ever counsel a patient to start drinking in order to reduce their risk of heart disease, just because that risk of cancer is there and that may outweigh it, especially for people who are more prone to cancer with their genetics.

So, yeah, you've got the immediate effects. You've got the long-term effects. It certainly can have its impacts, and again, something we see, I think, full range of that in the ER from the people with the injuries to the bleeding and cancer and all those sorts of things.

Scot: It impacts your sleep too. People don't sleep as well. A lot of times, people do drink to sleep. But I've talked to physicians that say that the research actually shows that you might think you're sleeping, but you're actually sleeping lighter or you have disturbed sleep. And, of course, that's one of our core four, so you're not getting as good a night's sleep.

And there are just kind of a lot of impacts. For me personally, when I was probably drinking more than I should, I started having digestive issues. I just was always miserable in my stomach. It wasn't as soon as I stopped, but within probably three, four months after really cutting back, that all improved for me.

So if you're experiencing some of those things and maybe you might be drinking a little more than you should, to me, that was almost worth it to give up a couple of beers to feel a little better. I hate stomach issues.

Troy: Yeah, the acid reflux. That's a common issue.

Scot: So a little bit later in the season, we're going to have somebody on the show who has had a journey with alcoholism, has gone through some of these steps. And we hope that having that individual on the show will perhaps help some other people through their story perhaps recognize a situation in their life that maybe you have time to turn around. You can turn this sort of thing around.

Is there anything else you want to add to this episode, Troy?

Troy: One thing it may be worth mentioning, too, Scot, we talked about the CAGE questionnaire. That's obviously such a quick test we can do. Let's say we talked about the CAGE questionnaire and you thought about, "Maybe two of those four I could answer yes to." Then you may ask, "Well, that's a pretty quick test. Is there anything more detailed I could go through, like a questionnaire, to see is there an issue?"

There's something called the Audit questionnaire, and you just search for that and you can find it online. But that goes through in more detail about getting into exactly how many drinks you have per week, like you mentioned, Scot, how many you have at once, getting into the whole binge drinking thing.

And some of those CAGE questions, it kind of goes through some of those again as part of it, but it's a 10-question questionnaire. And that really then breaks things down by a score to say, "Are you a medium risk? Are you a high risk? Are you at a point where addiction is likely?"

So it's an additional questionnaire. We don't need to go through all the questions on it, but I think that can be helpful as the next step to potentially see, "Is there an issue that I should get some help for, or where are things right now?"

Scot: And then if somebody decides that it is an issue, you've mentioned you've had people come to you in the ER. Is there perhaps a better place to go if it's not an emergent condition that you need to get rid of your dependency on alcohol?

Troy: Yeah, for sure. I think there are certainly lots of community resources. Alcoholics Anonymous being certainly something everyone has heard about if you are at a point where you say, "Hey, I've got an issue. I need to get help." That's a wonderful resource and I think something that's been proven over many years to be effective in terms of helping people.

If you're looking for inpatient treatment where you need inpatient detoxification and you need medically-assisted treatment to be able to just reduce your drinking or cut off from drinking, that's something you can talk to your doctor about. I think, regardless, I'd talk to your doctor. They can help set those things up for you. There are many community resources available for that as well.

In some people, it's just the sort of thing where they just reach a point and they just say, "I need help, and I need it now. I need to make this happen, and I don't have time to wait on that." We see those individuals in the ER on a regular basis. You can come in. We can talk to you about options. In some cases, we admit people to the hospital for this, if they are in withdrawal and they have severe symptoms. I'd say I admit people for this. It's a weekly thing for me where I'm admitting patients for this.

So wherever you are, like I said, there are community resources, all the way to going to the ER, coming in, seeing us, trying to get the help you need.

With any substance use disorder, I think the important thing is just reaching out for the help. And I think that's the hardest part, is taking that initial step. But if you can reach out to family and say, "Hey, I've got an issue. I need help," I think it's a huge thing just to be able to do that. And then you take it from there and you'll get the help you need as long as you just keep pushing forward.

Scot: All right. It's time for a brand new segment on the show on "Who Cares About Men's Health." We've got our nutrition expert, Thunder Jalili, in the studio to answer some nutrition myths. He's going to tell us whether our nutrition myths are truth or if they are going to get Thunder Debunked. What do you think?

Thunder: I like that, Thunder Debunked.

Troy: Can we call it Thunderstruck?

Thunder: Whoa.

Scot: Well, Thunderstruck . . .

Troy: Thunder will strike them down, strike down the myths. I like that.

Thunder: AC/DC may come after us for copyright infringement. But I'm willing to take the risk.

Scot: That's why I want Thunder debunked. I didn't want that to happen. I don't need an AC/DC lawsuit.

Troy: Because I know AC/DC listens to this podcast.

Scot: And I also know Troy wanted to call it Nutrition Myths Jalilied, but I told him that seemed weird.

Troy: I didn't, but I like it.

Scot: Thunder Debunked, Thunderstruck, it sounded so much better. We're going to give you a nutrition . . . something that you might find on the internet, and you're going to tell us whether it's truth, or if it's going to get Thunder Debunked. And I hope most of them get Thunder Debunked because that's fun.

Weight loss. Oftentimes, it's been said if you're trying to lose weight, it's just a simple equation of calories in versus calories out. So if you eat fewer calories than you expend, then you're going to lose weight. Is that truth, or is that myth going to be Thunder Debunked?

Thunder: I think that is going on the road to being Thunder Debunked. In the last few years, there's been a lot of work done in this area called time-restricted feeding. What that's been showing . . . and it started with animal models and it's gone to humans too, but it basically shows if you consume your calories in a short amount of time and have a long fasting period for a 24-hour cycle, you don't really gain weight.

And what's really interesting, especially in some of the animal studies, is it kind of doesn't matter what they feed these animals. They can eat a high-fat diet or things that usually make animals gain weight, and they still control their weight as long as they eat their food in a short period of time. So in the 24-hour cycle, give them 8 hours or 10 hours of eating, and then 14 to 16 hours of not eating.

That's why I think the calories in equals calories out is a little too simplistic now.

Scot: All right. Weight loss is just really calories in, calories out, that has been Thunder Debunked. Troy, will you do me a favor?

Troy: Thunder Debunked.

Scot: Will you do the honors of singing, "You've been Thunder Debunked?"

Troy: I think you already did it.

Scot: All right. Weight loss, is it really just calories in, calories out? That nutrition advice has just been Thunder Debunked.

Troy: Thunder Debunked.

Scot: "Just Going To Leave This Here." It might have something to do with health. It might be something totally random. Troy, why don't you go ahead and start "Just Going To Leave This Here"?

Troy: You're putting me on the spot again, Scot. I have to . . .

Scot: I'll take it. That's fine.

Troy: I'm going to let you . . . Scot, it's time for "Just Going To Leave This Here." How about you start us off today?

Scot: All right. Just Going To Leave This Here. So a couple of episodes ago, I was talking about how I wanted to look into exercising with kettlebells. I also mentioned my frustration that, because of COVID-19, home health equipment whether it's new or used, is becoming very scarce, kettlebells being one of those things. I contacted numerous people in the want ads, went to numerous exercise stores, "Nope, don't have them. Don't have them." Finally got my hands on some kettlebells.

Troy: Nice. You finally found them.

Scot: It was like doing a deal, man. It was like doing the seediest deal you've seen on any movie or TV show. I met a guy in a parking lot at a Walgreens in Bountiful. He popped his trunk. We did a quick per-pound price negotiation. By the way, kind of the going rate for kettlebells, $1.50 to $2 a pound. If you're paying more than that, they better be competition-level kettlebells, like really good quality ones . . .

Troy: Good to know.

Scot: . . . or you just really want them badly. I got my kettlebells for $1.10 a pound from the guy in the Walgreens parking lot.

Troy: Oh, he cut you a deal.

Scot: Yeah, cut me a deal. I don't know if he's just giving me that first kettlebell taste hoping I come back a little bit later.

Troy: He probably is like, "He'll get stronger and he'll need more. This will not be enough kettlebell for this man."

Scot: Anyway, I put them in my car, and I drove home, and they've sat in my garage since.

Troy: I was just hoping the next step in this story was that you did go back for more kettlebells.

Scot: No. I've messed around with them a little bit. I've got a routine I want to start. I just haven't quite gotten to it. Things have just been crazy. It's kind of that familiar story, isn't it, Troy? We go into our health things with the best intentions and sometimes we're just not ready for it.

Troy: And look at that effort you put forth. I mean, you met a random stranger in a parking lot.

Scot: Yeah, I did.

Troy: You did that. But at least you have the kettlebells now.

Scot: I do.

Troy: So you're ready to move forward.

Scot: And every once in a while I'll go out to the garage and I'll look at one of them . . .

