everything in between and we're really just here so that families out there know that they are not alone our guest today is talk to lara keogh dr keogh is an addiction medicine and primary care physician at mass general hospital she is a core member of mph a substance use disorder initiative which she is the medical director of the substance used to sort of bridge clinic and attending physician on the inpatient addiction consol team dr keogh also works at right turn which intense intensive outpatient addiction treatment facility located in watertown as if all that isn't enough she's also a founding member of the watertown task force which is a coalition working to expand prevention intervention  treatment for people with s u d in their families within the watertown community she is also a wife in the mom of three children in watertown thank you dr king to thank you for being our first guest we thought you were an important place to start get to start with the topic of this is a mental health issue a very important topic and what we're going to talk about today is about the science and stigma of addiction and i'd like to start actually with  message this is actually part of a national recovery month and it's simple and obvious to many of us who are here that addiction is not a weakness it's a disease and i'm going to hopefully by the end of the talk arm people with some evidence as to showing that this is a disease before we get into it i'd like to talk about the extent of the problem we know that forty million people or greater than one in seven ages twelve and older have an addiction and that includes tobacco drugs and alcohol this is actually more than the number of americans that we see with heart conditions where we see twenty seven million people diabetes at twenty six million in cancer one thousand million so it puts it purchase perspective when we think about the other chronic diseases that we treat readily with very good multi disciplinary treatments including medications and behavioral supports the the other thing we know is that only ten percent of people or one in ten invalid individuals who seek treatment actually receive it for addiction and as we all know you can't go a day without hearing the news or reading the newspaper or hearing about or knowing someone close to you  who has died of an opioid overdose and we know that it's actually now the number one cause of preventable accidental death a true crisis a true epidemic and to also put that in perspective the we are more likely to die all of us here of an opioid overdose than a car accident or of gun violence so it's a significant significant problem and the latest data that we have on the opioid related deaths are that the numbers are actually increasing despite many community local and federal implemented changes to address the epidemic and the latest numbers we have is that prescription opioids overdoses are now over eighteen thousand eight hundred ninety and there are almost eleven thousand deaths due to heroin and so what that down to a day what that brings us to massachusetts is that more than four people today died of a treatable preventable disease and  same will happen backing up a little bit i want to go over a little bit of definition to get to the crux of addiction and what we know is it's actually defined as a primary chronic brain disease characterized by compulsive drug seeking in use despite harmful consequences and that's really the basis of this disorder and as one of my colleagues says by definition then addiction is irrational because if something is really that horrible you're losing your relationships you're losing your children you're losing your life you're losing everything what then just stop and that's probably the hardest piece of this is that the part of the brain that is affected by all does all drugs that are addictive affects the part of the brain that controls these behaviors and that's what's so hard for family members policymakers physicians traders neighbors to understand and so that's really something that's very  important to really understand it also involves cycles of relapse and remission and that something just like every other chronic disease we treat we see it in diabetes and heart disease asthma is also about fifty percent genetics so the genes that we're born with as an infant predispose us to potentially having this disease if we're exposed to a drug so that speaks to prevention and we also know without treatment as we see that addiction has significant significant tragic outcomes and it can can result in severe deaths as we're seeing the other piece is going back to the primary chronic disease that means it's not manifestation of another mental illness it's its own disease in and of itself and often other mental disorders can cope curry with it but it is of itself its own disease we also know that addiction is really a pediatric disease and this also speaks to preventive efforts that we really need to be starting younger than we already are it's a developmental disease and what this means is anybody who has kids know that kids are impulsive and make decisions based on how they feel rather than slowing down and thinking about the consequences and this is actually a schematic of the functional images of brain development from age five up to age twenty and what it shows is the kind of the warm areas the red in the yellow the rainbow colors are immature brain as the brain content in green and as the brain develops you see it getting more blue and the thing to note is that even at age twenty still a lot of green in there and so we know that adults really full brain development doesn't fully engage in till really the mid to late twenty's so what this piece shows us is that that front part of the brain at the far right it's called the prefrontal cortex that's really the c e o of our brain that allows us to stop and say you know what this isn't fun anymore i don't buy i'm not enjoying this i've lost all of this i'm going