One new aspect of addiction treatment that has become popular in recent years is the use of medically assisted treatment (also known as MAT). It is used to treat many substance use disorders as well as to prevent overdose. Due to the recent opioid epidemic, MAT is being used as an alternative to abstinence based recovery. MAT is primarily used for the treatment of addiction to opioids such as heroin and prescription pain relievers that contain opiates. In this episode BlueCrest CEO Rich Hession, Mark Bonnani, Dr. Nicholas Coangelo and Dr. Muhammad Farhan Ijaz discuss this polarizing topic. Is medically assisted treatment effective when treating substance use disorder?

Transcript

Rich Hession:

Hi, everybody, my name is Richie Hession, and welcome to The Other Side, the official podcast of BlueCrest Recovery Center. I’m the CEO and we thank you for joining us today discuss one of the new… I don’t know if it’s a newer aspect of addiction treatment, Nick, but the use of Suboxone and other medically assisted treatment as an alternative to treating substance abuse disorder. We’re an abstinence-based place, BlueCrest, but MATs is the topic du jour and we’re going to get into it. This episode is going to be a lot about Suboxone, although, we are going to try as best we can, and you guys will hold me accountable to not just only talk about subs.

Rich Hession:

And that we can get to some of the other useful helpful MATs, and then one other that’s not particularly helpful at all. Maybe we should even talk about Methadone early in the podcast just so we can get the synthetic heroin out of the way. Then we can all just agree together that it’s not a reasonable substitute, and we can move on to other topics. Would you agree with that Nick?

Dr. Nicholas Coangelo:

I would agree with that.

Rich Hession:

Thank God, I just want to make sure. Let’s start by introducing everybody. First of all, remember that you can listen to this podcast on our website, bluecrestrc.com, or you could subscribe on iTunes, Spotify, SoundCloud, and YouTube. For anybody who is watching live on YouTube, sign into your YouTube account, and then you can ask questions. If you do, Nick is in the back. Nick, yell hello.

Nick:

Hello.

Rich Hession:

I hope everybody can hear that. But Nick is going to be yelling out every so often he’ll say, “Hey, we have a question from a listener.” Then he’ll yell it out and then we’ll do the best we can to answer it. Today, joining us for the podcast I have to my right, Mark Bonnani. Mark is the… can you say your title for Princeton Detox.

Mark Bonnani:

Director of Business Development for Princeton Detox and Recovery Center.

Rich Hession:

Boom, there it is, and we have Dr. Muhammad Ijaz.

Dr. Muhammad Farhan Ijaz:

Hi, Internal Medicine board certified, Addiction Medicine board certified. I practice in North Jersey, Clifton Patterson, aquanic, all across there.

Rich Hession:

Okay, and Nick Coangelo, the CEO of Brookdale Treatment… is it Brookdale Premier Treatment Center?

Dr. Nicholas Coangelo:

Brookdale Premier Treatment Center in Scotrun, Pennsylvania.

Rich Hession:

Scotrun?

Dr. Nicholas Coangelo:

Scotrun.

Rich Hession:

Okay, nice. These guys are my esteemed colleagues. Everyone at the table has a lot of experience with… I don’t know if we’re all pro or against, I think Nick said it before we started that it’s not either or, there’s no good or bad. There’s good uses and bad uses for Suboxone specifically. But what we’re going to do, we’re going to jump into, I’m going to read, I don’t usually go off the paper, but I’m going to read off the paper at least to start off and to set the tone. First topic introduction is the number of cases of opioid abuse disorder and substance abuse disorder are rapidly increasing each day. The most common treatment of these disorders is abstinence-based treatment. Due to the opioid epidemic, there has been alternative treatment that has become popular called Suboxone maintenance, which is a form of MAT.

Rich Hession:

MAT, new people just listening, Medically-Assisted Treatment, and it means that you take something instead of your drug of choice. In this case, what we’re going to be talking about are people are addicted to heroin, and instead of taking heroin, you take these little… they usually just come in strips, right?

Mark Bonnani:

Strips now.

Rich Hession:

Because that’s what I’m familiar with, the strips.

Mark Bonnani:

Maybe a pill.

Rich Hession:

They have little strips called Suboxone and they can be given… Hey, Doc, when you prescribe Suboxone to somebody, typically, and I can’t believe I’m going to use the number 24, but typically, they’ll be given any range from one milligram to 24 milligrams, is that accurate?

