Addiction As A Primary Care
April 28, 2020
We have guest Dr. Gilmore Chung joining us on the show today. Dr. Chung will be giving us some insight into how physicians can provide help to people with addictions during a primary care appointment. Following Dr. Chung we have Patrick Dunn, the President of Recovery Services at Landmark Recovery. Patrick will be joining to tell us about some of the the recent trends in the addiction treatment field that are resulting from the Corona Virus pandemic.
Welcome to Recovery Radio by Landmark Recovery with your host, Zach Crouch. In this program we’ll discuss the root causes and treatments of alcohol and substance addiction, speak with experts in related fields, and help navigate the road to recovery.
Now, here’s the host of Recovery Radio, Zach Crouch.
Zach: Hi. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and don’t forget to subscribe to get the most up-to-date information from leading experts.
We have guest Dr. Gilmore Chung joining us on the show today. Dr. Chung is the Director of Addiction Services at Venice Family Clinic, a community health center that serves 28,000 men, women, and children living in poverty. He graduated from the University Of Kentucky College Of Medicine in 2008 and he finished his residency in Internal Medicine and Pediatrics at LAC-USC in 2012. Dr. Chung will be giving us some insight into how physicians can provide help to people with addictions during a primary care appointment.
Dr. Chung, thank you so much for joining us on the show today.
Dr. Chung: Thank you.
Zach: Tell me a bit about yourself and why you decided to pursue a career in medicine.
Dr. Chung: The funny thing is I really didn’t intend to pursue a career in medicine. I was working on my Master’s in Spanish. I thought I was going to finish my PhD and then go teach literature or Spanish, something like that.
Zach: That’s romantic.
Dr. Chung: Yes, something. Yes. I ended up taking care of a friend’s mother and I realized that I would much rather be taking care of people for a living. That changed my life and I decided to go to med school and here we are.
Zach: Got it. In your practice at Venice Family Clinic, how do you address people’s concerns about their drinking or drug use for that matter?
Dr. Chung: That’s been an interesting journey for the clinic. I joined the clinic when they were just finishing working with Rand on a study about how to effectively address substance use in primary care. Prior to that study, it seems like most of the clinic didn’t really think that substance use was a problem for our patients; but through actually addressing it as an issue through screening every single patient starting from their teen years about their drug and alcohol use in their primary care appointments, we’ve worked on a model for providing substance use treatment in a primary care center.
We’ve got same-day counseling for patients. We have counselors available at each our sites so they can talk with patients the same day during the same appointment and if patients are interested they can follow up with a counselor. Even if they don’t want to speak to a counselor, most of them are quite happy to speak with our patients about their substance use. If a patient is interested, we can do what’s called a warm hand-up and introduce the patient to the counselor.
It’s important to have those on the same day available because all of our patients they’re living in poverty. It’s hard for them to come and go on another day or to get to another location to get help. They may not have transportation or their employer if they happen to be lucky enough to be employed they may not be able to take days off for another medical appointment. They may not have child care.
We do try to address the needs when the patients are interested and yes following up on that. A lot of times whenever patients are struggling with substance use, they may come up for air, so to speak and “Hey, you know what? I need some help right now.” It’s important to be able to address that need right then rather than, “Okay. You’re interested in some substance use help. Come back in a month.” Most of these patients’ lives are pretty disorganized so when they’re interested it’s important to be able to deal with their issues right then.
Zach: Absolutely. I’m just curious to know a little bit more about the conversation that takes place when someone walks in and it’s very apparent to you and maybe your staff that this person has an issue, but they are maybe just not open to the idea of admitting that they have a problem. How do you finesse that conversation?
Dr. Chung: It varies patient to patient. Sometimes, it’s interesting; we do screen all of our patients. There are just some short questionnaires asking how often in the past whatever amount of time they happen to have used any number of substances which is great for screening but then I found that doesn’t necessarily catch as many patients as you had hoped because as you would expect patients may be reticent to talk about their substance use with a stranger to start with.
The conversation, once again it’s going to depend on every single patient. Some come in because they have an abscess on their arm and they don’t even want to talk about why they have an abscess, why they have an infection, but then even though you’re asking, you’re trying to be as gentle as possible with it they may not come forward with it. When they’re coming in on another then they’re able to realize, “Hey, you know what? I’m being treated non-judgementally. They’re expecting me [Inaudible][05:47] and then they’re able to say, “You know what? I trust you. Let me talk about this.”
There’s one of my guys who, I think I started with him; he was in his 60’s and he had 40-some years of using heroin and he’s never ever talked to anybody about it. Through just taking care of his primary care issue which is skin infection and showing him we were accepting him, he was able to open up with us, talk about his substance use, and we’re able to offer him buprenorphine. We got him buprenorphine and he’s been great since and hasn’t really been using heroin. He’s had occasional use but for the most part has not had any serious substance use since.
Zach: That’s great. That’s fantastic. I’m curious also about…one of the big things that I think that’s been successful; I know it’s been successful at least with as far as working with people in the addictive process is the use of motivational interviewing techniques in questions. Is that something that your folks do there?