Troy: You're like, "Man, that looks heavy."

Scot: I'll pick it up and I'll swing it around, try to lift it over my head. I want to have somebody on the show that's done kettlebells before that maybe can give me some pointers or tips. Everywhere I read said 35 pounds is kind of where a guy that's just beginning should start. I don't know how that's possible. But hopefully, we'll have a guest on later. In the meantime, I'm . . .

Troy: Scot, I know a guy. I guarantee he will talk to us about kettlebells.

Scot: All right. Well . . .

Troy: We've got to get that guy on.

Scot: The drug parallels continue with the kettlebell.

Troy: Scot, I'm just going to leave this here. I'm not using kettlebells, but something I am using . . . do you do whiten your teeth? Do you use the whitening strips or anything like that?

Scot: I do not whiten my teeth. No.

Troy: Okay. Well, I found something I kind of like. I don't like the whitening strips just because those feel kind of gooey on my teeth. It's kind of a weird feeling. And I'd read some stuff online about using charcoal. I know this sounds weird. Have you ever heard about using charcoal on your teeth, like brushing your teeth with charcoal?

Scot: No. That sounds like something that we're going to debunk in a future episode.

Troy: It probably is. We need to get a dentist on here. I want to get a dentist on here just to ask all these dental questions to. But according to the internet, it works great. And I can tell you it's one of those things that looks really gross. It's like this powdered charcoal. I don't know what the source of the charcoal is, but it's purified, whatever. I'll just buy it online. You just brush your teeth with charcoal and your teeth look really gross, like your mouth is all . . . there's just black stuff all over it and all charcoal-y looking. Then you just wash your mouth out and your teeth look whiter.

So there may be someone out there listening who is like, "That is just the stupidest thing I've ever heard," like some medical professional or dentist, and is like, "Okay . . ." So let me know, contact us at hello@thescoperadio.com to let us know if I'm a total idiot for using charcoal to whiten my teeth. I think it works. It seems to be working. I've been using it for a few months. I'm happy with it so far. But maybe I'm totally off base here.

Scot: All right. So, as a medical professional, you're not recommending it. You are actually soliciting to find out if it's a good idea or not.

Troy: I will say I am not a dentist. When I use charcoal . . . this is interesting. We use charcoal for certain types of drug overdoses. We actually have the patients drink the charcoal, it goes in their stomach, and then it will bind to these things. They may have overdosed on pills. So we do use charcoal. That's the only time I've used charcoal.

And usually when they drink this stuff, it makes their mouth kind of look all black and all that just from the charcoal on their lips. That's how I look after I brush my teeth with charcoal. It's kind of weird stuff. I don't know. I think that's the idea. It's supposed to kind of bind to the stuff on your teeth and whiten them. Again, I'm curious. This is more a curiosity, but yeah.

Scot: I will reach out. We'll get a dentist on the show. We'll talk about that . . .

Troy: We need a dentist. We really do.

Scot: . . . and get the rest of your dental questions as well.

Troy: Yeah. We've never had a dentist. So I'm going to ask him about charcoal.

Scot: All right. Time to say the things that you say at the end of podcasts because we are at the end of our podcast. Troy, you get to start today. What do you want to say at the end of this podcast?

Troy: Hey, I want to say thanks for listening. Be sure and subscribe anywhere you get your podcast. If you like us, give us five stars. Tell your friends about us. You can reach out to us at hello@thescoperadio.com.

Scot: You can also go to facebook.com/WhoCaresMensHealth. And we have a brand new listener line you can leave a message at. You can leave your name or you don't have to. You can say you're John Smith. You can ask a question, leave a comment, tell Troy that he needs to get it together with the charcoal and brushing his . . . use toothpaste like normal people do.

Troy: Please. Hey, I use toothpaste too, just to clarify. I do use toothpaste. Anyway . . .

Scot: 601-55SCOPE. That's 601-55SCOPE. Thanks for listening. And together, Troy . . .

Together: Thanks for caring about men's health.

Scot: That's hard to do when you're not face-to-face and online, isn't it?

Troy: I tried to screw it up just to mess with you.

Dr. Jones: In the tragedy of the opioid epidemic, a new group of Americans has emerged as the most likely to die of prescription opioid overdose -- middle-aged women. These are mothers and grandmothers. How can this be? This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Women are the fastest growing segment of alcohol and drug users in the United States. Up to 4.5 million women over the age of 12 in the U.S. have a substance use disorder, and 3.5 million misuse prescription drugs, 3.1 million regularly use illicit drugs. That would be heroin or marijuana in states that don't allow it. Each year, over 200,000 American women die as a result of alcoholism and drug dependence, with more than 4 million women in the need of treatment for their addiction. Men are more likely to use opioids, including heroin and illegal narcotics, than women and are more likely to die of narcotics overdoses related to illegal substances than women. But when the issue is prescription opioids, the kind you get from your doctor, the problem is shifted more to women.

The 2013 National Survey on Drug Use and Health estimated that 6.5 million Americans misused or abused prescription drugs within the last year, and more than half of them were female. Women are more likely to experience chronic pain and anxiety than men, and are more likely to seek help from clinicians for these problems, and are more likely to use a combination of opioids and valium-like drugs than men, and that combination can be lethal. They're more likely to get and use prescribed medications, such as opioid pain relievers, sleeping pills, and tranquilizers than men. And middle-aged women are more likely to have chronic pain and anxiety than young women.

As a clinician, I must say that I used to think my patients, particularly those that were older in midlife, were older and wiser and were too smart to use or abuse prescription drugs, and I was wrong. And all of us who care for women need to take special care now. More women have died each year from drug overdoses than from motor vehicle accidents since 2007. Drugs given to treat anxiety, called benzodiazepines, are often combined with prescription opioids, and the combination is particularly dangerous and causes many of the deaths and emergency room visits related to opioid overdose.

According to a recent study by the Geisinger Health System in Pennsylvania, the group most at risk for prescription opioid overdose is made up of white, middle aged women, not the ones you'd think, huh? The study came from examining over 10 years' worth of health records comprising some 1.2 million patients and had the goal of predicting which people were at most risk of overdose from prescription opioids, like hydrocodone and OxyContin. Some of their findings were the average overdose patient in women was 52 years old. The majority of overdose patients were unmarried, unemployed females, but they probably weren't unemployed before their addiction problems started.

Almost 10% of patients who overdosed died within a year of that incident, meaning if you overdosed once but got resuscitated, got helped, 10% of those women die in a year. One reason why this high rate of increase for women is because the Centers for Disease Control reported that women may be more likely than men to engage in doctor shopping. Doctor shopping is when women actively seek out multiple types of prescription drugs from multiple providers. So they go to one doctor for one prescription and another doctor for another.

There's evidence that women become addicted to prescriptions such as narcotics and benzos much more quickly than men. This has been found for alcohol and nicotine as well, and it's not just that women are smaller because pound for pound, women became drunk faster than men and addicted more easily. It's probably a combination of biology and psychology of women.

This trend is alarming as women progress faster than men into addiction even when using a similar or lesser amount of substances, and ultimately suffer more health-related consequences. And while addiction is an equal opportunity disease, women become addicted differently, starting for different reasons, progress faster, recover differently, and relapse for different reasons than men. Women have a higher percent of body fat and lower percent of body water than men, both of which can affect how the drug is metabolized, and women are 70% more likely to suffer from depression than men. They're twice as likely to struggle with anxiety, post-traumatic stress disorder due to sexual abuse, violence, or childhood trauma.

So what should we be doing? As clinicians, we should be very careful in how we prescribe narcotics and benzodiazepines and sleeping pills. We should understand that women become addicted more quickly than men. After surgery or delivery, we should send women home with only the amount of narcotics needed and should be tailored to each woman, and we should be checking the prescribed medication databases to see if our patients have been getting these drugs from other clinicians if they're doctor shopping. We should be using alternative therapies for pain, anxiety, and insomnia where possible.

As caregivers, we need to be on the alert that our mothers, our sisters, our friends, and our daughters are in trouble. Changes in behavior, withdrawal from family, changes in sleeping patterns, these aren't necessarily signs of alcohol or narcotics addiction. It could be depression or anxiety, but the woman needs help. As women, we need to do our best to avoid the use of narcotics and anti-anxiety drugs like benzodiazepines or sleeping pills.

Anyone can become addicted in a matter of just a few days. If you've had an injury or surgery, use narcotic pain relievers first if possible. If you're seeking help for anxiety, try behavioral approaches first. And if you have problems with sleeping, behavioral approaches work better than sleeping pills in the long run. And if you believe that you have a problem, then you probably do. Tell someone, get professional help, there is a road back, and thank you for joining us on The Scope.