Dr. Muhammad Farhan Ijaz:

Right, yeah, average is about eight milligrams once a day, and then you reassess them within the next 24 to 48 hours to see how they did with that and go up and down based on that.

Rich Hession:

Okay. Now, you know what, so I’m not going to stick straight to the sheet because there’s going to be a lot of topics that come up. You and I have talked about this before, and so I’ll throw it out there to you. One of the arguments that’s been made, at least for us, just as far as the dosage goes, I’ve been told by people who use, who’ve used heroin for a long time, who’ve used subs for a long time. Who’ve used heroin and subs, who’ve done everything under the sun, who’ve told me that basically anything you prescribe over eight milligrams is pointless. That it just doesn’t even really make any additional difference at all. That eight should really be the cap realistically. What do you think about that?

Dr. Muhammad Farhan Ijaz:

Yeah, I would say, yeah, eight would probably cover about 70 to 80% of people. 16 should cover about 95 and then that 24 to 32 it gets into that range if the higher dose is even doing anything.

Rich Hession:

24, like what would somebody have to do in order to earn a 24 badge from you?

Dr. Muhammad Farhan Ijaz:

Probably out of probably 1000 patients, maybe one person is getting 24 and that’s because they came in at 24, or they’re [crosstalk 00:05:17]-

Rich Hession:

There it is, that’s a different thing.

Dr. Muhammad Farhan Ijaz:

Yeah, I would say 90% are not going over 16 for the most part.

Rich Hession:

What about your place, Nick?

Dr. Nicholas Coangelo:

I’d concur with that, with the exceptions and what we need to talk about here is we’re in treatment, we’re doing detox, we’re doing residential, we’re doing PHP. But there is also, in our field, this maintenance perspective that you’re going to be maintained. You’re not going to come off and some of that is in, unfortunately, the pharmaceutical literature and time and duration. We haven’t settled on something where everyone is speaking the same language. Those of us that are in treatment will assess the person, check their histories, see what they’re doing. I concur with if you can get them down to a stabilization of eight, if they’re going to stay on, there are people who will want to come off completely and step off, then there’re going to be people who need a shorter duration of it.

Dr. Nicholas Coangelo:

The human body is a vastly complex biochemical organism along with its own experience, so how do you assess that? How are the treatment people doing that? You and I talked about the people that come to us. What they’re used to? What they’re not used to? The people that then come to you, what are they used to, what do they want? The variable in all of this, in my mind’s eye, is that we have to end the treatment component, figure out what we’ve done. Now, Princeton Detox has done that, you have done what you’ve done, and we have embraced both an abstinent model with a medication model based on what the patient brings to them individually. But always trying to move them to something further down the road. It’s artwork more than it is science.

Dr. Nicholas Coangelo:

I had a conversation with your folks today about we are looking for partnerships of people that we can work with, something medically like you do and then pass on and then complete and get to abstinent. Now here’s the wild card, we’re a pretty big treatment center, there’s also the real harm reduction person. That harm reduction person may not be able to do it, the one in 1000 and we may get a little bit bigger sampling of that along the way. What do we do with those? What do those patients deserve? How do we handle that? This conversation goes all over the map, Richie.

Rich Hession:

Yeah, it does and you basically just I handed you off that simple question of, what, the milligrams, and you went right to the heart of exactly what we’re going to be talking today. I couldn’t interrupt because I won’t. I mean, you guys are stream of consciousness, I’m always a big fan and you got down to the brass tacks right away. We didn’t ease into it, but you jumped right into it and that’s the truth, that’s the crux of this whole thing. Probably appropriate, which is why everything comes out when it’s supposed to, how it’s supposed to, for whatever reason, and you just put it out there. Before we started the podcast, I said to everybody, we do these, hopefully we can help a family or two. If anybody sees this or listens to this, and some people are confused about what MATs are, what Suboxone is?

Rich Hession:

A lot of people are under illusions about that Suboxone is not a curative, I don’t think it was never designed to be a curative. But in the end, people have certain beliefs when it comes to treating addiction, and alcoholism and there’s different ways of doing that. I’m not going to argue, I won’t argue with people. I used to, I used to be somebody who would sit there and argue with someone that Suboxone maintenance is wrong and it should never be allowed.

Dr. Nicholas Coangelo:

Really?

Rich Hession:

Yeah, that’s shocking to believe.

Dr. Nicholas Coangelo:

Me too.