to stop and that's what's really hijacked substances and kids this is somebody who hasn't been exposed to substances this is their brain developing so kids are really hard wired to make these impulsive decisions so if they are then exposed to a substance that also damages that area they're even more likely to develop an addiction and we know that eighty percent of adolescents will experiment with drugs i know i did and a percentage of those that have the unfortunate exposure of genetics or environmental exposures or very early exposures the earlier kids are exposed are very highly likely to develop an addiction and we know that ninety percent of people who have addiction started when they were adolescents so it really is an adolescent pediatric disease this i put on here because there's this misconception that people who have addictions kind of chose this life so they should just deal with it and why is it my problem and i have to say again going back to childhood when we think about the genetic predisposition and you think about a five year old kid who has dreams and has aspirations and i think of my patients and when i talk to them tell me what your childhood was like tell me what you wanted to be when you grew up what do you want to do when you get better none of them said i aspired to be here right now i never wanted to do this and so that speaks to again that the underlying brain chemistry that changes this is a schematic of the circuits that are involved in addiction and it's simplified but also a little bit complicated but the basic message here that i want people to see is that the motivation part of our brain and this is the front part of the brain and the reward center a little bit further back it's called the again the prefrontal cortex that really important part that develops from back to front all of us it's the last part to fully develop is basically hijacked by all substances that are addict and what we see is normally for our species to actually continue to live it's a normal function that we all have this hormone called open mean that is secreted when things are pleasurable so if i eat a sunday i'm going to g have our species so when somebody is exposed to an addictive substance that also functions in this area and causes a secretion of this hormone dopamine it does it in levels that the body could never reach even the most euphoric experience you could experience such that the brain actually remodels to now try to support that function because that is the most pleasurable it could experience and actually it really changes the brain chemistry that now the brain is trying to continue to get to that level and to support that level of reward and that is also connected to memory so keep that comes back to triggers when people say i was in recovery for all these years and i walk down the street to a place where i used to use or i saw a paraphernalia or i saw someone that was was nodding off and looked positive experience so it can be positive and negative in this case it's negative it's also connected to motivation so a lot of people the only motivation at that point is because this circuit is going is to achieve that drug and inhibition that again that i've got to stop doing this this isn't fun anymore i'm going to i'm really going to stop it's completely hijacked this is a schematic also showing functional imaging of the brain of  receptors that we're talking about the pleasure of the reward hormone and in people who have an addiction and have developed a tolerance to this drug have really depleted their stores so at that point you can see why normal daily activities knowing that you can get maybe to this level fifty level with a nice dinner or reward from work reward from being with your family and to this level with substances and if you're down with nothing really nothing brings you pleasure anymore and what we know with opioid use disorder in particular the natural history of opioid use disorder is that people start experimenting say a kid in school tries oxy koda own and they initially go from feeling normal to no euphoric and it feels good so they want to do it again right things are pleasurable they try it again and as you can see there's a trajectory going down now from euphoria down and to normal and as you can see that peak now is much lower as you continue down to using in jumping into tolerance and physical dependence on very shortly in this can happen with a matter of weeks people go from feeling normal to now no longer getting the euphoria down into withdrawal and now we're at the stage where in order to function they are using the substance they are not using they're not even getting you euphoric they're not getting high and there's this misconception is all you want to do is go get high that's all you can think of actually they're not getting high anymore they're actually using so that they have some sort of function so they can get out of bed so they can get their kids to school so they can get themselves to school this is also as we said addiction is similar to every single chronic relapse and disease that we treat here on the left is a picture of the heart healthy heart rainbow colored and a functional image of one that suffered a heart attack you see that there is no rainbow coloring there at the scar tissue on the right somebody who is addicted you see on the left is a nice healthy bright yellow that front part of the brain the dopamine receptors are robust and on the right somebody who has suffered addiction and now has depleted those stores the good news is unlike heart disease where we see this dead tissue in addiction we see recovery and there's not death to the tissue and recovery it does take time but we do see it in this is a really important message for family members and for patients that there is hope that we have excellent treatments and people do get better but it's got to be the right treatment here we see again a normal brain with that rainbow color of and then a patient who