Dr. Chung: No. Thanks for reminding me. That was actually one of the…what I actually wanted to start with that previous question. All the staff have had at least some introduction, some have had more extensive training in motivational interviewing just to help patients that maybe you don’t where they’re at in the spectrum of use to recovery and help them to come to a point where maybe they are going to be accepting of help and interested in that. Yes, motivational interviewing has been a huge help with us.
Zach: I know that…I’m really happy to hear the piece around providing a space that’s non-judgemental for people to come in because I think if there’s somebody who’ll come in and they have just…they’re just full of shame around this issue.
What I found to be successful, at least without motivational interviewing is that it really does help the patient for themselves frame a solution a lot of the times in their words. It’s nothing more than their own narrative that they’re using to help them get towards the goals that they want to, maybe they don’t know it but they want to achieve.
Dr. Chung: Yes, that’s beautiful. It’s interesting that you bring up shame because that’s one of the recurring conversations that we have with our patients, whether they be individually or in groups.
Due to the COVID-19 pandemic we’re seeing a lot of our patients we’re doing phone interviews with including new patients. It’s great that we’re able to provide that service but there’s something that is definitely missed in the face-to-face interaction just because so many is new to our clinic or new to substance use treatment in general. They don’t know what to expect.
There’s a woman that I called the other day because she needed an appointment. She was able to talk a little bit but she really wasn’t able to fully open up about it because just exactly as you were saying, just shame. She really didn’t want to talk about anything especially not over the phone.
I asked her if she wanted to actually come in and she did come in and we’re able to talk a little bit more, establish more trust with her, and yes, she was able to open up and we’re able to make a lot more progress with that.
Zach: Got it. What does it look like though from a general practitioner perspective to try to help people either avoid addiction or get help when you see it?
Dr. Chung: Avoiding addiction, one if somebody has some pain issues trying to insofar as possible avoid introducing patients to long-term opiate use just because we know that the longer term and more amount patients are using opiates or benzodiazepines and then more likely they are to develop an addiction.
One is just trying to nip it in the bud before it becomes a problem or whenever patients do come in because we have a lot of patients coming in, new patients, “Hey, you know what? I’ve been on whatever amount of narco or Percocets for ages and I just need a refill.”
Talking to the patient, just seeing from their perspective how are they doing with their pain? How are they doing with their level of function? Have they noticed any changes in their life since they started on pain meds?
More often than not, you find that even though a patient may have started taking a medicine because, “Oh, you know it will help me function right,” they’re able to see that “Oh, actually maybe my functioning isn’t actually better,” and then you’re able to introduce that discrepancy in their own head. They will be able to see for themselves it isn’t helping and then maybe, “I need some help with my use.”
Zach: Question, just as a follow-up to that point, I’m curious to know just as far as pain goes because pain is obviously one of the main pieces that the opioid epidemic came out off. I shouldn’t say the pain; the pain medications to deal with pain. Are there some times or a lot of times where you have to have a conversation with a patient and just say, “Some level of pain is always going to be present in your life?”
Dr. Chung: Yes, absolutely. Yes. It’s important to set realistic goals. A lot of the times patients are expecting, “I want to get to, if you’ve got a pain scale of zero to ten, I want to get to a zero.” Helping them to understand that depending on what their condition is, it may not be realistic to get to that point. We would love to get there, but it may just not happen.
Working with them through physical therapy, sports rehab, even just behavioral help they’re able to adjust and able to work with themselves with other modalities to get to their best level of functioning and also learning to work with you and say, “Hey, you know what? Other medications such as Tylenol, ibuprofen, things like that are quite effective for pain in concert with other modalities.”
Zach: Is that difficult to convince people that this is going to be the way that it’s going to be?
Dr. Chung: It is. Sometimes you may not get to that on the very first conversation. It’s important though not to just pull somebody’s medical record where you can check, “Oh, you’ve been to this pharmacy and this provider,” and just hold it up and say, “See? You’ve been using different pharmacies and different providers.”
Zach: Right, right, right.
Dr. Chung: They end up feeling threatened. It’s important for them to feel recognized, feel understood before anything because if you’ll accuse somebody and you’re just trying to catch somebody then they’re just going to go to the next provider. Your day may have been easy because that was a really short visit and they left the office, but you haven’t helped them at all. It’s important to recognize their pain, validate it and then work with them.
Zach: You mentioned things like sports rehab. In realistic expectations, what are some of the other pieces that go into making a person’s treatment plan with you and your practice for that matter successful?
Dr. Chung: One of the things we do, if for example if somebody is on actually does have opiate use disorder for example; seeing if they’re interested in buprenorphine, just Suboxone, Sublocade, Zubsolv, etc. just because one, to treat their addiction and two, it actually does have enogenic properties as well and other things that help, behavioral help because working with a social worker, working with a therapist is very helpful, making sure to have wrap-around services.
If they have a significant disability, do they need to see an occupational therapist? Do they need to see a physical therapist? Just to get them to their highest level of functioning is there a surgical need? Addressing that because making sure that all things that can be fixed are fixed and anything else they can use to improve things does the same. Acupuncture has been very helpful for a lot of our patients as well.