Rich Hession:

But I believe it’s a bane on the existence of the addiction world. I think Suboxone, in and of itself, Suboxone maintenance long-term is an absolute horror show and a terrible idea. Yet, I’m also somebody who has conceded that there are those cases, there are those people who probably are better served being on long-term Suboxone maintenance. They are there, those people are out there. I just won’t ever be the person-

Mark Bonnani:

Minority, in the minority.

Rich Hession:

A huge minority I think, a huge minority I think, and I will never be the person. I don’t know, maybe I just don’t have enough guts for it. But I think it goes way beyond that. But I’m never going to be the guy that looks at another human being and says you’re never really going to be able to get actually better, and so I’m going to resign you to this muted life. When I say muted life, and I’ll ask you, I’ll go to you on it for this part of it, because now we’re going total stream of consciousness. But I’ll go to you and ask you, when somebody is on Suboxone long-term, they go on Suboxone maintenance. If you’re on Suboxone for long periods of time, would you think it’s safe to say that you don’t connect with people emotionally, mentally in ways that other people do? Does it make you a bit muted?

Mark Bonnani:

I think just the experience that I have with it is people, maybe not that they lack connection, they’re just not happy. The bottom line is all their emotions seem to be muted after years of being on it. Both people that I’ve met in person, and then obviously doing the job that we all do, talking to people begging to come off of it. I don’t know, but I always put it out there that I’m an abstinence-based recovery guy long-term so I always see the people that are miserable, and that it fails. I don’t know, I’m not small minded enough to think that there might not be some people out there that are doing okay on it. Lives have improved dramatically. We just don’t see those people in 12 step fellowships, because they found a different way for their lives to improve. But, yeah, they always want to come off, they’re just not happy.

Mark Bonnani:

Maybe, I don’t know, if it’s lack of connection or what it is, just tired of maybe having to take something every day. Then with the drug itself, and a lot of people say you’re not high, and I’ve taken it and you don’t feel high. But you must be a little high, it’s an opiate, so [crosstalk 00:11:31].

Rich Hession:

I’ll go there and I’m going to go over to you, Doc, and I’m going to ask you a question. But I’ll tell you a story first. Mark and I were at an event up in Cape Cod, and we have a little BlueCrest table set up and at these events is a way for a lot of the people in the treatment industry to meet one another and talk to one another and see who’s doing what and what’s going on. You meet with a lot of clinicians that come there to get their CEU hours for their licensure every year. You exchange ideas and you exchange business cards, and you tell stories, and you hopefully can form some meaningful relationships. Where a guy can help people from your area, and you can help people from mine and what we do. We were there and we’re manning our table and so some gentleman comes in he was somebody who was a big believer in Suboxone maintenance.

Rich Hession:

Now, to the point Nick made, and we’re going to get into it now. But the difference between utilizing Suboxone to bring somebody down until they’re off. Earl Hightower always says, he is the interventionist from the West Coast. He always tells clients, which I’d love to tell clients because it’s true, you want to go to detox because they’re going to load you up in the front end with a lot of meds and they’re going to bring you down smooth and easy. That’s the big fear is that they’re not going to be brought down smooth and easy. They don’t want to be sick, they don’t want to go through that horror of heroin withdrawals, and so Suboxone is one of the detox medications that they use, and these guys will speak to it. They give you a particular titration and they take you down and they taper you off and then you’re finally detox.

Rich Hession:

Then you’re left at zero when you’re clean, and a lot of people use the detoxes, I’m going to ask you guys these questions as tune-ups. People don’t ever look to do residential then PHP and IOP and get a doctor and be under someone’s care. To get a therapist and to go to AA or NA or CR or one of those places. People look to go into do tune-ups, so they can go and they can get everything out of their body. They know they need to get set back straight again and because they’ll get high, high, high.

Mark Bonnani:

Then relationship tune up. I’m going to hide out for a week and everyone will think I’m doing better now.

Rich Hession:

That too on top. Now, but Mark and I-

Dr. Nicholas Coangelo:

Heat off.

Mark Bonnani:

Yeah, heat off, heat off. That’s it.

Dr. Nicholas Coangelo:

Heat off.

