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The Language of Addiction

January 9th, 2021

In this episode, Zach is joined by Dr. Mario San Bartolome, a clinically active addiction medicine specialist, triple board certified in family medicine, addiction medicine, and preventative medicine. As the medical director of substance use disorders for Molina Healthcare, Dr. Mario guides medication policy, education, utilization management, and fraud/ waste/abuse initiatives involving substance use across the enterprise. The two discuss the meaning of the term “language of addiction” and how Dr. Mario helps his patients through relapse.

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 Zack Crouch.


Zach: Hi, I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. Listen, you can find us online wherever you get your podcast and don’t forget to subscribe to get the most up-to-date information from leading experts. We have guest Dr. Mario San Bartolome joining us on the show today. Dr. Mario is a clinically active addiction medicine specialist. He’s triple board certified in family medicine, addiction medicine and preventative medicine. 


He holds a master’s degree in business administration with an emphasis in information technology. As the medical director of substance use disorders from Molina Healthcare Dr. Mario guides medication policy, education, utilization management and fraud, waste abuse initiatives involving substance use across the enterprise in addition to impacting policy at the health plan level. He oversees withdrawal management, residential and outpatient care. He also serves as a faculty advisor for the ASAM Fundamentals in Addiction Medicine Live Training Program for primary care providers across the country. That’s great. 


He’s an active expert witness for many legal cases involving addiction treatment and he is a certified medical review officer and sought after expert in the area of drug testing and occupational medicine. Lastly, he is the chair for Be Well OC Substance Use Disorder Leadership Coalition. Dr. Mario that is a healthy resume sir. Welcome to the show.


Mario: Well, thank you. Thank you for having me. I appreciate it.


Zach: I need a drink of water after that. That’s quite an impressive resume. I’m curious. That’s a lot there. You went and got your MBA. You’ve been through medical training. What about the addiction recovery field interested you. How did you get involved in it?


Mario: That’s a great question. It happened early on in my training. I mean we all have experiences from our own lives, the families and friends, people we care about that might have been impacted by substance use but I’ll be honest, up until I was into my training from the standpoint of around the latter part of medical school and early part of residency I was fairly ignorant about the intricacies of how substance use issues affect somebody’s life. 


When I was in residency as a family medicine doctor because first and foremost I’m a family medicine physician. I’ll say up front that I really see addiction medicine which is really kind of a fairly new discipline out there as it’s kind of been put together academically as an extension of family medicine. There’s no situation that I can think of almost where family is not dragged into the whole thing. It’s a family issue and yes, there’s the individual that experiences a physical withdrawal or an individual that might experience an overdose. 


However in the background there’s a family member that hurts or cares for those individuals and also may even have a part in it. For those of you that that have experience in things like Al-Anon or just the role of others in the life of the person with the substance use disorder is important. 


As a family physician I was frustrated by kind of slamming my face into situations that other folks were looking at like for example somebody would show up with a fractured orbital bone which is the bones around the face. I’d see the person in the hospital or in the ER. They’d say well let’s fix that bone. Then I would say well, who punched you. That might have started a story, took down a route of alcohol use or domestic violence and then she might have come into the ER with a little kid. The little kid’s a little disheveled. Not completely clean, cleaned up. I might say hey, what’s going on? Little Jimmy hasn’t come in for his vaccines. He’s behind on his immunizations. How are you doing? What’s going on?


Then I’ll get a further story of the struggles of the house and maybe being homeless. There’s all these social issues that also impacted things. Initially, I like many folks probably faced this issue as an area of frustration because in medicine we want to fix things. You learn very quickly that that’s not the way it always happens in issues around addiction. You don’t necessarily go and just fix things. It’s way more complicated. That made me have to face my ignorance and have to learn more. That started a trajectory down eventually leading to a board certification and really wrapping my arms around substance use disorders as a discipline integrated into family medicine.


Zach: I’m curious you know because I’ve worked in hospitals, I ran a detox unit in a hospital and a med surg hospital here in Louisville at one point in my career. It was common I should say that much to hear that family medicine or even internal medicine docs don’t treat addiction. They don’t really want to mess too much with treating that population. I don’t see how you can’t though. I mean if you’re a med doc okay would you agree that you have an obligation to treat this population?


