In this episode, Zach is joined by Dr. Bryan Negrini, M.D., M.P.H., founding physician of Outpatient Addiction Recovery Services (OARS) in Pennsylvania. Working in healthcare for 30 years in Western Pennsylvania, Dr. Negrini observed the growing opioid epidemic and the need for affordable, holistic treatment. Dr. Negrini shares his journey into the recovery field, important questions to ask when seeking a treatment center, and more.
Tanscript
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: Zach Crouch is here. You’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. As always, you can find us online wherever you get your podcasts on what have you listening to the show, always like it when people hit that subscribe button. So, new content coming out each week. Different people in the field, different professionals, different experts love to have you. We have guest Dr. Brian Negrini, joining us on the show today.
Dr. Negrini has worked in healthcare in the Western Pennsylvania region for over 30 years. In 2015, after seeing a growing number of overdoses in the ER he worked in as an internist, he started a private substance abuse recovery clinic entitled Outpatient Addiction Recovery Services. Since 2015 OARS has opened clinics in Aliquippa, Butler, Carmichael’s, Matt Washington, New Castle, and Washington in PA and has conducted over 50,000 patient visits. Dr. Negrini, a pleasure to have you on show.
Dr. Negrini: Great. Thanks, Zach.
Zach: So, I was wanting to dig into this a little bit. You get into this field. People get into it typically with passion for the work. I always ask the question to start the show, what brought you to work in the recovery field? Can you share a little bit about your background?
Dr. Negrini: Sure, Zach. I have a pretty diverse training. I went to the Yale University of Michigan, University of Pittsburgh, and finished my internal medicine training back in 1997. Stayed there as a chief resident where I helped run the program for a year. I spent the last 30 years as an internal medicine physician, both in the outpatient clinics, in the hospital setting, in the emergency department setting, in nursing home settings, hospice settings. I’ve had a pretty varied experience.
In 2015, I started to get interested in Addiction Medicine because we had a growing number of patients coming into all of those venues, whether it’s the ER, or the hospital, or from my clinics. I didn’t know much about Addiction Medicine Treatment. I’m kind of a nerdy dude. I’m a nerdy back that likes to know what chemicals go for what diseases and how they work. I started to get interested in the one chemical that we use. It is Buprenorphine which is a medication that protects people from overdosing from any Opioids out there.
I went to a couple of clinics up in the North Hills and wasn’t pleased with my experience in the clinics. We’ve got a few questions that we’ll talk about what to look for in a good clinic and a bad clinic. We can talk about those. I had some not-great experiences and decided to start my own company. First, it was called Opioid Addiction Recovery Services (OARS). We changed at this last year because I went through the steps to become board certified not only as an Internal Medicine Physician but as an Addiction Medicine Physician.
So, it’s incredibly neat medicine. There are more medications now that can be used to help addictions of a variety of different types. We primarily have focused on Opioid Addiction where we have three chemicals that are used that are FDA approved to help those individuals addicted to opioids. But now, there’s a whole bunch of new chemicals that are starting to be used for people that have a Methamphetamine Abuse Syndrome or cocaine and the medications that we use for cigarette smoking for nicotine addiction and alcohol as well.
So, the science of Addiction Medicine has blossomed in the last couple of years. I’ve sort of given up my internal medicine practice to try and learn as much as I can to help as many people that are addicted to substances as I can. That’s what brought me into worse. We started in Aliquippa and we moved to Butler and Newcastle, and now I’m actually in our Washington office today seeing patients.
Zach: Awesome. I want to ask the question too. I’m curious about your experience in PA. You’ve worked in ER’s for a number of years. I’m curious to know if things are changing with regard to ER doctors. Are they taking more training on these kinds of issues with substances? For the reason I asked, for most people who come into an ER room, a doctor gets their attention even if there are overdoses, even if they are strung out on some substance of some kind. So, I would imagine that if doctors can speak fluently in intelligently about the resources that are available to people because again people listen to doctors versus just sent me some cross, but pawning them off with some social worker to tell them about the resources. Do you see any of this going on with doctors working in ER’s?
Dr. Negrini: If you take a look at the scientific literature, if patients have an addiction to opioids or overdosed and are brought in by an ambulance, or just craving because they don’t want to use but are having withdrawal symptoms, in the first place, they go to this emergency department if they’re trying to seek help. I wish I could tell you every emergency department has the best services available not only for medication prescribing, but to link these individuals to the complex social needs that they have. I haven’t experienced that.