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Interviewer: By focusing on the opioid epidemic, are we missing the bigger problem? We'll talk about that next on The Scope.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From the University of Utah Health Sciences, this is The Scope.

Interviewer: Mark Ilgen is an associate professor at the Department of Psychiatry at University of Michigan, and much of his current work focuses on improving treatment outcomes for patients struggling with substance abuse disorders that are also complicated by co-occurring problems like chronic pain. Dr. Ilgen, when you say that to really solve the opioid problem that the conversation needs to be about a bigger issue, can you tell me what you mean?

Dr. Ilgen: The topic of opioid use and opioid overuse has received a lot of attention in the national media. You often hear about what's often called the "opioid epidemic" as something that's grown within the last 5 or 10 years, but prior to even the last 7 to 10 years, there was still the problem that many individuals with pain were not functioning well. And a large portion of those individuals coped with their pain by misusing or overusing substances, and that's not limited to opioids.

Someone can drink too much to manage their pain, use marijuana to manage their pain or overuse marijuana to manage their pain, or use either street or prescription opioids. And so the broader issue of pain management has, in some ways, been lost. And there's really a lot of concern that in our conversation about, "How do we keep people safe from opioids," that we might also be losing sight of the fact that many people still have chronic and poorly-managed pain. And those individuals are often left without a lot of very attractive treatment options.

Interviewer: So what can you do? What is the bigger solution to the problem?

Dr. Ilgen: I think that pain management as a topic is one that I think we need to be giving more attention in our health care system, so it's a difficult topic for a lot of treatment providers to discuss. And I think a big part of why opioids became the problem that they are now is that they presented or were, in some ways, billed as a solution and as an easy solution to the problem of pain. And so that was appealing to primary care physicians and other treatment providers because they felt like they could do something to help someone who was struggling with chronic pain.

But a true, honest conversation about chronic pain requires going into more depth, understanding what the patient's going through, getting better diagnostic information about the pain, and then coming up with coping strategies that are more comprehensive that go beyond what you can usually achieve with a medication.

Interviewer: What are some of the solutions that you're seeing out there that are offering some promise?

Dr. Ilgen: Well, the hard thing with . . . it's a very complicated issue, and the solutions to pain are going to look very different, depending on the nature of the chronic pain. So again, unfortunately, for a long time, the solution to chronic pain was often pitched as opioids, and those were applied across a number of chronic pain conditions, from fibromyalgia to migraines to lower back pain.

But in fact, the different solutions to the pain conditions often really vary substantially, depending on what the presenting problem is. So a first step in doing something about the pain is just to make sure you get an accurate diagnosis, and in many cases, that means going to a pain specialist and getting a better sense of what's actually going on.

And for a lot of individuals who have musculoskeletal pain, they need forms of treatment that focus on their physical functioning as well as their pain level. And most effective treatments for long-term, let's say, back pain involve both helping the person manage the pain in the moment, but also helping them remain active in their life, get physical therapy, in some cases get certain pain-specific types of psychotherapy that help them cope with their pain and better adapt to the pain condition.

Interviewer: And to some extent, I would imagine one of the challenges, too, is helping us, as patients, overcome this notion of the easy solution of the pill, like the pill or the painkiller is the ultimate thing. Because physical therapy and staying active, all that stuff take commitment and work, and people can also be skeptical that that's actually going to do anything.

Dr. Ilgen: Exactly. I think managing expectations around what is or isn't possible is very important, so unfortunately, often the case, that you don't have an easy solution to the pain. Instead, you're looking at scaling back on the pain from a level that really is impairing to a level that's easy to cope with. But it often doesn't go away. It's just at a lower and more manageable level.

Interviewer: Yeah, so as a patient, suffering from pain from a particular condition, it sounds like your recommendation be, first, make sure that I have an accurate diagnosis of what's causing that pain. So then that would lead to the ability to come up with a plan to help manage that pain, which comes back to your concept of it might not go completely away, but you do what you can do. And then, at that point, just realize that it's a process, and it's going to take some time, and maybe that's a good trade-off for the downside of a potential addictive substance that could ruin your life.

Dr. Ilgen: Yeah, and I don't want to overstate the potential downsides of opioids. So there's a lot of controversy in the field about whether opioids are ever an effective and appropriate treatment for chronic pain, and then, if so, at what level? And I think those decisions are just made on a case-by-case basis with a treatment provider.

What we see that's problematic is when someone is taking a moderate or high dose of an opioid and not getting a lot of relief and then ends up escalating and needing a higher dose to get some relief and then even that's not working, that's when someone's kind of going down a path towards not getting a lot of return on the medication. It's not really giving them a lot of pain relief, and the risk for side effects is going up.

And that's when you really want to be concerned and be careful and to stop and have a really frank conversation with your treatment provider about, are you on the right path here? Or are you really getting greater and greater physical dependence on the medication for either continued not-very-good or maybe, in a lot of cases, a worse degree of pain relief than you did initially?

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Interviewer: Using Imodium to treat opioid withdrawals: a bad idea. We'll find out more about this disturbing trend next on The Scope.

Announcer: This is "From the Frontlines" with emergency room physician Doctor Troy Madsen on The Scope. On The Scope.

Interviewer: Doctor Troy Madsen is an emergency room physician at University of Utah Health Care and he said he'd seen a couple instances where people are using Imodium, which is an anti-diarrhea medication, as a way of trying to treat their withdrawal symptoms from opioids. I find this hard to believe. What's going on?

Dr. Madsen: Yeah. So this is really interesting. So as you may know, there's an opioid epidemic in our country and the Centers for Disease Control has acknowledged this and said we have so many people who are using opioids now. So prescription opioids, things like Percocet, Norco, Oxycodone are using that for to get high. Essentially what they may consider it legal high because they're getting a prescription or it's a prescription medication they're buying from someone.

So then, these individuals may then be saying to themselves, "I really can't be doing this. I need to get off this medication." So they're finding things on the Internet that discuss using Imodium or loperamide is the generic name and using that to sort of detox, taking that as a bridge to give yourself some of the same effects as the opioids give you while allowing your body to adapt and adjust and then gradually get off the medication.

Interviewer: So, first of all, bad idea trying to self-treat an addiction like that?

Dr. Madsen: Absolutely, not a great idea. But the reason they're doing this is because it's probably been out there for years and then I think it's just gained steam with some people posting things on the Internet about this. But Imodium or loperamide is actually an opioid. It doesn't give you the same high as things like Oxycodone, but it has kind of the same effects, acts on some of the same receptors in the body.

That's why it help with diarrhea because if you've ever heard of someone who says, "Hey, taking all these Percocets and I can't have a bowel movement. It constipates me." Well, that's kind of how this stuff works for diarrhea. Same kind of idea. It slows down the bowels but also then acts on somebody's same receptors in the body that opioids act on that people are using for highs.

Interviewer: Yeah. So self-treating bad but, above and beyond that, Imodium causes other problems that you see then?

Dr. Madsen: It does. And the big thing we're seeing is some of these people are just taking such incredibly high doses that it's been putting their heart into these arrhythmias, these abnormal heart rhythms that are life-threatening. And that's where we see it in the ER. I've seen cases of people coming in who are in just these crazy heart rhythms, these life-threatening heart rhythms and it's because they're taking large doses of Imodium and then that is triggering this heart rhythm.

And really, it's the kind of heart rhythm where you've got to shock their heart to get them out of it, get them on medication, do something for it or their hearts just not going to keep working and they're going to die from this.

Interviewer: That doesn't sound much better.

Dr. Madsen: It doesn't. It's not a great thing to do.

Interviewer: It doesn't sound like a great solution to the original problem.

Dr. Madsen: Yeah, there's not. There are much better solutions to opioid addiction and to getting off that. It's a sort of thing where you've come into the ER, we will often get people into in-patient detox programs. We can also prescribe medications that can help with this. So I would not recommend taking Imodium or loperamide. Again, that's the generic name for it. I would not recommend taking that to treat an opioid addiction because of the threat of these abnormal heart rhythms.

And this really comes up because there was actually just a study published or report in one of the big emergency medicine journals talking about increasing cases of this and increasing calls to poison centers for people who are taking more and more of these medications to try and treat opioid addictions and then are having very bad effects from this.

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Interviewer: Dr. Higgins, so when it comes to opioid pain pills, I'm getting the point personally, and I want to see how you would react to this with the physician perspective, that opioid pain medications, they're just really bad news and we really shouldn't have them in our medicine cabinets anymore. We really should look for other ways to treat pain because you continue to hear about deaths and overdoses and addictions. Am I being a little overstated on that?

Dr. Higgins: Yes and no.

Interviewer: Okay.
Dr. Higgins: There are certainly indications and uses for opioid pain medicines, where appropriate. And the presence of them in your medicine cabinet, by themselves, is not harmful. It is the chronicity of use, using them over a longer period of time, and ramping up the doses, which is, and this is proven in the literature, this is where people get in trouble.