Zach: Got it.
Dr. Chung: One more thing, groups; groups of patients that are undergoing similar circumstances, whether they be 12-Step or non-12-Step-based have been really helpful just for our patients not to feel alone, for them to see other people that are in a similar situation and especially if it’s a group that is led by a counselor to sort of guide the conversation. That we’ve found to be tremendously helpful.
Zach: All right. What in your eyes, Dr. Chung constitutes, I guess this is kind of a tossed-around word but recovery? What does that mean for you?
Dr. Chung: I’m still looking for that answer. I’m still looking for what does success mean.
Dr. Chung: Honestly, I’ve never even known if I’m an optimist or a pessimist on this because I always feel that we’re not doing enough just that there’s always more to do; but then if I try to look a little bit less critically then I can see, “Hey, this patient came in, was using, wanted two grams a day, was possibly sharing needles, was having lots of interaction with law enforcement, etc.”
“Now they aren’t using heroin anymore. They’re on buprenorphine. They’re making their appointments. They’re back with their families. They’re working. They’ve got a roof over their head. They’re not in jail every so often.”
Dr. Chung: That for me would be a success. Sometimes though it’s somebody going from using every day to “Hey, you know what? I only use every couple of weeks.” That still is quite an improvement if you actually look at it. Somebody may go from drinking a fifth of vodka a day to a couple of shots. That is improvement.
I guess it’s having realistic and flexible goals. Asking the patient what their goals are and trying to meet them there and then over time hopefully you’ll be able to do motivational interviewing, maybe get them to have other goals besides “Hey, you know what? How do I just make sure I don’t end up in jail?” Maybe if you stay off enough, we’ll be able to get your seat taken care of. Maybe if you’re able to not use, you’ll be able to get a job; maybe you’ll be able to get off the streets.
Dr. Chung: One, being patient with patients and not imposing whatever I want.
Zach: Your expectations are, right. Yes. Yes. I think one of the things that probably needs to be said is that to that end would you agree that there are some people where abstinence just won’t be possible?
Dr. Chung: Yes. I definitely do believe that. I would love to say no, it’s possible. Maybe it is and maybe it’s just we’ll get there much further down the line, but I think for a lot of patients it’s simply unrealistic to expect that.
Zach: What kinds of patients have you seen that come to mind where that’s just unattainable?
Dr. Chung: Some of my patients who, for example has dual diagnosis for example. Somebody who comes in with a long history of physical, sexual, emotional abuse with post-traumatic stress disorder, untreated anxiety, depression, things like that that they’re using whatever substances to self-medicate. Those would be some of the most obvious patients I think, chronically homeless and have been treating themselves.
It’s I think a great way to be disappointed if you’re looking for those patients to reach sobriety and 12-Step, understanding of such, but if you can help them to just be using in a safer way then I think that’s much more attainable for both patients and for you it’s going to provide much less provider burnout. The patient can actually make more progress that way because if you start off with an unrealistic goal, the patient is going to feel like a failure and the provider as well and you probably won’t make as much progress.
Zach: Yes. I’m curious to hear from you as well on this question. How do we bridge the gap then between…I think we’re really talking about obviously two different schools of treatment or recovery: one is harm reduction-based model and then the other is more or less an abstinence-based model of recovery. Unfortunately…fortunately, unfortunately there are two different camps often.
How would you suggest that…what would be some of the steps or maybe they’re already happening to bridge the gap, so to speak between the two so we can help more people out? Do you understand what I’m saying, between these two?
Dr. Chung: I do, yes.
Dr. Chung: Just one, I don’t care how somebody gets to recovery or how they’re defining recovery just as long as they’re getting there. I know plenty of people who have followed 12-Step programs and that’s done great for them. Other ones, I know of plenty of patients who have gone to 12-Step and they’d felt tremendously judged and as such they just dropped out of recovery completely. One, communication is hugely important.
For example, one of my patients he had I think for the first time in his life several months of recovery on buprenorphine, otherwise had been on I think heroin for the past 20 years or so. For him, it had just been a complete life-changer, but the organization for whom he was working they noted he was on buprenorphine and they wanted to know when is he going to stop using, when is he going to get off this drug because he just switched one drug for another.
It was very important for me to just actually talk to them just to say, to help explain to them what buprenorphine was, how it wasn’t actually something they envisioned for him to get intoxicated on, that he’s not abusing it. Education was tremendously important and I think will continue to be important.
Patients also recognizing that “I may have these things but there are some people for whom that it’s going to be completely unacceptable,” and recognizing that “I can’t force my views on everyone.” That’s okay just as long as they understand that there are other options if somebody is not able to attain abstinence or recovery through their program. Okay, what are their options? How else can a patient be helped?
Dr. Chung: Communication and education I think, yes. You could talk about that being useful for substance abuse or just in general.
Zach: I’m curious to know also on the front-end at the Venice Family Clinic, what are some of the assessment tools that you guys employ to get a thick description, so to speak of the person that’s sitting in front of you to know which would be the right course of action in terms of the treatment?