Mario: Absolutely. There really is no room any longer for thinking of substance use issues as a silo. You can’t silo it out. In the past we looked at it as a psychiatric issue or a mental health issue. Then unfortunately stigma which I’m sure you can appreciate this very well given your experience, the stigma from the standpoint of the non-professional world as well as the professional world has heard it a lot too because they look at it as a moral failure or a weakness or these other kind of ways of viewing it or a criminal justice issue rather than a chronic disease of the brain that is very much multifactorial from a lot of other standpoints genetic, social, spiritual, a lot of other more complexities. 


You’re right. There really is no reason to look at it as a separate thing. I think that there’s been a lack of training in all medical specialties not just in family medicine. I would say even in psychiatry I can’t tell you how many times I also meet with psychiatrists and say well, look. I mean I’m a psychiatrist and I got like 30 hours of training in substance use step at some detox during my residency. That’s not really understanding substance use. That’s improving. There’s many people working on trying to improve that. That happens at the level of the medical training and then learning about how the comorbid conditions around substance use really do affect both mental health and physical medicine. 


If you have an opioid use disorder and you’re injecting heroin what’s the likelihood that you’re going to be exposed to hepatitis C or endocarditis, these conditions that come from the behavioral exposures. You’ve run a withdrawal management unit so you know you can die from withdrawal if done incorrectly. The idea that there’s some separate world that that involves addiction versus all the other things that happen in life that are physical is no longer accepted. We do view it as a chronic disease of the brain that has the potential to improve, to live a fruitful life. It is not a death sentence and very much worth treating.


Zach: I’m wondering to hear from you because you brought up a very interesting point at the beginning of the conversation about the lady with a fractured eye socket or even being able to talk to little Jimmy as you said. Who or what or how did you learn to talk to folks about those issues? Was that just from your own history of growing up with someone who has had that problem and you saw a lot? Was it somebody like I don’t know? I mean because not everybody does that. Not everybody takes the time to sit and listen and really kind of get through the thicker description of who this person really is.


Mario: There’s I think one very important principle in all of healthcare whether the clinical side or the medical side is that you need to learn to be a good listener. That’s not easy. It’s not easy. It’s a muscle that you have to actually work on. I think family medicine in particular has an aspect of it. I mean again even in the in the name family medicine you get used to chaos. 


You’re used to being in your office. Somebody comes in for a urinary tract infection. She’s holding her one-year-old in her arm and grandpa may be on the other side of the room who has mild dementia. Then little Susie might be writing on your wall. The thing is that’s chaos. You have to be probably be a little attracted to that. In family medicine you need to be comfortable with not controlling everything. 


That’s not simple for doctors I tell you but being faced with the situations that were not getting better by as far as how effective I was being with traditional ways of  approaching like you would not approach it like a urinary tract infection where you say hey, urinate in the cup. Let me put the little dipstick in there. The little dipstick tells me you have this. I’m going to give you this antibiotic and then in a few days you’re done.  I never need to see you again for that. 


That’s generally not the way it works. You have to be comfortable with those principles plus with time and experience you also learn that really the focus is not you. It’s the patient. It’s the individual, the family and their experience and you need to meet them where they’re at. That’s not always easy either because in medicine you’re also kind of used to this idea that okay look, I diagnosed this issue. I give a recommendation for the treatment. The individual does the treatment and then they get better. 


That’s not a model that works in substance. Sometimes the individual because inherent in the disease could be denial. They could like hey, get away from me. I don’t want any help and you have to still figure out how to harm reduce. In other words I might not be able to address and get you to buy into full-on treatment, whatever that means if we design a treatment plan however if you’ll come back to talk to me again in a week or a month and we just talk about how do we approach this maybe in other ways and create a relationship then you’ve done a lot actually. You’ve done a lot.


Zach: The relationship part, would you agree that really is everything. The relationship where I mean you are the doc and doctors do have a special place in our culture. They are looked up to and I mean this is no dis but I’ve met a lot of doctors and a lot of doctors like to play God. I mean they do believe that they know everything. They know a lot. they know a whole lot but a lot of the times what I’ve also seen is that docs can be incredibly powerful in keeping people from sort of telling the truth because that isn’t relegated to just addiction either. 