Rich Hession:

Mark and I are at this event and one of these doctors comes around to us and starts asking us questions and talking to us. He starts talking to us and he didn’t realize it, but he brought up to us and he was like, “Oh, yeah, Suboxone is the best thing that ever happened to the community.” I’m like, “Really?” I said, “Do you really believe that Suboxone is the best thing that ever happened?” I said, “Do you mean as a detox medication or?” He’s like, “No, no, I’m talking about Suboxone maintenance. You never have to use heroin again.” I’m like, “Yeah, but you’re just exchanging one addiction for another addiction and the difference is…” Again, this is just for me, I said that the difference is that heroin at least when you go through withdrawals, five days and you’re done, you’re done. It’s super uncomfortable, but you’re done.

Rich Hession:

If you get on long-term Suboxone maintenance, I’ve seen the withdrawals last four months. I’ve seen people shaking out of their skin that have been on it for years for high doses. Very hard to kick once you get kicked on there. I’m like, “You’re basically just low level high everyday for your life and you’re calling that sober and I just don’t call that sober.” The guy looked at me and he looked at Mark and he was very serious and he said, “Suboxone doesn’t get you high.” I said, “I’m sorry, what?” He said, “Suboxone doesn’t get you high.” Mark goes, “Wait, do you really believe that Suboxone doesn’t get you high?” The guy was like, “It doesn’t get you high.”

Rich Hession:

Mark said, “Really?” He said, “What I would recommend you do is take one milligram strip of Suboxone and put it on your tongue and swallow it.” He said, “In about 12, for 12 hours you’ll be laying on the floor drooling. You’ll be so high because you’ve probably never done heroin in your life.” Don’t tell me it doesn’t get you high. The difference is, to an addict, that’s used to a particular level of high after you’ve been on subs for a little bit, it’s… what do they call it, just getting right. When you’re not looking to get high, you’re just looking to do enough heroin to get right. Now to a heroin addict, and it’s real, it’s no bullshit, they’ll go into a room, they’ll do heroin enough just to not get sick, to get right. They know the difference, they’re not going to do enough to get actually high. They’re going to do enough where they can actually function like we are and talking right now and they’re not high.

Mark Bonnani:

Did it for a long time.

Rich Hession:

There you go, and anybody would tell him, “Well, what are you talking about? You just went and got high.” Mark would legitimately say, “I didn’t go get high. I just went and got right.” In him there’s a differentiation there, but in the end of the day, with Suboxone, you’re talking long-term use. We see the back end of that, we see people who are looking to come off long-term Suboxone use, and it is uglier than any heroin addiction that I’ve ever seen kick. I’ll put it over to you, Dr. Ijaz, when somebody comes and we’ll go down the line, for people that are looking to get well, and people who have heroin addiction specifically. When they come to you and they come to you care what do you do? Walk us through you get a phone call. Most of your stuff comes from a phone call or a personal referral?

Dr. Muhammad Farhan Ijaz:

Right, pretty much.

Rich Hession:

You’ll get a call and somebody named Joe Q Citizen will call you up on the phone and just give us a rundown on what you do and how you manage a situation case by case? Assuming that we probably need detox first, but just tell us a little bit about what you do?

Dr. Muhammad Farhan Ijaz:

Typically, depending on what they’re using, and then what resources they have available. There’s a lot of other components like their psych component, where they’re living, socioeconomic stuff also. But just from the substance use part of it, typically, when they come in, we’ll do an evaluation and if it’s something that we can handle in an ambulatory setting, then we’ll explain the precipitated withdrawal. What they’re using, is it long acting, short acting, how often are they doing it? We’ll do a urine drug test, and then we’ll formulate a plan on initiating them on Suboxone. That’s typically the process for that. Then we’ll reassess them within a day, two, three days.

Dr. Muhammad Farhan Ijaz:

Now, it’s a little bit longer with COVID and see where they are, and stabilize them on the medication. There are people that, after a while, say, “Hey, I want to come down.” They do come down. Some people come off also. But the part that you’re saying about months of symptoms and long-term use, and the phenomenon or situation is basically referred to as post-acute withdrawal syndrome. It’ll be pretty severe in those type of cases. Similar to if you’re on Xanax long-term and they’ll have the similar kind of episodes. I think you mentioned that there’s no real number that… it’s not like you have a UTI and take antibiotics for 10 days, and you’re good to go. Everybody has different situations there.