There is a potential to use something like Buprenorphine or even Naltrexone, the two medications we use for Opioids in the emergency department setting. Most physicians aren’t trained and they’re not that comfortable with those medications. So, patients get supportive medications. They get discharged after an overdose. Although they may be given a piece of paper with a few phone numbers to call, there really isn’t a comprehensive approach to try and help them not come back the second time. I wish I had better information. From my experiences, it just doesn’t exist at the present time.
Zach: We have this in Louisville, Kentucky what they call Bridge Clinics embedded in the ER or bridge programs where a person could start on some Suboxone or Buprenorphine. The folks there at the ER set them up with an ongoing appointment, the bridge, a three or four days with worth of Buprenorphine to get them to an appointment outside and then continue on treatment. Do you all have that?
Dr. Negrini: I can’t speak for the majority of Emergency Departments. I’ve only worked in two. One within UPMC and one up in Butler that I worked at didn’t do that. The literature shows that if you start somebody that comes in after an overdose on Buprenorphine or Naltrexone that their risk of a subsequent overdose goes down by five times, 500%. So, the medications are incredibly effective. In my experience, just not used in that setting as much as they should be.
I’m not entirely sure why. Maybe it’s an education issue. Maybe it’s that the ER’s are just very busy and it’s one more thing for them to process. I can’t speak for all the emergency physician doctors out there. I’m sure some of the emergency departments do incredibly well and some don’t do it at all. I have a good consensus of everything that goes on. From my own experiences, I didn’t have a great perspective of where I worked that was being done well.
Zach: Let’s get into what I would say are some of the meat and potatoes of this conversation. There are only two questions that we have here. I’m sure that there’s a lot of avenues and areas we’re going to go down when asked this. So listeners, tune in. This is I think a question I get asked a lot. It’s a great topic to talk about. I wanted to ask you. What are the top three questions you think an individual who is seeking out a treatment center before they actually commit to going to that facility? What are three things that they would benefit from asking that facility?
Dr. Negrini: Can you just try and limit this discussion just to opioids. If someone’s addicted to an opioid, you can enter the system in several different areas. You can enter the system if you’re starting to get addicted and looking for education advice, if you’re already significantly addicted and don’t want to have your first overdose, or if you’ve had an overdose. So, you can enter the system at a variety of points. What I talked to people about when they come in is they have to understand that addiction is a lifelong disorder.
Once you have been addicted to opioids, the chemistry and the neural pathways in your brain change forever. You’re always at risk of going back to your worst behavior and you have to find a system that allows you to enter it at various places. If you go to an outpatient clinic, they should be linked to or at least have a good connection with inpatient detox, inpatient rehab, long-term, individual living, residential, living, three-quarter houses, halfway houses. The whole connection of all these pieces that allows you to go through the system comes out with a stable recovery but then has close contact with the system.
A lot of the clinics, like our clinic, for example, are Medication-Assisted Treatment clinics. We’re starting to do counseling inside of our facilities. Primarily, we’ve referred. We have a good referral network for people that need counseling, for people that need more intensive care than you would get in an outpatient setting. Today, we had a patient that needs a little bit more than we can provide and we got them into rehab right away. It’s just having a connection to the whole system. A lot of the addiction clinics that are out here in Western Pennsylvania just want to give you a prescription, take your cash, and don’t get involved in all of the other follow up in the social determinants of health care that these individuals need to be successful in their recovery.
Zach: I want to come back to something that you mentioned there. I think it’s very important to talk about which is, as you mentioned, the neuro pathways and people begin to abuse opioids. Their neuro pathways are permanently changed forever, as you said. People have come on this show and it’s been said before, how does neuroplasticity play into this with the brain? Go ahead.
Dr. Negrini: It’s a great question. A year ago took the addiction boards and the person in charge of the American Board of preventive medicine that does the Addiction Medicine study has been doing just Addiction Medicine for the entire life, he showed this fantastic picture of the neural pathways and a brain that has never had opioids. The neuro pathways in our brain that had opioids consistently for five days. All it took is five days to change the pathways, to change the way that the arrows get bigger or smaller that lets you get from enjoying the medications to becoming dependent on them, to becoming addicted to them.
So, it’s incredible how that works. Everybody has some neuroplasticity, which means that your nerves can change your pathways. The interesting thing when you start looking at functional MRIs and pet scanners is that for someone who is significantly addicted to opioids, those pathways never revert back to normal completely. They may tend to get there over time but it’s like a switch has been turned on in your brain that you always have a risk of going back to your worst behavior. Everybody has a different degree of neuroplasticity that can allow their brains to change and adapt.