I mean like if you come in and you maybe know something about your body and you get a doctor in front of you and they’re maybe had a bad day or they’re asking questions that don’t seem inviting you’re probably not going to tell them everything. Would you agree?


Mario: A 100%. One of the things that we’re evolving in the language we use around addiction. We’re evolving in the approaches. I do many trainings for folks in healthcare. It’s a particular area that I’m interested in that has to do with preparing people that aren’t addiction specialists to deal with addiction issues in their scope. If you’re an OB GYN invariably you’re going to see a pregnant mom who is potentially struggling with some sort of substance issue. That’s a very, very stigmatized group. 


How your body language, how your voice intonates, how you respect privacy that you ensure non-judgmental types of approaches. It could be the difference between somebody reaching out for help or crawling back into a little cave and withdrawing from everything out of fear. Of course that has other things. In the case of a pregnant woman for example who she has another, a little being to worry about. If we fail to give her access to care because of the issues around stigma and we also we will be condemning a baby to have worse kind of consequences whether it’s around neonatal abstinence syndrome or other things that are developmental depending on the substance. There’s a lot of reasons why making the language we use, the body language and everything else it matters. 


Now look that’s not just in in addiction. If you had a potential to get a diagnosis for cancer because you have say, you had a skin lesion. You went to your primary care doctor and they biopsied it. I’ve done a thousand biopsies in my time on folks. I am very aware that when we have a follow-up when we get the lab results back that this person probably stood on it every day from the date of the biopsy and they probably think you’re going to tell them they’re going to die on the day that you’re talking to them about the results. Their family is worried and it’s affecting their life. How you handle that makes all the difference even if the news is bad.


Zach: Wow. That’s such a good point. I want to just spend 30 seconds on that. Let’s just say that you do. You do have a bad outcome to share with the patient. Let’s just say it’s cancer. What preps you in your mind say for instance you’ve had a bad day. Maybe you didn’t get enough sleep last night. Maybe you and your partner, your family are there was something said this morning that just rub you the wrong way and we all have those days but what preps you to go in there to have that kind of conversation?


Mario: That’s a very insightful thing. Anybody involved in healthcare in any way, I would say even a person that schedules people that’s not necessarily a clinician you have to learn to always check yourself for those technical issues that we work around, transference and counter transference and all that kind of stuff. There’s more technical terms for certain things but also for just you’re two human beings in front of each other. How you show up might matter. You sometimes do have to take a deep breath and you have to check yourself. 


You have to say am I in the right place? Am I in my mind? Then you have to dig deep. I think that if you’re somebody that doesn’t have the empathy part for what you’re doing and the passion part for what you’re doing then probably do something else because there really is the responsibility is for in this case, in this example for the doctor, for me to be able to check myself and to say to myself this is about this person right now. I need to move aside all the other things that I’m dealing with and respect my role for what I’m going to be helping them through. 


You need to reach down deep sometimes especially if it’s tragic. I mean how difficult would it be to tell a mom that her sick sixteen-year-old child just passed away of an overdose. I mean I’m a parent so there’s a whole other level of that too. It’s not just did you get up in a crappy mood but boy, I have very visceral like inside me there’s like my guts start churning around when there’s things like that because I can relate in my own way of being say in that case say being a parent or being the son. My mom had cancer at one point in the kidney. My father passed away of that. 


If I had to deal with those there’s an empathy part that I can draw in that’s not a bad side however I can’t let that be the focus. You definitely have to dig deep into the passion of why you’re doing what you’re doing and be professional. Then there is a distinction. There is a different standard that is on the provider of the healthcare side that you need to be part of that’s why you’re a professional.


Zach: I want to come back to something we were talking about a couple of minutes ago being in the conversation about doctors and internal family medicine doctors and even psychiatrists you brought up aren’t really trained well in addictions. Do you think and has it been your experience that doctors, are they against additional training because this is maybe more work, it’s more time or do you think that they would be open and glad to receive additional training so that they could help more people?


Mario: I think the latter. I think that we’re seeing these examples really coming from the roots, grassroots from the medical students. They’re creating their own little groups while in training in medical school around substance use. I mentor several of them. I think that people want to be trained. People that are physicians and nurses and others, they want to know how to do well at dealing with problems that patients come to you with. 