Dr. Muhammad Farhan Ijaz:

I think there’s a group of people where long-term Suboxone does work and there’s other people that can come off of it. They’ve done some studies to differentiate people that will do well with the recovery, and one of them was IQ based. People that are higher functioning, CPAs, lawyers, doctors, they were able to get clean and stay clean longer than people that were doing different type of work. Then there have been some other studies where Suboxone did prevent overdoses. We’re talking about two different things. We’re talking about long-term and then we’re talking about just keeping this guy clean. The get right method that you said that you experience, that opens you up to overdoses. Right now I think we’re going to… I think we broke the record already in New Jersey in terms of-

Rich Hession:

It’s going to be over 100,000 this year, for sure.

Dr. Muhammad Farhan Ijaz:

Yeah, so ultimately, right now, we’re just trying to prevent overdoses and then we can-

Rich Hession:

Let’s talk about that for a second. I’m going to ask everybody else, because it’s an interesting question. Because normally I wouldn’t-

Mark Bonnani:

The mic, the mic.

Rich Hession:

Oh, let’s ask everybody because, normally, I’m not a proponent at all for Suboxone. To me, I don’t agree with a lot of what you guys do in giving it to somebody with an unknown ending of when they’re going to come off of it. Let’s see, it’s different for everybody. I’ve read a lot of the studies as well. There’s studies, and then there’s the boots on the ground reality, at least, that I see. Although, mine is anecdotal because I can only go by my personal experience, whereas you’re talking about studies that arguably have thousands of test cases that are followed through, mine’s anecdotal. But I have a lot of anecdotal evidence from what I see day to day, boots on the ground. But I will say that right now we’re in a weird… this is one time where Suboxone, we’re going to have over 100,000 overdose deaths this year alone.

Rich Hession:

Well, over 100,000 and that’s just overdose deaths. Forget about all the other deaths that comes with surrounding addiction this year because of suicide. Don’t think that alcohol and drugs don’t play a huge part into that stuff when people actually finally go that direction. There’s thousands of other things, car accidents and this and that and so much death surrounding addiction in so many ways that don’t get tallied or canceled. But I will say that in this weird stretch of time, because of everything going on in the planet between COVID, the lockdown, these are not normal times and that’s why we’re seeing such a spike. It’s one of the few times where I would agree that Suboxone is probably preventing short-term, preventing a lot of additional deaths.

Rich Hession:

But when I say prevent, I don’t really believe it prevents them, what I believe it does, depending on what you do afterwards, it delays them. That’s my belief. When you look at the success ratios, and Mark, you tell me and be honest, have you ever… this is so anecdotal, anyway, you can only go by your life experience, although, I know you have dealt with hundreds and hundreds and hundreds of on the ground people. Have you ever seen Suboxone long-term actually work for anyone?

Mark Bonnani:

No, one person, and it was not long ago. Who had long-term, was clean, on maintenance long-term, six, seven years. Life together, family, all stuff, one out of hundreds, hundreds.

Rich Hession:

Most of the people seem to do well for a period of time, and inevitably, from what we see, they do well for a period of time. This is what I always ask treatment facilities. We all have our success rates, I go like, “So what’s your success rate?” They go, “We have a 95% success rate?” I’m like, “No, you don’t.” “Absolutely, we do.” Then when you look into the numbers, it’s 95% success rate of people who complete their three-week program or whatever. However, whatever data, they put that around, and if you’ve graduated and made it up to graduated and made it up to this point. There are some of these people where they’ve told me that they have 90%, or whatever it is, success rate, but I know for a fact that at least one person was in there like five times.

Rich Hession:

Because they were back in that program in one year more than five times, and that person was five of that overall success rate of 90%. For me, outcomes, we talked about that before this started with the insurance companies, I base success on one, two, three, and now for us, it’s going to be four-year coins. But that’s how I base it on long-term recovery. But delaying overdose deaths right now I think that’s probably important given that we’re going to be 100,000 plus deaths this year. Given our current circumstances, it’s the one time where I won’t disagree with that, that it’s probably a good idea right now given the outside forces that are coming to bear. What do you think, Nick?

Dr. Nicholas Coangelo:

Well, I’ve got several thoughts. The first one is that this isn’t brand new. This is just like alcoholism. I’ve been at this for a very long time and people had a lot of opinions about alcoholics and the stigma that went with it. Everybody wanted one fix across the board for alcoholism and abstinence was one of the most substantial. We also find that with all the other drugs that have come down the road over the years, but we still have this. Everyone wants the magic bullet. They want the McDonald’s for all addiction. A very long time ago, I was in a class with Dr. David Smith from Haight Ashbury, 40 some odd years ago. He had a statement about what addiction is, and his statement was, “It is dose plus frequency, plus physiologic, plus psychological makeup, equal addiction.”