Dr. Chung: Yes. I’m completely blanking on the exact assessment tools that we use, but just some quick screeners that are available on the electronic health records. Yes, I cannot remember the exact ones off the top of my head.
Zach: Fine. I was just kind of curious if you guys were looking at…you named them. You mentioned things like trauma history. That’s a big thing that we do at Landmark where the patients that come into our care we do an ACE questionnaire with them.
Dr. Chung: Yes.
Zach: That’s very important.
Dr. Chung: Yes.
Zach: Beyond that, we’re also looking at have there been previous treatment histories, where have they been, has it been successful, those kinds of things. I’m sure you guys are doing those things.
Dr. Chung: Of course. Yes, I guess the psychosocial history is probably the most important part of this. I guess with that just making sure that there’s time. There might not be time in their schedule. You’re going to need to make time just because otherwise if you don’t understand these things, if you don’t understand the patient then you’re really going to not be working with a full deck. You’re not going to be able to help your patient very well.
Zach: Yes, yes, absolutely. I’m kind of curious, too. How do you see your work with patients over the years help lower the rates of addiction in the community that you work in?
Dr. Chung: With that, I guess…let me try to think how to answer that a little bit better. Among our patients, about I think it’s 15 percent, 4,000 to 5,000 of them are our patients are homeless. A lot of those have substance use issues.
For example, one of our patients she was 23 when I met her. She was homeless. She was using heroin. She had started using pain pills after surgery and whenever her dose ran out she was able to get on heroin to basically help with her pain issues. Whenever she came in she was basically just withdrawing and had tried many, many times to stop heroin and failed which makes sense because it’s like when you’ve got the flu but so much worse than anything else.
Dr. Chung: With her just introducing her to buprenorphine, getting her partner as well on buprenorphine that was I think around four years ago at this point. She and her partner have never looked back. They’ve both been employed. They’ve got a healthy young boy and they’ve been doing great.
As far as the rates of addiction in the community, I don’t have the data on how many people in West Los Angeles or Los Angeles have substance use disorders and I don’t have any before/after. I have lots of anecdotes and I have increasing numbers of patients in the community.
Dr. Chung: I think when I got there we had around five patients, maybe 10 and now I think there are over 300, perhaps 400 patients that come in from Medical Services and around a thousand from Behavioral Health Services related to addiction.
Zach: Got it.
Dr. Chung: I don’t have percentages or anything, just give you some gross numbers that have increased.
Zach: I get the impression that this is something that’s very near and dear to your heart like this is something that you’re very passionate about. That’s why you got in to medicine.
Dr. Chung: Yes. That sounds about right, yes.
Zach: Yes. When you see a patient that is exhibiting signs of addiction and as their general practitioner, what do you do to help them?
Dr. Chung: One, just by I would do with any other patient, just ask how they are, just see what they’re going through, sit down with them, let them tell their own story and just let them know that it’s okay to tell you whatever they need to that that’s the reason why we’re there; that if we don’t have patients that have medical problems then we have absolutely no reason to exist as providers.
It’s hard for patients sometimes to understand that just with they have for years been trying to minimize or hide their use because you can’t tell your parents. You can’t tell your family. You definitely can’t tell law enforcement or your employer that “Hey, I use this.”
They walk in. It’s not going to be very easy just for them to say even though they obviously have signs of using meth or heroin or they’re slurring their words because they’ve been drinking in-clinic. It’s going to be hard for them to actually open up about that, but just by helping to provide that safe space for them lets them realize that they can open up and then you can actually feel what their needs are, what their goals are and then you can actually start to help make a change in their life.
Zach: Good stuff. At the Venice Family Clinic, you guys serve a lot of people. 28,000 men, women, and children. That’s a whole lot. That’s a city right there. Are your services going to be expanding?
Dr. Chung: They’re constantly expanding and so far there are always more patients that need help that we have a lot of homeless outreach teams just as I’m sure you know Los Angeles has a rather significant homeless population so we’re always working to expand our services for homeless not only in West Los Angeles. That will be Venice, Santa Monica, Inglewood, some of the high schools. We don’t limit our scope of practice.
I see a lot of patients from, I’m not sure how familiar you are with the LA area but from the Valley to the North or to the South, seeing patients that have travelled over three hours to get to us just because they don’t know where to access services anywhere.
Dr. Chung: Yes, we definitely are not limiting our services. Basically we try to provide services to anybody who is in need of them regardless of ability to pay.
Zach: Los Angeles is how many people? About ten million people I guess, Dr. Chung?
Dr. Chung: Thereabouts.
Zach: I know that obviously if you’re homeless you want to live and be in a place where there’s good weather. I imagine…total homeless people in that city, how many are there?
Dr. Chung: I think depending on the count but 50,000 give or take.
Zach: Got it. We might have mentioned this at the beginning but how long have you been their Director of Addiction Services at the Venice Family Clinic?
Dr. Chung: I’ve been at the clinic for, coming up on five years. I’ve been Director of Addiction Services for a few months but involved in Addiction Services for as long as I’ve been there.