It’s genetically motivated. It’s certainly environmentally motivated. Addiction itself is a 50-50 split. 50% of it comes from genetics, 50% of it comes from your environment in addition to those genetics. So, it’s a great question in terms of who gets addicted, who’s able to recover quicker than others? That’s still very active. All the neuropathways are still being very actively researched in the scientific world.
Zach: Thank you. One of the questions that kind of came up as you’re talking, I was thinking about with the use of MHC with Buprenorphine, Methadone, Naltrexone, whatever it is. If the neuropathways have been exhausted so much for so long and so often, is that the reason behind getting people to a therapeutic dose of a particular form of MAT to keep them from going back because the neural pathways have just been simply saying fried, right?
Dr. Negrini: I put together a nice brochure. It’s called The Bucket Philosophy. It’s on our website at oarsmat.com, O-A-R-S-M-A-T .com. It’s a pictorial representation of what happens to the brain or the bucket with these different chemicals. There are actually three different types of chemicals that affect Opioid receptors. There’s a full agonist which fully activates the receptors and those are medications like any kind of pain pills, Vicodin, Percocet, Opana, Fentanyl, Heroin.
So, they fully activate the receptors in the brain. If all the receptors in your brain are fully activated, you have a bucket that has all those receptors and it can overflow. What overflowing means in this analogy is that you keep taking 100% fully agonist medications. You can overflow the bucket which means your brainstem goes to sleep and you have an overdose. Methadone is actually a full agonist but it’s a different type of molecule. It has a long half-life so it can allow you to reach a point where you’re not impaired but you don’t have cravings.
The bad part about methadone is you can always pop it off. You can always take another full agonist on top of your Methadone dose and overdose. Buprenorphine is the second type of medication which is called a partial agonist and only activates your receptors 30%. So, if you think of the bucket only being filled at its most in regardless of how much you take 30%, it’s a more protective way. In that, you’re filling your bucket 30%. You’re not having cravings. You’re not having withdrawal symptoms. You’re also blocking that bucket from filling with any other full agonist because it sticks to those receptors a little bit stronger.
The third type is Naltrexone, which comes in the form of a Revia pill or Vivitrol is a shot that lasts for a month. That is in a full antagonist that goes to the receptors. It sticks on really tightly but it doesn’t activate them at all, 0% activity. If you think of the normal brain with our endorphins, from day to day, whether you’re exercising or eating chocolate, you have a little bit of endorphin that comes out. If you have this bucket filling from 0% to 5%, that’s the way the normal brain functions.
What we do at OARS is we have a strategic approach where we take people from 100%, fill bucket to 30%, full bucket and then we try and wean the 30% down to a 0% so that their brain, the normal pathways can start to wake up again and reactivate. So, that’s what we call it sort of The Bucket Analogy. But essentially, we take someone from 100% medication to 0% medications to allow the brain pathways to wake up again. And while doing that, we protect them as well from overdoses.
Zach: To me, that’s such a refreshing model because many MAT providers don’t think ahead of the schedule of prescribing but also the weaning off with these medications. I’m wondering. From your perspective, is it just because some MAT providers who are prescribing that are just unaware or not educated enough on how to do this? I mean, there’s a number of different reasons but this seems to me like a great model to use.
Dr. Negrini: There’s no easy way to answer that question because you can imagine all of the permutations are wide. Why MAT providers would keep someone on either a partial agonist or full agonist like Methadone for a long period of time? It’s a repetitive business model. It also protects the patient. So, while on those medications, you’re protecting them from an overdose. When you take them off those medications, you increase the risk of relapse and overdose.
That’s why you have to have this continuity of a system to make sure that all the other pieces of the recovery process are being met. We’ve started trying to transition most of our patients that are on Buprenorphine, either the sublingual tablets or the sublingual films to the shot which is a monthly preparation of pure Buprenorphine that may last for a month. You get a little shot in the belly subcutaneously forms a little ball of jelly that dissolves and it continues to have a stable level of Buprenorphine. We had incredible success in getting all of our patients from pills or films to the shot, continuing the shot for six months or so.
By doing that, what it does is allows the person who is an addict to get away from the process of taking something twice a day, or three times a day, or four times a day. So, you break that whole behavioral pathway. A majority of our patients that want to recover and want to get off one of the MAT medications eventually are having great success by breaking the chemical problem, the chemical dependency by breaking the behavioral dependency.
And then we stopped the shots because of the mechanism that goes out of your system so slowly over six months. You don’t have any withdrawal as you wean. Essentially, stopping the shot after six months, you wean like 1% a day and you don’t have any symptoms. We’ve had great success in getting folks off of that, either do nothing or to a full antagonist like the Naltrexone.