There’s also not a lot of access to addiction specialists. It’s not like they have a choice of a plethora of people to refer out to. There’s not a lot of board certified addiction folks or folks that even in other disciplines like in say psychology or their social workers that have special certifications in or experience in working with folks that have substance use disorders. 


It really does especially if you’re in an area that’s a rural, if you’re in a rural area you could be the number one person for all these things. It’s going to cross you because if you’re treating pain I mean what’s the likelihood that a primary care doctor treats somebody with pain, back pain, knee pain. I mean almost 100%. It’s a hundred percent you will do that. What if you have to use an opioid or what if that becomes a now you are dealing with a potential problem that you have to understand and you have to know how to help somebody with appropriate use. 


Benzodiazepines for folks that might have either acute anxiety issues or even seizure disorders that require them to be on these benzodiazepines in some cases which can also result in independencies. No matter what I think it’s there. I think that people do. 


I’ll tell you. There’s kind of a dirty little secret behind all of this that probably only somebody that teaches in some sort of a medical discipline understands really well is that the systems that are around teaching, the residencies, the fellowships, the medical school they teach around requirements for examinations. In the case of medical students they have to take what’s called a USMLE. That’s the medical licensing exam for medical people.


If I require a certain percentage of questions from the board, the people that run that whole system, if I say 5% will be on let’s say respiratory issues. Well the training will try to match 5% of the exposure into respiratory training. In the past there have not been room for sticking in there a significant amount of substance use requirement. Therefore a lot of the program directors around training programs have said well, I can’t. I don’t have the time. I mean there’s tens of thousands of hours that people spend to become a doctor for the training. Each one of those hours are kind of allocated in a certain way to cover to make sure people pass those basic standardized exams. 


That’s a kind of a very detailed reason but guess what? We have to target that and that when we are, we’re changing that now. There’s lots of places that are to make sure that adequate time and training that residency requires not by choice but we demand it. When you leave this residency or when you leave medical school that you understand the fundamentals of addiction, of substance use disorders and kind of all their flavors and then can operate in your scope whatever you’re doing in a more informed manner that’s safer. So that you know your lane and then you also know when to refer and when to integrate some of the non-medical things into the person’s care plan around therapy, around peer support and to appreciate some of those things as it relates to the continuum of care in a chronic disease like substance use disorders.


Zach: One of the things you talked about with me was this sort of idea the term language of addiction. Can you explain a little bit about that?


Mario: The way I’m using it here I really do mean by professionals. The language of addiction medicine is not what the average person is speaking. You go walk up to somebody that’s not a medical provider and ask some questions about addiction. I mean we use all sorts of terms. We say oh I’m addicted to chocolate. Well, I get where you’re coming with that but you’re probably not going to sell your body for a Hershey bar one day. It’s probably not going to happen. There’s some distinctions in terms of how far plus there’s neurobiological parts. Is it going to involve the release of dopamine in certain parts of the brain? Is it going to affect the reward system and in some cases there might be an overlap particularly in foods. 


In the case of a professional it’s something very specific. There’s this body of knowledge that’s been created around what we now call addiction medicine. It didn’t exist before in the same way. It’s important that the people that hold themselves out as professionals be part of the tip of the spear for being mindful of using language that is medically and scientifically accurate number one, number two, non-stigmatizing and number three, that really is useful in communicating between people so that when I say something like an opioid use disorder that you know exactly what I’m talking about on the other end because you understand that that’s based on the DSM-5 and what that means and what criteria. 


We can have a discussion about what that means versus somebody’s using terms like this person’s a junkie. That’s a very dramatic term that probably won’t commonly be found as a way to describe somebody between say two doctors but you could probably commonly find people and we’re beginning to even move away from the term addict. The idea is that language is a social cultural phenomenon in addition to being a tool. It’s always evolving and I’m not an expert in language.


Zach: I want to ask a good question. That’s something that I think in our area too that the replacement of that word, the vernacular of the word addict. What are you finding is a more helpful or useful term for this population versus addicts and alcoholics?


Mario: For these terms what we’ve been doing is that we’ve been adopting a mechanism for describing somebody that we call person first language. In other words rather than saying somebody is an addict or a user or a junkie or an alcoholic or a drunk we say a person with a substance use disorder, a person with an opioid use disorder, a person with an alcohol use disorder because they’re not defined by the disease that you are diagnosing them with. 