with an addiction who is one month post detox and you still see there's very little red in there so it's still this is somebody who's gone there they're still not feeling that great very very high risk of relapsing and then somebody fourteen months post abstinence or they've had recovery and this slide is really important for people to see that a you can get better but be one months post detox this is a really important slide to look at our system  set up to treat an acute acute disease excuse me to treat a chronic disease and acute care model is actually potentially fueling the epidemic of overdoses because if somebody comes out of a detox if they're lucky enough to get in for a month and they come out without appropriate treatment they are so there is such high risk that we see a percent ninety to ninety five percent relapse rate within a month because of the underlying and healed literally unchanged brain chemistry so that fourteen months we see we're seeing recovery but it takes fourteen months we are getting back to addiction as a treatable disorder this is a nice comparison again hypertension heart disease diabetes here we see before someone is treated with hypertension it's out of control when they get on treatment medication they start exercising eating differently it's controlled and when they stop taking their meds which happens the same rate as people in terms of people of it here and it goes out of control again same with addiction on the right somebody is not engaged in treatment they're out of control and using when they get in treatment they're controlled and when that treatment is taken away they relapse and the relapse rate as we said about fifty percent relapse rate for substance use disorders diabetes hypertension and asthma so they're extraordinarily comparable cross the  board one note about relapse is that relapse happens we talked about this is a chronic relapsing disorder and that's at a time even within addiction treatment facilities we see people panicking in people saying they're not ready they're not compliant they need a higher level of care and they often ask the patient who's now struggling who has a symptom of their disease that is out of control and we ask them to find their higher level of care so many of these programs that we send people to that a higher level of care actually are lower level of care and that speaks to the peace that they may say ok well if we just take them out of their environment and send them to a farm several states away but don't offer them the rest of the treatment which includes really specifically with opiate use disorder because people present with such severe  disease that they need medication to stabilize the brain which will then allow them to engage in the behavioral supports and you know i ask this question all the time what we do if a cancer survivor i see a patient who has lymphoma and they come in with a  enlarged they've had a recurrence of their lymphoma i would reach out to the cancer doctor i would you know our team would work together to get the patient there we wouldn't say here's a list call this doctor and get yourself hooked up for an evaluation which many times when people are going into detox that's what it is that's exactly what it is they have to do their own research and make their own phone calls and you know what wendy even within within addiction treatment centers that happens to there's this there's this thought that even the best programs there's this thought well really underlying they got themselves into this they can kind of deal with this so here here's a list and make the calls and it really really is missing the point  missing the science that we know behind this that this is somebody who at this point really needs more support than they did before when they were getting it so here we have this is the perfect segue we have this access to treatment in this enormous gap so we have this you know over two and a half million people twelve and older who have an opioid use disorder yet less than a million of them get treatment twelve twelve and older yup and  hundred twenty people a day are dying of this preventable disease treatable disease and we let them present really advanced stages and so when you think about it again in the again in the lens of heart disease which is a great comparison we have pre hypertension we have hypertension with people who have heart disease blockage of the arteries have had heart attacks and congestive heart failure so we're seeing all of these patients really in congestive heart failure stage and if you think about it when we talk about treatment if you've ever known anybody who's had heart disease can you imagine if they'd had a heart attack and people withheld medication from them or somebody with congestive heart failure they would get aspirin cholesterol medication blood pressure medicine di and it wouldn't even be questioned and i guess your screening in the beginning you screen for all these other things absolutely that they don't happen and you catch them in the earliest stages possible exactly and so that and that's what in primary care we do our our one of our biggest goals is working on prevention yet this is one disease that and i'm one of the people too i graduated from medical school with very little education of maybe an hour or two lecture of addictions and had to find my own education after seeing all these patients with this overarching disorder that really is connected with multiple other diseases that we treat and we think that's changing is that the change in that absolutely absolutely changing theirs and that's the one thing you know the silver lining in this horrible horrible american tragedy is that we're finally having fantastic you know the fact that we're doing this here that we have a governor who has made this primary goal we have our hospital has made it their number one initiative that our president is talking about it that we have all of these community organizations people