Zach: I wanted to ask the question about, as you brought up in the indicators of success, can you share with the listeners from the OARS perspective that your clinics have? What are some of the indicators of success for you sort of going towards the next stage of what we’ll say completely weaning off? What would be some clues that kind of bring you into, “Alright. Now, it’s time to start trying. We’re down to 30…” Whatever. I don’t even know. But I mean, what kind of clues you all into making those decisions?
Dr. Negrini: At OARS, we use a proprietary collection of questions, 10 questions that patients fill out every time they come in? Do you have a job? The options are no, maybe, or yes. It’s graded in, “Yes. Everything’s going well.”, “No, everything’s horrible.”, or “I’m in the middle” Do you have a single significant other in a stable relationship? How are your kids doing? Do you have a car? So, we ask a series of questions that are most likely linked to relapses and we score. If you did one, if you had a perfect score, everything is great. On 10 questions, you’d get a score of 10. If everything’s horrible on all the 10 questions, you get a score of 30.
We look at that score, as an overall score from a visit to visit. Every progress note that we have to take a look at where you were last week, where you are this week, and then the individual providers can drill down to find out what specific issue is a problem. Most of the folks that come in to see us start with a 30 which is 10 questions with all horrible answers. As they improve, as they become stable, as they have clean time, as they start getting a car and getting their kids back from New COI’s type of interactions, as they start getting there, you can see them getting ready to recover.
You can see all these social determinants of health that are very important to follow. As the score goes from 30 to 10, you can start talking about weaning because they’re in a better environment now than they were when they first came in. Everybody I think uses some type of hope they use some type of formula that’s that follows the social determinants of health. Pretty successful that OARS been field-tested. Folks that want to win but have a score of 30, tend not to encourage that because life isn’t so good and they’re not ready for that.
Zach: I appreciate that. From your perspective, if you could list a red flag that you would tell people to avoid when looking for a treatment center. On the other side of that one, the green flag kind of goes for what people should actively look for what would those be.
Dr. Negrini: Ellie, who’s my social media consultant and I talked about this yesterday. When I first started looking at some programs and been working as a physician and an MAT program up north. The three things that I think you could consider red flags are flies in the light, porn on the computer screens that the providers are using, and privacy. So, you have to take a good look at the physical place you go to. If you feel uncomfortable in the place you’re going to, it’s probably not a good place. One of the facilities that I went to up in the North Hills has decades of flies in the light that it was so dark because the flies were interfering with the light coming from the light.
It is clearly not a good indicator of a nice place. One of the physician’s computers had pornography on the screen when I walked into the room. That’s probably not a good indicator. You had a room full of 50 patients right next to each other and there’s no privacy whatsoever. On the green flags, no flies is good, no bad computers, and attention to HIPAA or privacy is probably a good thing. No one thing that is a red flag or a green flag. If you go to a place that you feel uncomfortable in, you usually should go with that gut instinct and try and find another place.
Zach: Fantastic. Number one, keep up the good work. Sounds like you guys are having great success and for good reason in Pennsylvania. I really do appreciate all the training that you’ve done. I think you’re helping a lot of people out there. I wish more people would get more certified in addictions because it certainly only informs and helps other people who come forward in there will be many more. So, we do appreciate your time today, Dr. Negrini.
Dr. Negrini: Thanks for allowing me to talk. I like to leave on one not-so-great and sad note is that I’m out here in Washington County. The coroner for Washington County is the landlord for the building we’re in. He’s a good friend. He talks to us often. They have 55 overdoses so far this year in Washington County which exceeds the worst overdose list back in 2018 and 2019. What’s happening on the streets now is that Heroin is no longer there. Heroin is kind of a commodity and had a known strength and attics could usually get by safely by titrating what they wanted.
Now, everything is synthetic, man-made sentinels are mixed with all the other substances, someone can have one bag of dope. But the dope is now 10,000 times stronger if you get carfentanil than you would in the past. Unfortunately, all these folks are finding themselves addicted to pills and then upscale into something that they think is a heroin product. It’s just instant death. And if I can say one thing to everybody out there that’s struggling or thinking of the fact that they’re playing around with these medications, just don’t do it. You have no control over it. You don’t know what you’re going to get and you will die if you use what’s being used on the streets these days.
Zach: That’s absolutely true. I always in to by saying, if you do know someone who is struggling and you’re searching for answers, you can also visit us at Landmark Recovery. That’s landmarkrecovery.com. In there, you’re going to learn more about substance abuse programs that not only help the patient but the family. So, until next week. I’m Zack Crouch with Landmark Recovery Radio, wishing you well. Take care, everybody.
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