We do this in other parts of medicine. This is not just in addiction. I’ll acknowledge that language is complex in the sense that there are subgroups that pick up language sometimes for shorthand. If you were in a surgical suite and it’s a discussion between a surgeon and the scheduling nurse. They’re going to say hey what am I doing at three. Well doctor you have that gallbladder at three, you have the tumor removal at 4. Those terms are like shorthand that people use in a very industry specific way. 


I would say that even those terms should still be changed. How would you feel if you heard your doctor say, you’re the lymphoma guy? That’s not going to feel good. Same thing with the use of addiction. Do I want to be labeled by something like that? I mean does that really encapsulate who I am? In diabetes care, do we do that too? If you up for a colonoscopy do I call you oh you’re the diabetic? We don’t know do that although it has been done. It’s just not a good way to do it. Person first language helps, it shows that the person has a problem rather than the person is the problem. That’s a big distinction. 


We want to avoid that. We don’t want to elicit negative associations. We don’t want to elicit punitive attitudes. We don’t want people to live in blame when we discuss an opioid use disorder or a benzoyl use disorder because they’re going to believe you especially you mentioned before that although there are some bad examples of some doctors just like in every industry that maybe they’re a little more ego driven. For those let’s move them aside for a moment and say somebody that has a healthy ego and understands what they’re doing well, your patient might have a level of respect for the role you’re playing. They’re trusting you. You’ll appreciate this. Sometimes patients tell you things that they don’t even tell their spouses. I mean that’s a privilege that you have to respect.


Zach: It’s a sacred kind of space I would say that much. Not to put religion in the mix because it’s not about that but there’s something almost sacred about that interaction.


Mario: That’s a perfect term. It is a sacred space. When I’m training other folks I literally draw a little box in that sacred space. When you’re in front of somebody it’s a very important thing that’s why even body language and tone matter. It’s important that they buy into, that they yes they might have, if you’ve come to the conclusion that there is a substance use disorder that you can explain to them how what that means from the standpoint of science but also you give them the hope, an accurate hope that this is a treatable condition. 


It does require a lot of effort. It is multifactorial. It’s not a direct line from A to B but they’re not broken that they’re not defined by the condition. That’s important because that sets the tone for how they view the future of the rest of their life.


Zach: Let’s talk about this idea of relapse for a minute because this is common. This does happen especially for people with opiate use disorder. What’s been your experience in helping those patients through that experience though when they do relapse?


Mario: We do view the continuum of addictive disorders as involving recurrences not unlike some people that have cancer can have recurrences of the cancer. We can acknowledge that even outside of addiction there are and we would never scoff at somebody saying oh you relapsed. Your lymphoma’s returned. There’s been a relapse. We would never scoff at somebody for that or blame them or say hey you’ve been to the oncologist five times already. Why aren’t you cured of that? Yet we do see that with people with substance use. It’s like man, you’ve been in rehab five times. Well, aren’t you done with this? What do you mean you relapsed?


There’s kind of the colloquial, vernacular type of way to view what relapse and recurrence. Then there’s actually in the world of mental health, physical medicine and addiction there are variations of what we mean by relapse versus a recurrence. A lot of it has to do with research of how you identify these. Sometimes it might be for example that well a relapse could be that it means that you’ve had again these symptoms that have returned after starting a remission but before you entered recovery whereas a recurrence would be after you experienced full recovery which in most textbooks these days is about six months period, a six month period of time of abstinence of being in that recovery. 


Let’s not split hairs. People think of it in terms of man, I’m using again. It’s important to one, not be judgmental during those times. We do know that in addiction these things happen. We expect them almost to happen. You want to make sure that the person doesn’t view it as a moral failure. Unfortunately there’s still lots of stigmatic kind of stigmatizing attitudes that are out there even in the kind of like the 12-step community about that. I mean there’s a high premium to having your chip and to basically being able to say I have 10 years in recovery. 