Interview: What should we do about what seems to be going on? It seems almost like a national health epidemic. And there again, I may be overstating this.

Dr. Higgins: It's absolutely not overstating it. It is a national health epidemic. If you set aside cancer and heart disease, the thing that was most likely to kill an American under 65 was their car with some sort of motor vehicle accident. It was that way for some time. In 2003, it was the first year in the state of Utah where a prescription opiate was more than likely to lead your demise than a motor vehicle wreck. That was kind of revolutionary at the time. Now, it's that way in greater than half the states.

Interviewer: Okay. So we were kind of ahead of the curve.

Dr. Higgins: Yeah, it's nothing to be proud of.

Interviewer: Yeah, in a bad way, yeah. So it is something that we need to address. As a patient, if my doctor says, "I'm going to prescribe you some pain medication that's opioid-based," should I say, "I'd rather look for a different solution?"

Dr. Higgins: If you want to do that, your doctor should definitely respond. The old teaching was that as long as you had discomfort, the opioids [Audio skips 00:02:12] likely to be taking someone else's medicines. The people in the 40 to 60 age group are more likely to be taking their own medicine and they were on it chronically and they were on higher doses. And there are people here doing some pretty fascinating research on what the susceptibilities are. We may all have genetic susceptibilities to flip that switch. So even if you don't think you have "an addictive personality," then you can certainly develop one rapidly even if you don't think it's in you.
The other thing is to not necessarily judge those people that have had problems. Plenty of very prominent people and people who we wouldn't necessarily expect have certainly run into problems and, in some cases, have been fatal.

Interviewer: So at the end of the day, a physician perspective, what do we do to solve the problem?

Dr. Higgins: I think it's critically important of late that the public becomes aware and this happens through the lay press. And then, from a physician standpoint, we have to educate the patient at the beginning, the initiation of treatment. Secondly, have an exit strategy. Thirdly, entertain other modalities we can be using besides these medicines to treat the pain.

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Interviewer: You may have heard recently of a drug called Naloxone. What it does is it reverses opioid-based overdoses. So if you have an opioid-based pain pill or if somebody has a drug overdose that's based on opioids, it can actually reverse it and save their lives. Dr. Jennifer Plumb is one of the founders of UtahNaloxone.org, is also in pediatric emergency medicine here at University of Utah Healthcare, and Sam Plumb is the program's manager at UtahNaloxone.org.

I wanted to ask you both, why is this important to you? I've gone to the website. I see that you've put a lot of work into it. I see on my Facebook feed a lot of times you're trying to increase awareness. Dr. Plumb, why?

Dr. Plumb: We are in this position, I think, at a position of passion, but also at a position of a true desire that we can bring awareness to the epidemic that's gripping our state with opioid overdoses. We are fourth in the nation, which is a distinction that certainly nobody wants. We're not talking about it a whole lot, and I think that there are a lot of people out there who have at-risk family members.

We unfortunately lost our brother in 1996 to a heroin overdose, and since that time the situation has just gotten worse and worse. Naloxone was not legal to have in the home setting when Andy died, and it is legal now. So I think that we both feel very passionately that if one family can be spared what we went through, it's all worth it.

Interviewer: It would've saved his life you believe?

Dr. Plumb: Absolutely, I believe it would've saved his life. It would've saved his life.

Interviewer: So when you say we have opioid-based overdoses, are you talking about pain pill overdoses, intentional, accidental? I mean, what are we talking about here, people abusing?

Dr. Plumb: When the figures all come out, the Health Department puts them together and the CDC also puts them together, and they do look at all of those categories. They look at intentional or suicides. They look at accidental or poisonings. We are seeing in this state that we have continued accidental overdose increases. So what do these look like from an opioid perspective? Most of these poisonings and overdose deaths in Utah are from opioid substances.

There are some others, cocaine, methamphetamine, alcohol, that can also kill people, and unfortunately does kill people. But the majority are from the opioid-based substances. Of those, the majority probably still is prescribed pain medications. So the pain pills, OxyContins, Percocets, codeines, these medications that we all have heard about in different incarnations in our lives, but heroin is another big one.

The CDC just this year basically released data and released recommendations calling it an epidemic. It's truly an epidemic what's happening. Since 2000, I believe, we're almost up 400% for heroin overdoses nationwide. It's everywhere.

Interviewer: Not a problem here, though, right? Not in Utah.

Dr. Plumb: You certainly wouldn't think so.

Interviewer: But it is.

Dr. Plumb: It absolutely is. It's really challenging, because I get that people don't want to talk about it. There's a lot of stigma around it. But to me, it really is just another medical problem, a critical one and one that will kill someone if it's not dealt with, and if we don't get people help. But we don't talk about it. You're exactly right. It doesn't exist if we don't talk about it. We don't see billboards about it. We don't see PSAs. We need to. We need to start encouraging conversations surrounding these substances so other families don't go through what we have gone through.

Interviewer: Sam, you're also involved in UtahNaloxone.org. You're the program's manager, and I understand you do a lot of outreach to people that have a drug addiction problem. Talk about that a little bit, and how Naloxone can change things.

Sam: Well, I think it could potentially have a drug addiction problem. When you're doing community street outreach, you're dealing with a population that they obviously aren't in a good place. If they themselves aren't active users, they could know people who are at risk of an overdose, for instance. So the idea is these are people that are typically missed by other realms of the medical field.

They don't typically go to the doctor. They don't have access to the pharmacy. They don't often have insurance. So for that reason, these people are most at risk for having an overdose and not having the access to Naloxone, which can save them.

Interviewer: You actually make these available to those at-risk individuals.

Sam: Yes. We go out to different areas, and you start to have an understanding of more at-risk areas of the city. For instance, I know Pioneer Park is one that people typically think of. The Road Home, places where there are typically going to be people that are living outside or don't have the means to often take care of themselves, or provide themselves the shelter. We will go out and we will educate each and every person that gets a kit so that they know everything that they need to do should they witness an overdose, or should they themselves have an overdose.

Then, we distribute the kits, and we've really had a great response for that matter from that group of people, and they're very willing to be honest about it. If you ask them if they're using, they will tell you frankly, "Yes, I am." When you tell them that you're willing to help them, to say that they're gracious is an understatement.

Interviewer: I'm going to be cynical here for a moment and say, what do you say to individuals that would say, "Well, they have a drug addiction, that's their own problem?"

Sam: I mean, that is probably what we hear the most frequently about that population. But these are people that do not have the typical resources that even somebody of no means may have, for instance family, support, friends, a place to stay, any type of income. Without some type of help, that doesn't mean that they should just die as a result. For these people, you can't recover if you're dead. So Naloxone gives them that chance to actually recover from a potentially fatal overdose, and then also have the opportunity to seek some type of treatment or go into recovery.

It's really surprising, and I think that if you have a doctor or an EMS responder, they revive you, well that person is just doing their job. But if you have a friend, or a mother, a father, actually revive you, I think that that has more of an impact on your future usage as well.

Dr. Plumb: We've seen that too. We've seen firsthand, as well as anecdotal reports from other states. But we've seen firsthand, if someone is revived by their mom, and they wake up and their mom is begging them not to die, there's a different lightbulb that goes off. There is a realization that, "Wow. Somebody really wants me to be alive. I need to be here for myself. I need to be here for them. My life does matter to them." It's been reported in the literature too that actually bystander-administered Naloxone is a much more powerful tool to get people to have that realization that their rock bottom has come.

Interviewer: So that very much near death experience is actually the thing that will help turn them around and perhaps get them unaddicted, or more willing to seek treatment?

Dr. Plumb: On a healthier path, basically.

Interviewer: Yeah.

Dr. Plumb: Just to have that realization that, "Wow. I actually need to be here. Someone else sees that I need to be here, not just someone whose job it was to save me. Someone else made the conscious decision to save my life. They're not medical. They just care about me."

Sam: It also is very important to mention that the experience of having Naloxone administered to you, especially if you are an active user, an addict, it is something that is terribly painful. It kicks them into instant withdrawals. Some of the people that we've spoken to have said, "I'd rather be tazed or shot before I get that Naloxone again." You're like, "Well, would you rather be dead?" "No. Well, if I'm going to die, then yes you can give it to me." But other than that, I mean, it's a terribly painful experience. So it's not something that people would use or to . . .

Interviewer: Yeah. Because I was going to ask, I was going to say, now I've got my safety net so, woo, party's on. Right?

Dr. Plumb: Your parachute, kind of. We hear people say, "Oh, you're providing a parachute to people," and that's just not the reality.