Zach: What are your biggest challenges day to day speaking with that position?
Dr. Chung: With that position, I always feel that there are so many patients that we’re not reaching. I will drive around and I’ll see patients that obviously need services or I’m always just…I’m not sure what the word be. I’m always just disappointed sometimes when I find out that a patient has been using maybe just down the street or a couple of miles away and then they come in the clinic. They realize, “Oh wow. You guys could treat my substance use disorder.”
Just making sure that people in the community know that there are services or making sure that other places are referring to us. I also work at jail and sometimes I’ll see patients that come in. When somebody’s been using for a while they’re not using to get high. They’re not using to enjoy. They’re just using not to get sick. I’ll try to tell the patient, “Hey, did you know that there are services available whether at our clinic or other ones?” So many patients have no idea that addiction treatment is something for which they can get help.
Zach: Yes. Why do you think that is? Do you think part of it is just because of the amount of resources available there’s just not a lot of time or energy resources I guess to get the word out correctly?
Dr. Chung: I think that’s definitely part of it. I think sometimes people just like patients don’t open up to providers initially to say they have an issue. Nobody’s going to know to actually refer them and then other places may not want to actually treat them.
I don’t know how many times I’ve seen on somebody’s discharge somebody from a hospital. Maybe they went in for endocarditis or hepatitis C, basically something relative to their substance use. The discharge summary, the instructions will say “Heroin use or alcohol use.” The instructions would be “Stop using.”
Just that there’s a gross lack of understanding of substance use as a treatable disorder as opposed to a moral failing; that is a huge problem so people don’t understand that, “Hey this is actually something for which I can make a referral to possibly change this person’s life.”
Zach: Absolutely. Are there things that you see right now that your program’s doing well that other programs similar across the US could emulate?
Dr. Chung: One of the things that I…
Zach: I hear a sweet baby I think in the background.
Dr. Chung: Yes. Thank you. I’m pretty much melting down.
Zach: That’s all right. Go ahead.
Dr. Chung: Sorry about that. One of the things that I think we do well is actually retaining patients and reaching out to patients that have been seen in our clinics. One of the most important things that we’ve done is making sure that all staff have been trained whether it be security, front desk, janitorial staff, pharmacy, making sure that everybody understands how we’re approaching the issue, making sure that they understand harm reduction, making sure that they understand patients.
My medical assistant, one of our first who started working in our clinic she was a little bit horrified and terrified just, “What? Why is this patient acting like this? Why is this patient looking like this?”
Dr. Chung: Looking at her now a few years, I’m so proud to see her being defensive of our patients, recognizing them just as a normal human being who happens to have a substance abuse disorder. I think just the acceptance of our patients and sort of it takes a village approach to our care.
Zach: Truer words couldn’t have been spoken especially when it comes to this particular form of treatment with substance abuse because the more people are on board with helping people in whatever form or fashion that takes and breaking through their own biases about what constitutes recovery, whether that’s your pastor, your police officer. All those people are huge, huge, can potentially be huge, huge assets in this whole fight, so to speak.
Dr. Chung: Right.
Zach: Listen. I really appreciate your time today. I know that you have your hands full as I’m sure a lot of us do right now especially you given the fact that you’re running a very large clinic and you have a nine-month old?
Dr. Chung: A nine-month-old, yes.
Zach: Yes. Congratulations.
Dr. Chung: Yes. Thank you.
Zach: I just thank you so much for coming on the show today. I really appreciate it.
Dr. Chung: No. I appreciate the chance. It was great talking with you.
Zach: If you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn more about substance abuse programs that are both saving lives and empowering families.
Until next week, I’m Zach Crouch with Landmark Recovery Radio.
Zach: Hi. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and please subscribe to get the most up-to-date information from leading experts.
We have guest Patrick Dunn joining us on the show today. Patrick has been in the field of substance abuse treatment for well over 15 years. He currently serves as the President of Recovery Services at Landmark Recovery. Patrick received his undergrad in Counseling Psychology and is currently getting his PhD in Research Psychology.
He’ll be speaking with us today about his current role with Landmark Recovery as well as the recent trends in the addiction treatment field that are resulting from the coronavirus pandemic.
Patrick, it’s great to have you on.
Patrick: Hey, Zach. Glad to be here.
Zach: Can you tell us about your current position and what are some of the day-to-day responsibilities of your role?
Patrick: Yes. President over the Recovery Division at Landmark Recovery involves me overseeing all our current operations that we have at our three residential centers and also planning ahead at the three residential centers that will be opening by the end of the year; everything from when they get there to admissions to the whole client experience, staffing, ensuring the clinical excellence in our clinical model as well as all that fun stuff, budget and licensing and all that stuff.
Patrick: Keeps you busy.
Zach: Absolutely, man. As you mentioned, we’re going to be expanding into other states. Can you give some of the listeners an idea about where Landmark’s footprint is heading?
Patrick: Yes, for sure. Currently in Louisville, Kentucky we have detox residential facility for commercial insurance. We have detox residential facility for Medicaid. North of Indianapolis and Carmel, Indiana we have a commercial facility. In Oklahoma City we have a commercial facility. Our goal is going to be to offer both commercial insurance and Medicaid services everywhere that we have facilities.