coming out people talking about their recovery  stigmatise it which is the leading cause of why this has not been seen as a disease and it's largely due to lack of education about it and that's really the crux of it so you know providers are not trained and because of that providers don't know about it so they're afraid of these patients they there's a lot of negative attitudes toward medication from the public from providers as well it's a disease that's been really criminally managed in punitively managed as opposed to focusing on therapeutic interventions and the criminal justice system has actually been allowed to make medical decisions for this which would be malpractise for any other disorder  so the key is also that when we look at again a treatment the treatment gap that we have when we say it's a treatable disease we have very limited resources and that's working to be expanded but they have to be evidence based resources we know that less than fifty percent of addiction treatment centers offer medication in addition to the behavioral supports and less than five percent of physicians are waiver to prescribe a life saving medication lifesaving medications that actually have been shown repeatedly over and over for decades to save lives  would like to and with the message from one of my mentors that when people are not doing well with addiction we have to look at that people don't fail treatment but the treatment fails people into revisit just like we do with every other disease  and good people make bad decisions when their substance use disorder is active and that is reflective again of the part of the brain that is affected and hijacked by these disorders by these drugs change takes time and patience and it takes trust when the disease is flare to enlist the care of multiple team members family members reach out and this is no different again and then we would do for any other significant disease and positive reinforcement really works for people who are invalid and just like other diseases remembering that no no no no one size fits all  diabetes heart disease and management peers with their severity and same with this way of life saving medications way of life saving behavioral supports and we have really important family support we have to remember this is a family disease so hopefully this has highlighted some of the important science behind addiction and if there are a couple of things that i would make a plug for is to continue to educate people about the science behind this disease and to remind people that this is a very treatable condition and to give people hope that change is here but we still have a lot of work to do and we're here to provide that support  spouse who has lost somebody to a substance use disorder or they're in the thick of it now how do you i mean i think people trouble reconciling that relationship right around or standing that they're not choosing the drug or th relationship right exactly so first for the person who's lost a child to substance abuse disorder or any loved one that's unfathomable and it's it truly  is one of the worst tragedies there are there is in any any death is horrible but this is particularly confounded because of the stigma because of the shame because of the isolation the lack of resources even when people go to get care they get mixed messages they may not have gotten the best care and so there's so much guilt and built up into that that the first thing i say is you know how are they doing because to get through that to me is unfathomable and i've seen people do it and they're the most strong people i think i've met and particularly people who come forward and tell their story of their family struggle and knowing that that they also survived this and continue to support themselves and get that support with other people who have been through the same thing for people who have somebody who's struggling with an active addiction that's extraordinarily difficult in the key is as you said wendy to try to remind yourself and other people around you that their behaviors are a manifestation of an untreated disease that they're not bad people they're doing these things because of the area that is affected and again if it were the part of the brain that affected their vision or their hearing or their able to billeted to move their arms it would be a very different discussion but it's because of that it's so hard and it's so hard for anybody you know to to not be tried by that what to do though is to remind that person that you love them that you're there for them you're going to help we know that confrontation does not work the outcomes have shown that it does not work to to threaten and confront but supportive care does and that's it's easier said than done but when i say supportive care that also means trying to find really good help that can help you with this the b c s website has a good resource there as well and then another website that's excellent is the national institute of drug abuse night has a fantastic website if you just google that they have a section for each group and there's one for families that's excellent actually as a tool it goes through what if this what if this and questions how to down to even the language of how you can talk to somebody ok that's an idea that an id a dad or well put actually put that up at the end ok perfect so  volkow is the director there and she's another change agent who is leading the cause to the stigma ties this and really get this and she's a scientist doing all of this research to really expand the education and also the support i would also say for people who are struggling with someone with a dick with an addiction is the isolation in the shame and we're doing a really good job i think on hoping helping people to feel comforted more comfortable talking about it but we still again there's still so much to do but if people can find groups to talk to thank you so much thank you i know linda and i just want to say that part of