Sam: Because if you think about it too, these people who are active users, number one, nobody wants to overdose, nobody wants to be an addict, and beyond that they don't want to waste their last fix. So if you give them Naloxone and they've overdosed, they've just lost their last high. So it's another way to think about it.

Dr. Plumb: Yeah. We do get questions about that, though. "Well, aren't you just enabling use? Aren't you just enabling riskier use? Aren't you just basically telling people you're okay with this choice that they make?" The reality of it is, no, we're not. What we're telling them is, "Hey, listen. We want you to get to a healthier place. We want you to get to a place where your life is not so encompassed by your addiction. But we can't get you there and you can't get yourself there if you're not alive." Naloxone will get you basically breathing again if you've overdosed. That's all it does.

Interviewer: So I know that you're an advocate for having the conversation. It's not just for people that are homeless or at The Road Home. There are plenty of other people that have drug addictions, that have families and live in homes. What would you say to a person that's in that situation that's listening?

Dr. Plumb: Well, I think probably the best way to speak to them would be to provide some examples of folks that have reached out to us. Sam and I can both give you examples of different conversations that we've had with people. I think one of the most powerful ones for me thus far, since we have embarked on this, has come from a mom who desperately reached out to us to get Naloxone. She had asked multiple providers, her physician, other physicians, emergency department physicians, addiction physicians.

She'd asked for a prescription for Naloxone for her son, who was a heroin addict, and at the time he was clean. We all know that one of the times that you're most at risk of overdosing is when you've had a period of sobriety. So your body is not at all accustomed to opiates, even as short as a period of three days and you go back to using what you used before, and you can overdose. So this mom reached out to us and in desperation said, "Can you please help me get Naloxone?"

She came up to Primary Children's and met with me. I educated her on how to use that. I was willing to write her a prescription. She was so uncomfortable getting it from the pharmacy that I ended up just giving her a free kit, which we have the ability to do. She didn't want that on her record. She didn't want that anywhere in the medical record.

Despite the fact that it's completely legal, insurance companies cover it, that it's been done for two decades now in the U.S., she had that stigmatization worry. She got the kit, and within a week she had to use it to save her son. I mean, it gives me chills even now thinking about it, because whether it was her motherly sixth sense or her experiences from the past, but she knew, and she almost didn't have that opportunity to save her son's life. Sam took a call today from a gentleman . . .

Sam: He has some type of chronic back disorder and he's in tremendous pain, and surprisingly he told me that his prescription for pain relief is morphine. He's receiving six doses of morphine throughout one single day of 60 milligrams each dose. Typically, 100 milligrams is something where you start to think of somebody as very high risk, or is a very high dosage, and he's taking 360 milligrams a day.

He's bedridden, he can't work, but he made the effort to call out to get Naloxone, because he said, "I fear for my life with the amount of medication that I am being prescribed, and I worry that my doctor may prescribe more. I want my family to be able to save me if I overdose."

This is a similar story that we hear from other people as well. These aren't just people that are down on their luck. These are people who are taking their medication as prescribed.

Dr. Plumb: And are still just at risk, because at the bottom line, end of the day, these are risky substances. It isn't about a risky person. It isn't about a moral character judgment. It's about these are risky substances, and they are everywhere in our society. I think all of us should take a little thought about, "Do I have these in my home? Do I have these in my home for a legitimate reason, or what may be an illegitimate reason?"

It doesn't matter to me. If they're in the home, they don't discriminate. They can absolutely cause an overdose and a death, and being prepared is really just not only smart, but it's appropriate. It's not asking for anything wrong by asking to be able to keep yourself or the people that you love alive.

Interviewer: It's like having a fire extinguisher or a first-aid kit, or an EpiPen, or an inhaler, or any of those things that you would use.

Dr. Plumb: Absolutely. Although, interestingly, an EpiPen which is absolutely vital for people who have anaphylaxis or allergic reactions to things, an EpiPen can actually hurt you. It's epinephrine, adrenaline. That can cause heart arrhythmias. That can actually hurt you. Naloxone can't hurt you. So I mean, even a level beyond it, I absolutely advocate for EpiPens and think they should be everywhere we know where they should be, but Naloxone is even safer. But it is very much the same thinking, that if there were to be that worst case scenario, you'd be prepared.

Sam: I think that's something that is particularly salient here in Utah, because we have our own culture here and it is a very stigmatized issue, whether it's an opioid pain medication or if it's an illicit substance. But we do hear from people that call us to talk about Naloxone after it's too late. Oftentimes in Utah, unfortunately, the conversation starts too late, when somebody has already been lost and there's nothing that can be done. So given how simple it is and how safe it is, it just makes complete sense to have it.

Interviewer: That's right. This can be that conversation.

Dr. Plumb: Right. Absolutely.

Interviewer: Right?

Dr. Plumb: Think about it.

Interviewer: This is the conversation and now go out and get . . . So do you just, prescription from your physician?

Dr. Plumb: Yeah. Your physician can absolutely prescribe it there. It's 100% legal for them to do so. Some physicians are a little uncomfortable with it, and I think that this will come in time. The law is pretty fresh still. I think physicians will become more comfortable with it.

But if you do run into a conversation where your physician states they're not comfortable, reach out to us. I can absolutely call in a prescription statewide, and we have done so from St. George to Brigham City and Wendover to Vernal, statewide. It's absolutely legal for me to call in a prescription for anyone who's either at risk of an overdose or at risk of witnessing an overdose.

Sam: For more information or to view our training videos, or even for other resources such as treatment and medication-assisted treatment, we have all of that listed at www.UtahNaloxone.org.

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Interviewer: How to treat addiction based on what we understand about the neuroscience of addiction. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Eric Garland is a clinical researcher and practicing licensed psychotherapist at the University of Utah. Neuroscience is looking at a new way of thinking about addiction which then would guide how we would treat addiction. Give me a little background, how the school of thought in neuroscience treats addiction right now or thinks about addiction.

Eric: Sure. So there's really a way of understanding addiction that has emerged out of the past couple of decades, and there's been a lot of research and time and energy put into understanding this problem, and what we're coming to realize is that addiction is really a process of normal learning gone awry. The same processes in the brain that facilitate normal learning get hijacked by drugs of abuse.

Normally when we learn things, when we have an experience and the experience is rewarding, this tells the brain to do this thing again. And so we learn that that activity or that experience is valuable. We get some sort of pleasure or reward out of it.

In everyday life that might be good relationships with people that we care about, doing activities and hobbies that we love. It might be something simple like enjoying the pleasure of a tasty, healthy meal or a beautiful sunset or the snow on the mountains, but as a person becomes addicted, the effects of addictive drugs on the dopamine system in the brain cause changes in this normal learning pattern such that what was once rewarding becomes less rewarding and the brain becomes more and more dependent on drugs to receive the same amount of pleasure and reward.

Even drug use itself in the beginning is highly stimulating and rewarding to the brain. It produces a surge of dopamine release. But over time, the drug itself produces less reward and drug use becomes more and more of an automatic habit. People start to use drugs on automatic pilot without getting any pleasure out of it. It's just like any other habit we have that we do. The more you do it, the easier it becomes, the more automatic it becomes, the less you have to think about it, and that habit starts to become triggered by cues. For example, if you're an alcoholic driving past the bar or driving past a liquor store, or if you're a smoker and you smoke in social situations.

Interviewer: Or just even driving. I've known smokers that I could predict when they pull a cigarette out based on where we were in a trip.

Eric: Exactly.

Interviewer: By the time we hit the stop sign at the end of the street, a cigarette is going to be out. By the time we hit here, another cigarette's going to be out.

Eric: Exactly.

Interviewer: So wow, okay.

Eric: And they may not even intend to be smoking it. They may not even realize that they're smoking it. A lot of smokers have the experience of sort of looking down and seeing that half their cigarette's gone up and they don't even remember smoking it. It just becomes an automatic habit. It doesn't even give them pleasure anymore.

Interviewer: And then worse yet, the other things that didn't give them pleasure, don't give them pleasure anymore.

Eric: That's right.

Interviewer: So what do you do with that point? How do you break this cycle?

Eric: Right, and so the cycle, it gets worse because the things that used to give them pleasure are no longer giving them pleasure and the drug isn't giving them pleasure. The person is in a deficit. They're in a negative mood state and that really drives them to take higher and higher doses of the drug just to feel okay. And there's the addictive cycle right before you.

Interviewer: So how do you solve that?

Eric: Well, if this is the problem then it seems that we need treatments that can do two things. One, they can help a person become aware of the automatic habit of addiction, to become aware of when cues are triggering this automatic habit so that the person can begin to exercise some self-control over the automatic habit.

And then two, we need treatments that can help people to find a way to enjoy pleasure in life again, to teach the brain to relearn how to feel a sense of pleasure and reward from everyday activities that used to bring them pleasure.