Even though there’s some positive ways that that can be used, it also can be a negative thing for some people because they feel that they failed. Oftentimes that can also make them want to hide from their very own community of support. Like if they have a recovery community of people that are mutual support type in like an AA or NA, they might avoid them because of shame around the fact that well man, I had five years in and look at this. I blew it. Now, I have to start over again as if they don’t get credit for all of the effort and tools that they learned and how they evolved over that other five year period before. 


That’s important is that you have to couch it as this is not a failure. What this is another part of the road bumps that teach us things along the way and we need to look at this analyze what happened. Was there a trigger? Was there something that caused the craving and what was done in that situation? How do we then make the tools that are going to help you be successful downstream? That’s the way that it needs to be viewed so not with shame and not as a failure. Very important part.


Zach: I think it’s so important to say that because there’s so many folks who go to recovery support group meetings and you are right. They feel if they have relapsed that their seat at the table is no longer reserved. They can’t sit down at the table anymore. I believe in my heart that those people have the first seat at the table like they absolutely deserve to be there because they need to be there. They need to see the hope and that this can change. 


I’m curious what advice do you have though for someone who let’s just say that they are in recovery but they are scared to death about relapse?


Mario: There can be a healthy use of a little bit of fear around that. I mean things like anxiety at its core exist to keep us aware of things but it can’t be the driving force. It needs to be a healthy approach to the possibility of a relapse. That should breed a level of respect for it to take it seriously, to always be in a constant state of learning. Just like in areas of academic pursuits where boy, I get scared if I ever hear a doctor or scientist or anyone else say I know everything about this. I don’t need to learn anymore. That already tells me that this guy’s probably pretty ignorant from the get-go.


In the case of a recovery that’s an ongoing constant sharpening of the saw. If you’re a carpenter you’re going to be constantly sharpening the saw. Sometimes there’s going to be things that don’t work. There’s experiences that you weren’t prepared for. You may have a loss, a type of loss that you’ve never experienced that shook your emotional way of coping with things that triggered it. You may have a kind of a recurrence in a thought pattern that existed before out of traumas because a lot of folks with substance use disorders also experience traumas at a very early age. 


These adverse childhood experiences that we hear of now. You never know sometimes those pop up. Life throws a lot of things at you and sometimes those can be triggers. They need to know that okay, I need to accept that these are possibilities. Hopefully, they’re with somebody that brings the barriers down and says hey, when these opportunities come up to improve things you need to you need to be able to reach out for help. You’re not going to get a lecture.


I literally say this to my patients. I do a lot of treatment now for medication assisted treatment particularly in community clinics. I don’t tell people what to do number one. I’m not a judge. I’m not a cop and I’m not your father. I’m your resource. I’m your consultant in some ways and I want to advocate for you even if I suspect you’re not advocating for yourself. To that end there’s never a good reason to not tell me because you’re not going to get a big lecture from me. I’m going to focus on your quality of life. Quality of life at the end of the day is really are you in a state to love and be loved. 


All the mumbo jumbo that I can come up with scientifically to cloud what that means otherwise quality of life years or some obscure medical term. No, it’s like let’s simplify. Are you in a state to love and be loved because when you’re in your disease neither of those two things work very well. Quality of life is the focus and that’s how I’m going to approach it. Hopefully that makes it so that they feel like I’m going to tell Dr. Mario this happened to me. I can tell you almost always, I don’t have to rely on a drug test. Almost always my patients tell me they say oh, doc this happened. We discuss it and we say how do we make this a better situation than what it is. Not how do we fix it. Not how we fix you but how do we make this better so that your quality of life is improved after we’re done.


Zach: I love it. Dr. Mario, it has been a pleasure sir. Keep up the good work out there that you’re doing in California. Love to have this conversation again at some point. Thank you.


Mario: Thank you. I appreciate the opportunity through the BYOC Initiative. I think that’s going to be a transformational initiative that’s happening in Orange County that really puts together mental health systems along with substance use. In the past substance use has not been in that conversation. I’m happy to be part of that and to kind of represent that here as well. I appreciate what you do educating folks about recovery and about substance use. Thanks again for the opportunity.


Zach: Thank you. Listen, if you know someone struggling with an addiction and you’re searching for answers visit us at landmarkrecovery.com to learn more about substance abuse programs that are saving lives and empowering families. Until next week, I’m Zach Crouch with Landmark Recovery Radio.


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