We’re opening in Indianapolis in September, large building closer to Indianapolis and that will be a blend of both commercial and Medicaid insurance. We’ll be opening in Concord which is close to Boston, commercial facility in October. By December we’ll be opening North of Cleveland in Euclid, Ohio. We’re really looking to serve the Midwest. Our goal originally is to be somewhere where you can come. You can use your insurance and you could drive to treatment.
Zach: Makes a lot of sense especially that the fact that most people when you involve the family members and the people that support a person going through their treatment, they would certainly like to be a part of that treatment experience as well.
Patrick: Yes, that’s a really good point. As we know that addiction is most often a family disease and it really makes sense that a family solution in recovery.
Zach: Thank you.
Patrick: We pride ourselves for our family program. It’s really important to us that it’s accessible. Treatment’s really changed over the last five, seven, eight years and it’s become a lot more regional. You don’t see people flying across the country anymore. People want to stay much closer to home. That’s why we make it accessible to them.
Zach: Can you talk a little bit to our listeners about our family program? It happens every week. Obviously some things are scaled back a little bit right now because of precautions that we’re taking with this pandemic. On a regular basis, so to speak what is the value that you’d say Landmark brings to the family and what does that look like specifically maybe on a Saturday?
Patrick: The value for families to be involved in the process is really priceless. Some of the longest-standing centers across the country really focus on the essential part of having the family involved. For us, our goal is to educate family members first and foremost and then also let them kind of dip their toe in the therapeutic experience a little bit. Really it’s just as important for us that families understand what the patient’s going through but it’s also important for patients to understand what the family is going through.
Patrick: They can meet on the same level. The hardest part of treatment is getting out. Very often when someone completes treatment they go back in to the family dynamic. It’s super important that they have as much knowledge and the foundations so they can all recover together.
Zach: Appreciate that. You mentioned, a minute or two ago you were talking about the client experience and improving that. You’ve obviously been in this field for quite some time and you’ve been in various treatment centers. You’ve probably seen a lot of different treatment centers, worked for different treatment centers. What would you say overall in your time and experience is great in terms of the client experience and what do you see often missing?
Patrick: I can tell you about Landmark. One of the reasons that I came to Landmark is because of the clinical model. I really feel, also with the kind of the burst in network and all the insular services I think a lot of programs have got, drifted away from the clinical model. When I was first introduced to Landmark, I was very impressed at the structure and how robust the clinical services are.
The idea of meeting with your individual therapist twice a week, how important, our treatment is so short. Treatment is such a short experience and you come in there with a lifetime of stuff. It would only makes sense that you would have as much time both individually and in group that you can get. That’s really important to us.
Individually that we maximize the time with individual therapists and in group was, it’s awesome for me that the group process throughout the month, month-and-a-half that patients are in treatment that it’s very structured, that they have handouts, that they get to take those handouts home with them, that they’re able to retain and follow up on the knowledge.
For us, a combination of both informing and the therapeutic experience is important. An example would be for trauma, we use Seeking Safety miles and they get a Seeking Safety group every day.
Patrick: It’s a really good combination to really meet people where they’re at with identifying that what they went through is not necessarily who they are, that it’s important to understand that what you went through trauma does affect how you felt in relationships, how you react to people, and stuff like that. Yes, that’s a big part of it is the clinical program. Some of the things that we’re working on which is really important to me are engagement and after-care at Landmark has a great alumna program.
Patrick: I have a lot of experience in building out, using technology to build out continued after-care services, really trying to lean in with insurance companies to monitor people for a longer period of time, six months, nine months, and a year. That’s something we’re actively working on Landmark, rowing out [Inaudible][45:25] rewards based on research of continuous management that says people in early recovery need to build short-term rewards and long-term rewards. We’re working on systems like that.
I’m really working hard with insurance companies for them to understand the need for longer treatment stays. We’re being really creative. I work with insurance companies a lot because research shows the longer that you stay in treatment and the longer you stay connected with your treatment provider, the higher likelihood you’re going to be able to reach your treatment goals.
Zach: I hope that our listeners heard that because yes, the research will point that out that if a person is able to do stay in the process and we’re not talking about, yes 30, 45 days is a great start for a lot of people, but I think getting to that year or two-year mark of sobriety and recovery is critical. It’s critical.
Patrick: Oh, a hundred percent yes. Treatment is not supposed to fix anybody. Our goal in treatment is to lay the foundation to be able to help somebody take a step back from the chaos, take a deep breath, and then lay a foundation for long-term recovery. Nobody gets fixed in treatment. You can feel better. The clouds can lift and you can get kind of set on a good direction, but treatment merely sets the foundation. That’s why it’s so important to stay engaged with patients and with their treatment goals and their providers.
Zach: If we know as a field at least that there’s a lot, there’s a good amount of solid evidence-based treatments that work really well for this population, for people with substance use disorder co-occurring, what do you think the difficulty is that facilities, programs, etc. run into in implementing these different evidence-based models in treatment? Why aren’t they successful do you think?