Interviewer: And what are some of those things that you can do to start discovering pleasure in life again?

Eric: Yeah, so that is where a technique called mindfulness comes into play because mindfulness is really, although it's based on some ancient techniques for training the mind, we're coming to realize now with neuroscience that this approach actually strengthens both of those processes, both self-control over automatic habits as well as increasing attentional focus that might enhance the experience of reward.

Interviewer: Let me jump back for a second. So this is just one way of looking at addiction, what you've described to me. How sure are we that this is the way it is? I mean, how have they figured out this much?

Eric: There've been multiple millions of dollars invested by the National Institutes of Health, specifically the National Institute on Drug Abuse and the National Institute on Alcoholism devoted to this topic. These studies range from studies with animals, studies with humans and even studies down to the cellular level to understand how neurons communicate to each other and how drugs actually affect neurotransmission.

One simple way that this has been shown to be the case is by putting people in a brain scanner and watching how their brains respond when they're shown drug-related cues on a screen, for example, pictures of cigarettes, and showing activations in brain circuits in the reward center of the brain, and as addiction progresses seeing activations in the dorsal striatum which is the part of the brain that's involved in habit responses, and conversely seeing the opposite effects with regard to naturally rewarding queues.

So if you put somebody in a brain scanner and this person has developed addiction and you show them, for example, cues of smiling babies or beautiful sunsets or couples holding hands, the brain responds less sensitively to those cues.

Interviewer: It seems like some people are more prone to addiction. With this way of thinking, why would that be, or is that a false statement to begin with?

Eric: No, there's quite a bit of research looking into, for example, the genetic factors that predispose somebody to addiction, but in the line of discussion that we're talking about, people vary to the extent to which they're naturally sensitive to rewards. They vary to the extent to which they seek out novelty, they're sensation-seeking is the term, and they also vary to the extent to which they can control their impulses. Some people are just better naturally at stopping themselves and exerting self-control than others.

But my interest as a therapist is how people can train those capacities so that no matter where you start from, you can train your mind to strengthen self-control and strengthen your ability to experience pleasure in everyday life.

Interviewer: Are there any resources that if somebody wanted to learn more on their own that you could steer them towards?

Eric: There are a number of practitioners in the community that are practicing mindfulness-based therapies and there are also a number of providers in the community that are practicing other evidence-based treatments for addiction like motivational interviewing and cognitive behavioral therapy.

Interviewer: How is this way of treating being approached right now by the rest of the addiction community, people that don't subscribe to this philosophy?

Eric: This is a really hot topic right now in the addiction research field in terms of the importance of reward, the importance of sensitivity to natural reward as a predictor of addiction-related problems, but the idea that we could actually improve this capacity in somebody who is addicted and has lost the ability to feel pleasure in everyday life, this is a brand new thing. So it's a pretty hot topic and controversial.

Interviewer: Yeah, and not only overcoming addiction but actually maybe even be happier than they were ever before.

Eric: Exactly. It has a lot of applications to other issues, too, like depression or chronic pain and just improving the healthy response in life.

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Interviewer: Using mindfulness to overcome pain pill addiction. We'll tell you how, next on The Scope.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: You or somebody you know suffers from chronic pain and as a result now has an addiction to the pain pills. Eric Garland is a clinical researcher and practicing licensed psychotherapist at the University of Utah, and there is a technique called mindfulness that could actually help get rid of the addiction and manage the pain as well. Tell me a little about that. First of all, does it really work?

Dr. Garland: It seems like it works. We have a body of research that's building that indicates that mindfulness is a really useful treatment for addiction. We're still actively studying this area, and really, it's an emerging research area, but there have been some pretty big well-controlled trials to show that it's helpful for this problem. I myself have done some of them.

Interviewer: I think sometimes people think of mindfulness and they think, "Oh, mind over matter. If it was only that easy." Right?

Dr. Garland: Right, and it's certainly not easy and I don't want to be flippant about it. This is tough stuff. We're talking about deeply entrenched habits. And it takes a lot of energy to change a deeply entrenched habit. But if you think about it, what mindfulness really is, it's a form of mental training.

So think of it this way. If you wanted to build up your bicep, you would curl a dumbbell and you have to put in a lot of energy, rep after rep, week after week, grueling workout after grueling workout to build the strength of your bicep. Well, if you want to build the strength of your mind to enhance your self-control over addictive habits, then you have to apply the same principle of repetition after repetition of mindfulness practice over and over again, day after day, week after week and you build up your mental strength through a very similar type of process.

Interviewer: So tell me, then, now. With somebody with pain pill addiction, how do they use mindfulness to overcome it? What would they do? Walk me through that process.

Dr. Garland: Yeah, let me walk you through the process. So let's assume that we have someone who's taking pain pills for a chronic pain condition but their use of the pain pills has sort of gotten out of control. One of the techniques we teach them is to practice mindful breathing before taking their opioid medicine. What that means is when the person is getting ready to take the opioids, instead of just popping the pill they stop, they pause, and they begin to focus on their breathing, and as they begin to focus on their breathing they begin to notice thoughts and feelings and urges, for example, the urge to take the pain medicine. In practicing mindfulness like this, the person may begin to realize whether their taking opioids is a means of alleviating pain or perhaps they're taking opioids as a means of getting rid of a craving, satisfying an urge as opposed to satisfying a genuine need for pain relief.

Interviewer: So then at that point what do you do? You just make the decision that wait, it is a craving. I'm not going to take this pill.

Dr. Garland: Well, in the case of somebody who is really dependent on opioids that would be dangerous to just stop taking the pill at that point, but by gaining that awareness the person might decide that they want to change their opioid use habit, so they might be able to work with their doctor to gradually decrease their dosage.

Now, if a person is really dependent and they start to decrease their dosage of opioids under a doctor's supervision, they may experience withdrawal or they may experience craving, and mindfulness techniques can be useful to help a person cope with the unpleasant feelings in their body and the unpleasant emotions in their mind during that process.

Interviewer: So it's really just kind of coming into touch with, "What am I feeling right now," and not just assuming that you're feeling pain or whatever, and then assessing that, and then deciding what you're going to do with that.

Dr. Garland: That's definitely a part of it. That's a big part of it. Another part of it is this process that we call mindful savoring, which is using your attention and your awareness to experience greater pleasure out of everyday activities and events. So again, as we discussed, from a neuroscience perspective addiction involves a process where the person becomes less sensitive to natural pleasure. When practicing mindfulness we can teach people to focus their attention on the positive and good aspects of their life so that they can actually enjoy it more. So let me give you an example of that.

In this mindfulness technique we have patients practice by focusing their attention on a bouquet of flowers. So they focus on the beautiful sights of the flowers, the colors, the textures, the touch of the pedals against their skin, the scent of the flowers, and whenever their mind wanders off to random thoughts they notice that their mind has wandered and they bring the focus of their attention back to the pleasant features of the flowers; the scent, the smell, the texture, the color. As they do this, they become aware of positive feelings in their mind and their body, and then the positive feelings and thoughts that arise in their mind and body become the focus of mindfulness practice. So we encourage the patient to focus their attention on any positive emotions or thoughts that come up.

This technique involves practice both in sessions with a therapist but also practice at home with other enjoyable things in the person's everyday life, and this technique is designed to help them to re-learn how to experience pleasure.

Interviewer: So with somebody with a pain pill addiction, the first thing that they would do is use mindfulness to just kind of become aware of, "Why am I popping this pill," and then if they've decided, "I want to do something different about that," you would recommend going to their physician and telling them, "I would like to get myself off these pain pills."

Dr. Garland: That's right

Interviewer: And a therapist would probably likely be involved as well with some mindfulness training.

Dr. Garland: That's right. So as the person goes to the process of reducing their use, they may experience craving for opioids, and mindfulness can be used to cope with the craving, again by first helping the person become aware of the sensations in their body, their craving-related thoughts and emotions. As the person becomes aware of the craving the feelings may start to get overwhelming, so they can use mindfulness techniques to focus on their breathing as a way to calm down the mind and relax the body to help the person to cope with the difficult thoughts and feelings without giving in to opioid use. And when this process is repeated over time, the craving can become weaker and weaker.

Interviewer: Any tips for somebody that's listening and they're convinced, "I want to do this". Do you have any tips for them, anything they should watch out for, anything they should absolutely do?

Dr. Garland: They should absolutely work with a trained and licensed therapist through this process. I don't think it's something that somebody could do so easily on their own in the beginning, but as a person learns these techniques with a skilled teacher they can begin to practice them at home alone by themselves, and that'll help them overcome the problem.

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Interviewer: You have somebody in your life who is entering the alcohol recovery process or is in recovery and you want to be supportive but some of the things you say might actually be harmful.

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Interviewer: We're talking with Dr. Jason Hunziker, psychiatrist at the University of Utah. Dr. Hunziker, people who are recovering from alcohol addiction, it's a really hard process and they need all the support they can get.

Dr. Hunziker: The choice to go into recovery is a big deal for everyone who does it. It's a very difficult process and it does take a lot of support not only internally but from people in the environment and from systems that help people enter the recovery process. We do have to be careful however what we say to people as they are getting ready to enter that process and as they are in that process so that we can motivate them to stay sober and make this big change in their life.

Some of the things I recommend that we don't say are things like, "Hey you can have just one, and it's not going to hurt anything." That clearly is not going to be helpful to somebody who is telling you that their life has been destroyed by alcohol. That's sets you up for failure in your process and in your program and so that's something that should be avoided.

Interviewer: So what are some other things that people say sometimes that you think are supportive but really aren't?

Dr. Hunziker: Somebody is in the program and you think you're being supportive by visiting them and then you say, "You know I'm glad you're doing this right now. It's a good time for you to do this but one day you're going to be able to drink again."

Interviewer: Really? They say that?

Dr. Hunziker: Yes, and again that is not something that is helpful at all to maintain the sobriety that they're looking for. When you stop, you still have the addiction. You just choose now not to use. And I use the word choose pretty lightly because if it was that easy to quit, everybody would just quit. So they make the decision to everyday get up in the morning and realize that they're not going to use and then go through that day not using even though they still have some cravings, they still have some desires and they still fight that impulse to go get some alcohol.

Interviewer: Okay, what are some other things that people might say?

Dr. Hunziker: Other things people say when they don't realize you don't realize you're an alcoholic at all they'll say, "Wait a minute. I see you go to work every day. You have a job. You're still making money. How can you be an alcoholic?" They think that just because you can function that you're not an alcoholic. But that still does not mean that this does not interfere with other aspects of your life.

Some people will say when you've been in the process for a long time and you've been going to your recovery meetings and you haven't had a drink they'll say, "Aren't you done yet? I mean, you've been doing this for years, shouldn't you be cured already?" There's no cure. I mean the cure is to not drink and the only way to not drink is to get positive support and to be actively making sure that doesn't happen.

Interviewer: Okay, any other things that people might say they think are supportive to a recovering alcoholic but might not really be that supportive?

Dr. Hunziker: Well I think sometimes people want to down play or minimize the alcoholism in the other person's life and so they will say things like, "Well I eat food every day, that doesn't make me addict so how could you be an addict?"

Interviewer: Because those two things are so comparable.

Dr. Hunziker: Exactly, exactly. So clearly our words are very important when somebody has made the decision to go into recovery and we need to choose those words carefully. We don't shy away from having conversations but I don't think we want to interfere and actively seek out information about the alcoholism. If somebody wants to give it to us, great. Let's listen, let's be supportive but if you start asking a lot questions people feel like you're being intrusive and then when you're intrusive it sets them up for failure.

Interviewer: So what are the words and the conversations that you can say to recovering or you should be saying to a recovering alcoholic?

Dr. Hunziker: It's not so much what you say all the time but some of the things that you do. Be available so if they call you in the middle of the night you don't say, "Oh, you're just drunk again" or " Oh, here it goes again." You're supportive, you're available, and you're encouraging them to use you as a support system so they don't go drink. Other things, you stay positive. Keep giving them encouragement all the time because it is a difficult process.

I mean you could imagine if you had to give up something you really enjoyed doing even if you didn't really think it was causing you that much problems. So you want to make sure that you're positive and they get encouraged by you so they will continue to fight the addiction.

Interviewer: So say you know someone who is thinking, who is considering the recovery process, what can you say to them to kind of motivate them to enter it?

Dr. Hunziker: You know I think normally what you want to do is have them think about how this helps them or doesn't help them. If you can say to them, "Okay, let's make a list of how alcohol helps you in your life, and then let's make a list of how alcohol hurts your."

Interviewer: Doesn't help you in your life.

Dr. Hunziker: Exactly, exactly.

Interviewer: Pros and cons.

Dr. Hunziker: And then people can look at that and then you can provide motivation based on the positive feature say, "Look what you can... You want these, you want that, you want this. The only way to get that is to be sober and if you can be sober, good things are going to come."

Interviewer: So any final thoughts that you have about recovering alcoholics, what you should and shouldn't be saying?

Dr. Hunziker: The only thought I have is that if somebody comes to you and says, "I'm contemplating stopping my drug use or my alcohol use." Please refer them to somebody who has a knowledge of recovery, has a knowledge of treatment, their primary care doctor, Alcoholics Anonymous, Al-Anon, somewhere that they can get that process moved from contemplation to full active recovery.

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updated: March 12, 2019
originally published: November 5, 2014

Interviewer: I think most of us at one time or another may have joked that, "We're addicted to chocolate," or, "I'm addicted to that TV show," but those addictions aren't real addictions. We're going to examine addictions next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Elizabeth Howell is with the University of Utah Hospital. Let's talk about addiction for a second. Now everybody jokes about, "I'm addicted to chocolate." That's not really addiction, is it?

Dr. Howell: Not really. I mean, some of the same brain processes are involved, but chocolate doesn't usually cause people to lose their family and their house and their life. It's a compulsion maybe to eat chocolate . . .

Interviewer: Sure.

Dr. Howell: . . . but it's not something that's going to kill you.

Interviewer: So let's talk about true addictions. I was doing a little bit of reading, and it just really was strange to me that if somebody is truly addicted, they can't look out for their own well being, they can't make decent decisions, because a lot of times people, you'll hear them say, "Well, wow, why didn't they just make a better choice than doing drugs?" But they really don't have that ability, if I understand correctly. Is that accurate?

Dr. Howell: Well, yeah. You have some choices about some things, but I think the main thing to remember is that when you're actively addicted, and you're using drugs or alcohol or both, that your brain is not working right. I mean, it's not the same as having a brain that is sort of firing on all cylinders at the same time.

Interviewer: Yeah. Is it the actual addiction, or is it the drugs, or a combination of both?

Dr. Howell: Both, really.

Interviewer: All right.

Dr. Howell: So the drugs actually, they alter how you perceive the world and how you see things, but they also do something that's very important, which is they activate the process in the brain, which is the addiction process, that really distorts how people think. So in Pennsylvania, there's kind of an epidemic of people mixing fentanyl, which is a very potent opioid, with heroin, and a lot of overdose deaths have happened because of that. And if you're someone in the public, you'll say, "Wow, that's really scary. If I were a heroin addict, I wouldn't be using anything right now . . .

Interviewer: Yeah, sure.

Dr. Howell: . . . because I'd be afraid I'd kill myself."

Interviewer: Yeah.

Dr. Howell: But if you're a real active addict, what you think is, "How did they get the good stuff?"

Interviewer: Really, that's the thought process?

Dr. Howell: That is the thought process.

Interviewer: And they want that.

Dr. Howell: And they want that, because they want something that is so good that it might kill them, and that is the insanity, as they say in the 12-step programs, of the addiction. The insanity of the disease is that your thinking is very distorted.

Interviewer: And that's how they frame in the head, "I want something so good it'll kill me?"

Dr. Howell: Well, it could be, yeah.

Interviewer: Wow.

Dr. Howell: You could get to that point.

Interviewer: So inside the brain, let's say somebody just has an addiction, but they're not currently using.

Dr. Howell: Right.

Interviewer: Is their brain a little different than somebody without that predisposition towards an addiction?

Dr. Howell: There are probably some differences in the brains of people before they ever start using. In the twin studies that have been done using alcoholic families, and alcohol is the easiest thing to study compared to other drugs, if a child was born to an alcoholic father and adopted into a non-alcoholic home, they still had a much higher risk of becoming alcoholic. The highest risk was a child of an alcoholic biological father adopted into an alcoholic home. So the nurture part, the environment, did play a certain role, but by far the biggest risk for addiction is genetic.

Interviewer: Does the brain physically get rewired because of addiction?

Dr. Howell: I don't know if it gets completely rewired, but there are certain genes that are turned on or off, depending on the different genes, when you start using.

Interviewer: Okay.

Dr. Howell: And, like you say, they're kind of laying there dormant.

Interviewer: Sure.

Dr. Howell: It's like a room with the lights off, but when you turn the lights on . . .

Interviewer: By taking a drink or doing a drug.

Dr. Howell: . . . right, then certain genes could be turned on or turned off. And the way that this happens, it's not like the first time you ever use that all the changes that happen, by the time you've been using for 20 years, are there. They happen over a period of time and in sort of wave of different changes in the brain, different parts of the brain, different systems of the brain, and it's quite complicated. I don't know if you would call it rewiring, but it's definitely a re-engineering of the brain.