Patrick: I can tell you. I think it’s lack of commitment to the model. It’s kind of like if you kind of workout plan. You can have the intention to have a workout plan.
Zach: It’s a good one.
Patrick: If you don’t put the action to the workout plan, you’re probably not going to lose weight or gain weight or whatever you’re looking to do. I think that a lot of programs have the intention but don’t follow it up with the action of evidence-based. When you say you’re using an evidence-based plan, that means you’re using it and taking the action to use it as it’s been researched, not just saying, “Hey, yes we do DBT and we do a DBT group once a week.”
DBT is a whole program from morning to night if you’re really following the model. A lot of programs say they do stuff but they’re not…
Zach: It’s really intense, too, Patrick that the DBT piece for people to follow it.
Patrick: Oh, yes.
Zach: To be trained in it with fidelity, it takes a ton of work.
Patrick: Oh, yes, a hundred percent. When somebody says evidence-based, it’s just not saying you do like I said you do a group a week. It’s you structure the program around it. It’s a daily thing with homework and follow-up. Michelle McGinnis, our Chief Clinical Officer at Landmark has when you do group and everyone’s allowed I’ll pop in and I’ll do groups at the different centers and the curriculum rolls into each other throughout the day so there’s a theme throughout the day.
You don’t go to one group and then the next group you’re like, “Oh, it’s something new.” Everything flows to it. The theme from Seeking Safety rolls into after-care rolls in the SMART Recovery rolls into life skills and everything kind of flows throughout the day and then you get those skills in a packet to be able to take home and reference them after you transition.
When you’re really talking about fidelity to a model, it’s a lot more than unfortunately what a lot of treatment it seems like it’s been which is just kind of a mish-mash of a bunch of things together.
Zach: As a consumer, you’re not going to notice from the front-end. As an example, if you’re hearing that there is evidence-based treatment yes, that’s great, but I think what you’re getting at a lot of is that do the policies and procedures of that particular program reflect the implementation of this particular model.
Patrick: That’s right. What I would really challenge the consumer to do is ask for like the day-to-day.
Patrick: Can I have a schedule? What does the schedule look like? Hey listen, pictures are great. Websites are great, but can I have a class schedule? Do you have any information on the curriculum? I see on your website it says evidence-based, can you tell me more about what is the evidence? What is the evidence based on? Why are you guys using this? Treatment isn’t cheap and it’s a really big commitment. The truth is if you do treatment…
Zach: [Inaudible][50:54] for a lot of people, right?
Patrick: That’s right. If you do treatment right and you’re really committed to find a place that serves your needs individually, you can do it once.
Zach: Glad to hear that.
Zach: I appreciate that. I want to switch gears a little bit. You have worked for a few different recovery facilities. What have you seen in terms of the ratio of patients who come to treatment for drugs versus say, alcohol use disorder?
Patrick: That’s a good question. The opiate epidemic currently is awful. It’s never been so bad. The introduction of fentanyl in the market has really, really, really caused a lot of people to seek treatment for opiates, but alcohol is and always is will be the king. The majority of people seeking treatment will always be alcohol.
A lot of times people seek treatment with polysubstance abuse meaning they’re using more than one substance, but alcohol, especially now in these last two months with this epidemic the rise of alcohol sales and the rise of people seeking treatment for alcohol has really, really increased. I think that alcohol doesn’t always get the due set that it deserves, but it is most definitely always the majority.
Markets differ. Where you go I know there’s, for us in Kentucky, in Eastern Kentucky, Eastern Tennessee, the opiate addiction is a lot more of a problem based on kind of socioeconomics, but really alcohol is really taking a surge lately but it still remains to be the majority of what people seek treatment for.
Zach: Thank you. I’m curious to hear your thoughts as a person obviously in the field. We have here locally and I’m sure across the different states liquor stores have remained open during this pandemic. I was talking to somebody. He was a medical professional, might have been a therapist.
They brought up an interesting point. They said that if we close liquor stores think about how many people would be flooding the hospitals because now they’re in danger of going through some pretty significant withdrawal especially for those that are consuming a lot. Do you have any thoughts on just that just like in terms of keeping these liquor stores open, those kinds of things? Just popped in to my head as we were talking about that.
Patrick: Kentucky doesn’t lead the nation in a lot of things, but as you know from being a native we do have more bourbon barrels of liquor stocked in Kentucky than we do people.
Patrick: It’s a business. Alcohol is a business. It’s most definitely sure stopping alcohol cold turkey is one of the most dangerous things you can do. Yes, we’ve seen a lot of people doing that as of late, but essential. I mean the gun stores are open, too.
Patrick: I think it’s relative. I think with all the closings and stuff there is a lot of consumer stuff involved. They made a decision I think probably countrywide to keep liquor stores open and that’s what they did. I think we would definitely see a flux of people that would enter the hospital.
The most interesting thing is when people stop drinking alcohol cold turkey is how baffled and surprised they are at their body reaction to it. Even long-term drinkers when you quit cold turkey vary. We’re talking violent shakes, seizures. People are always really surprised at that when they quit cold turkey.