Interviewer: So we've talked a lot about addiction. I want to talk for a moment now, and kind of wrap this up with, if somebody is a loved one of somebody who is addicted, help them be in the mindset of the addicted person so they can better help them.

Dr. Howell: I would try to imagine it as thinking of something that you feel like you have to have for life, like it's something that you need to survive. And when you're in the throes of addiction, the person who's addicted really feels as if that is the most important thing in life, that it is actually more important than food, or their children, or whatever, and that the drive to use is so strong that their behavior seems insane, because it is. Because what you can't control is the craving and the mental obsession and the compulsion. Now people obviously get into recovery, and they stop using, so we could get into this is it really a disease, can you really control it sort of debate, but what you can't control is what your brain is telling you. That's like saying if you're diabetic, I will not let my blood sugar go up.

Interviewer: Yeah.

Dr. Howell: You can do as much as you possibly can to keep your blood sugar from going up, but you can't always control that, because that's a physiologic process that is independent. And that's what the addiction is. Once it gets started, it's an independent physiologic process that can be managed, but it can't be just gotten rid of or controlled.

Interviewer: Or cured.

Dr. Howell: Or cured, yeah.

Interviewer: It's always there.

Dr. Howell: Right.

Interviewer: So what could somebody do to help that person? Because I don't think this is a do-it-yourself sort of a thing.

Dr. Howell: No, not really. And what we tell family members first is get informed and find out what you need to know about addiction and take care of yourself, because many times a person comes in for addiction treatment, their family has been trying to help them, but they've been doing it sort of in a backwards way. They're well-meaning, but they've been kind of enabling the person. They've been covering up for them. They've been bailing them out of jail. They've been doing this and that. And so you don't want to do that.
People need to experience the consequences of their addiction, and sometimes it's the only thing that will wake them up, because your brain is all changed, it's not working right, and you need a big wake-up call, and sometimes that needs to be letting people "hit bottom." Where you don't want somebody to hit bottom is if they're in danger of dying and hitting bottom, but if they're going to go to jail, or whatever, then I would let that play out, and then have a plan that, "Okay, we'll help you get out of jail," if that's what's happening, "if you will go to treatment."
There are some medications that can help, although we don't have enough, and then there are also many psychological, psychosocial treatments that include psychotherapy and changing behavior, more behavioral therapy, going to 12-step meetings, or some kind of support group.
The other thing you have to make sure of is that anything else that is involved that may be impacting the addiction is being treated. So if someone's depressed, they have post-traumatic stress disorder, or they're bipolar, or whatever, some sort of mental illness or mental disorder gets treated appropriately without addicting medications.

Interviewer: Yeah.

Dr. Howell: Yeah, because that's where I see a lot of people getting into trouble, is they have anxiety, so they're put on something else, like a benzodiazepine that's addicting, like Xanax or one of the others, and that's only going to make the problem worse. And the other thing that you need to do is make sure that besides that you're treating the psychiatric or mental problems, that you're also treating any physical problems that are going on. Somebody could have hyperthyroidism or something that could be triggering them to drink.

Interviewer: Sure.

Dr. Howell: I mean, there are a number of things. So the physical and the mental you want to take care of, and make sure that whatever treatment program you're looking at has the ability to check for those things and treat them, if appropriate.

Announcer: We're you're daily dose of science, conversation, medicine. This is The Scope. The University of Utah Health Sciences Radio.

Interviewer: Sixty-six percent of Americans say they occasionally drink, and that number is increasing. Are we drinking too much, too little, just the right amount? How does this all affect your mental health? That's coming up next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: We're here with Dr. Jason Hunziker, psychiatrist at the University of Utah Hospital. Dr. Hunziker, the first question is mental health and alcohol addiction. Is there a connection between the two?

Dr. Jason Hunziker: Clearly. There's clearly a connection. Unfortunately, it's a complex connection, and there are several different theories on how this happens. Is it the alcohol changing neurotransmitters in you brain that causes the mental health? Were you already depressed and anxious, so you started drinking as a way to fix your anxiety and your depression? Did the alcohol and the depression start at the same time? Is it mixed that way? It's really hard to know in most people which came first and what the connection is, but we do know that mixing the two is not healthy for you.

Interviewer: What do you mean by mixing the two?

Dr. Jason Hunziker: If you're depressed, you're already putting yourself in a position, particularly if you're not getting treatment, that you have a hard time taking care of yourself. Getting out of bed is a struggle, trying to get to work, and if you have kids, taking care of your children, it's very difficult.
Then, you throw alcohol on top of that which is in and of itself a central nervous system depressant. The alcohol actually makes you more depressed. It makes it harder for you to function. You lose time at work. You have marital problems, relationship issues with your children. It can lead to more trouble taking care of yourself and lead to childhood abuse and neglect.

Interviewer: It's almost like the chicken and the egg thing. You don't really know if it's a mental thing first or if it's an addiction first, right?

Dr. Jason Hunziker: That's correct. It's really hard to know for a lot of people, and when we evaluate people who come in with alcohol and mood disorder we have to take some time to figure out were they already depressed first or did the alcohol come first and that's what caused the depression.

Interviewer: Is that important in the treatment, to know which one came first?

Dr. Jason Hunziker: It's definitely important in the way we diagnose the illness. Often, we don't diagnose depression or anxiety if we feel like the alcohol was the direct cause of that. Often, what we see is people have been depressed unknowingly for a long time and then picked up the alcohol as a way to kind of medicate that, and it didn't work.

Interviewer: I mentioned earlier that we both talked about how alcohol has become such a normal part in American society, American life. It's like a part of your day. Is that normal? Is that healthy? What's going on there?

Dr. Jason Hunziker: Again, healthy, probably not...

Interviewer: Not even the red wine?

Dr. Jason Hunziker: There is some evidence that red wine can be healthy if you drink it in the five ounce or less per night and that's all you have. The problem with most people is...

Interviewer: That's not all they have.

Dr. Jason Hunziker: ...that's not all they have. In fact, a study that came out recently from the CDC shows that 38 million Americans say they drink too much.

Interviewer: Really, they admit that?

Dr. Jason Hunziker: They admit it, and these are people who aren't considered alcohol dependent.

Interviewer: How do you treat that? Can you treat it, or is it classified as a mental illness at that point?

Dr. Jason Hunziker: It is, and in the new DSM-V it's called the substance use disorder.

Interviewer: Okay.

Dr. Jason Hunziker: Yes, there is treatment for it. First and foremost, you need to make sure if you've been drinking too much that you talk to your medical doctor. Alcohol detoxification can be tricky and at times deadly and needs to be monitored closely just to get you through that initial phase of getting the alcohol out of your body.
The detox part, believe it or not, is the easy part to this process. Staying off of alcohol is when it becomes very difficult, because if you go back and drink one drink it is never enough for you and you will start drinking again and again and again. Then, it leads to all those problems that brought you in in the first place.
We do have treatment. There are inpatient programs where you can go stay for 30 to 90 days, learn all about addiction, learn what to watch for, make sure that you stay sober. There's AA, which is free meetings all over the town. Every hour somewhere there's a meeting with great support system to help you stay sober. There's intensive outpatient programs that are available for people to go to which are four days a week at night time when most people are drinking, so it keeps people from using alcohol.
The reason alcohol is so important is that it doesn't just affect your life.

Interviewer: Right.

Dr. Jason Hunziker: It can affect everyone around you. When you're addicted to alcohol often you do drink by yourself, because you don't want people to see how much you're drinking. You'll start drinking at work. You'll drink in your car. You'll drink while you go grocery shopping. You'll drink Listerine and mouthwash and Nyquil just to get the alcohol out of it?

Interviewer: Really? Oh, so it's...

Dr. Jason Hunziker: It leads to all kinds of medical complications.

Interviewer: What are some of those medical complications that you just mentioned?

Dr. Jason Hunziker: Some of the medical complications can be liver failure.

Interviewer: Of course.

Dr. Jason Hunziker: Alcohol can also lead to hypertension. It can lead to problems with respiratory drive and respiration. Then, of course, the family issues that come from alcohol can be devastating. You're causing yourself issues, the depression, the anxiety. That can bleed over as anger and frustration to your significant other and your children, which then gets perpetrated later again in life by your kids.

Interviewer: Any final thoughts?

Dr. Jason Hunziker: I think that if you or someone you know or love or care about you think has an alcohol problem, please approach them about that. Tell them why you're concerned and what the concern is. Get them to their doctor where they can get some more resources. There are plenty of things online that you can pull up and say hey, this is where I can go get treatment.
If nothing else, go to an AA meeting. They're everywhere all the time. Everybody has an hour that they can go sit. Even if you're intoxicated, go sit in the meeting and hear what these people say about sobriety and how they can help you get sober so you can improve your life and the life of everyone around you.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.