Patrick: The two most dangerous things are to stop doing cold turkey and I hope anybody listening never try to do or make sure people don’t have to do is alcohol and benzodiazepine, Xanax, lorazepam. Both of those things can kill you if you try to quit those cold turkey without support.
Zach: I was actually part of a hospital detox prior to this job. To your point, the worst withdrawals that I would see were people going through alcohol withdrawal because these were people that were drinking massive amounts. Even at day three or four, it was interesting because they would usually say, “I’m starting to feel better” at day two or day three, but it was interesting to see that they thank God they’re in the hospital by day four, day five.
Patrick: Right, right.
Zach: You bring up a good point because I think that’s part of the risks is that people just assume, “Well, it’s been a couple of days. I feel pretty good. Nothing’s going on.” It’s really by the 80thor hundredth hour that some bad stuff can start to happen.
Patrick: Oh, yes.
Zach: We are facing a really strange time with the coronavirus pandemic right now obviously. Have you seen this impact the number of people seeking treatment?
Patrick: Yes, most definitely. It wasn’t until a couple of weeks into after the shutdown we saw very high surges in calls. When you take a step back and look at it, this is a really good time to come to treatment. A lot of people are on furlough. A lot of people aren’t working.
Patrick: A lot of people have benefits or even if you were laid-off you continue to have benefits or you can use your co-benefits. It’s a really good time to come to treatment.
Zach: Sure is.
Patrick: We have definitely found a lot higher call volume, a lot more severity in what people are doing when they get to treatment.
Patrick: We have been very, very grateful that we’re able to serve this influx in the communities where we reside.
Zach: Absolutely. Yes. I think now more than ever because we’re all at home a lot more and our loved ones, our families are there where it was perhaps possible for someone to, and I don’t mean this in a pejorative way but to hide their use from their loved ones it’s much more difficult now.
Patrick: Yes, most definitely. This would not be the time to live with your parents and try to hide the use when you can’t leave the house. That would be very challenging.
Zach: Yes. For all those people that are stuck at home right now which are a good lot of us right now, what are some things you might recommend to help them stay strong and not let things like boredom lure them back in to some of these self-destructive behaviors?
Patrick: Me like everybody else is really struggling with this kind of change. I’m an outside person and I like to go, go, go. This has really put a lot of changes on my personal lifestyle and it’s taken a lot for someone who likes, I’m in long-term recovery myself. I go to recovery meetings almost every day and to be able to make that shift to just doing stuff online has been difficult. It’s difficult for everybody. I think what we have found is the use of technology to really connect with people.
Patrick: It doesn’t have to be a structured thing to be able to call somebody and video chat that you haven’t talked to in a while. AA and NA, and all the12-Step meetings have really taken off with their ability to do virtual stuff. You can find meetings all day every day everywhere.
Patrick: I think it really takes some effort. I know for us at Landmark if anybody’s struggling, you can call the admissions’ line and even if treatment isn’t right for you right now, we can guide you and help you to where to get some resources that can help you, whether that’s locally or whether that’s other resources, mental health resources. I would just encourage anybody that’s struggling to call.
Zach: Thank you for that. That’s absolutely correct. I appreciate you bringing up the fact that there are just a lot of online meetings that people can take advantage of right now. If you want to Google your local city and then online meetings, AA or NA or even SMART Recovery, those are things that you can do right now.
Patrick: Oh, a hundred percent. A hundred percent. I think this is really going to change the way we use technology to access those kinds of resources in the future. It’s exciting to see. I feel like what we hear on the news is we might be over the curve and even though we’re being super vigilant for all of our patients and employees in all of our locations I feel like we’re starting to head out of this.
Zach: You bring up an interesting point, too just are there things say, recovery-related right now that people are doing in their own programs that you hope continue post pandemic, so to speak?
Patrick: Yes. I think traditionally and I’ve been in recovery for a long time is that if you’re running late to a meeting or if you can’t get to a meeting it’s easy to be like, “I missed the meeting.” That’s not really the case now.
Patrick: I’ve seen a lot of Zoom platforms but if you’re running late, you can check in late. If you don’t feel like being on video, you don’t have to be on video. I’ve led a lot of meetings. I’ve really had some contact with meetings that I never would have been able to go to in person based on where I am and where I’m working and stuff like that. It’s really exciting to see how this has really kind of changed access to after-care resources and people’s willingness to use technology in a positive way.
Zach: A hundred percent. Any last thoughts, Patrick? I really appreciate you coming on the show today.
Patrick: Man, I couldn’t be happier to be on, Zach. I’m really excited to be on the Landmark team and our growth and our goals, not only the three locations that we’ll add on this year but looking to add on another five or six next year. Our goal is to really, really serve people in the Midwest regionally. I’m really excited to be on a team that is looking to serve sort of the masses with a good product at a fair price.
Zach: I appreciate that.
Listen, if you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn more about substance abuse programs that are both saving lives and empowering families.
Until next week, I’m Zach Crouch with Landmark Recovery Radio.
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