Dr. Nicholas Coangelo:

You know what he just said, it’s different for every individual coming down the deal, and we try to spray magic on them. Suboxone is the newest magic spray for addiction and I think it’s a wonderful medication to save a life in the moment. Then it is how it is managed, and how treatment people develop a consistent management of that human being coming down.

Rich Hession:

I want to shoot it back to Dr. Ijaz because before we started this, and you bring that up before we started the podcast, we were talking and we were talking about how messed up this year is and how difficult things are. One of the things that he was saying that bothered him so much was seeing all, like we’re all seeing right now, the additional relapses and overdose deaths and everything that’s actually going on because of everything going on. What he was saying was how it can… I’m paraphrasing, but he basically said it could break your heart when you do a lot of hard work with these people. You put in a lot of time, invest yourself in this case, and then to see the guy lose his job, lose his girl, lose blah, blah, blah, and all of a sudden they’ve relapsed again.

Rich Hession:

We feel it because we take it home, and that’s one of the reasons why I’m glad we asked you to come to be on the panel. Because there’s people out there that are just writing sub prescriptions like drug dealers. I know you’re not one of those people, which is why you’re here. To kick it back to you, I lose my train of thought, but Nick, when you were just talking about that, it made me realize that I wanted to go back to Dr. Ijaz and what was the reason? God, and we’re in a live podcast. Just so everybody knows, when I speak, I go on speaking commitments all the time. I’ve been in a room full of 3000 people, and totally lost what I was just saying, and I look at the people in the front row, and I go, “What was I just saying?”

Rich Hession:

Literally people will laugh, and I’m like, “No, I’m serious. My brain is broken because of all the use and abuse of alcoholism.” But I bounce it back to you because when you were talking about before, again, given the state of where we’re in with the Suboxone, and that’s what it was. You had said that it’s how we prescribe it, you can save a life. But then after that, what does it look like? Because I cut you off, what does it look like after? But I like it, because you see the cases through, that’s my point. You’re not just writing prescriptions and saying, “Here you go, see you next week.” I got to tell you, doc, I got to tell you how many times we hear the story where we’ll have somebody call us, and they’ll want to come to our place or they want to go…

Rich Hession:

Sometimes it’s methadone too, by the way, which I know you’re probably not somebody who prescribes methadone. But there’s people are like, and even benzos, and will tell them like, “Listen, go to your doctor and tell your doctor that they got to stop bringing you, we can’t take you, you’re way too high. Tell your doctor.” The doctor tells him, “No, no, I’m not doing that.” “What do you mean you’re not doing that?” You’re supposed to be getting treatment while you’re on Suboxone in the first place. When you’re on MAT, you’re supposed to have counseling, which is what you do. You see these people, and you see their case through as they go.

Rich Hession:

Then, arguably, except for the cases where, and who am I to say, for people who stay on long-term. But if people are the goal, I’m assuming then what do you with, in conjunction with them and what they’re looking at and how they see it, the goal is to, what, get them off eventually to zero? If that’s what their stated goal is. How do you judge that? How do you do that?

Dr. Muhammad Farhan Ijaz:

First time I see them, I just had a case recently, the guy lost his job, he relapsed, and he lost everything and he was basically living in his car. That guy is not going to… the question number or option number one is not going to be, “Okay, pick this and we’re going to try to get you off.” It’s like I don’t want you to overdose in your car while you’re homeless. Because the other thing is also a lot of the other IOP programs, I know you guys are still running, a lot of places shut down. A lot of doctors that were giving Suboxone closed up shop. They were older docs and they didn’t want to be exposed to COVID, so a lot of the patients did get abandoned. That’s what I saw on the ground, basically, to try to give as much support and try to stabilize people and keep them in a safe enough environment where they aren’t overdosing.

Dr. Muhammad Farhan Ijaz:

But, in general, I had someone else that relapsed. He tells me he’s got a nice place in Jersey City with a great view of the city and water and this and that, so that person relapsed. Then that person we would have… he has a more stable environment, we would come up with the plan, “Okay, this is how we’re going to go about it. This is not your first rodeo and these are the signs and these are the milestones that we want to hit, and then try to get you off and obviously counseling and therapy is a big part of that.”

Rich Hession:

Yeah, no doubt. Now, Nick, let’s jump over to you. Let’s go to your level of care. You get a phone call as well, you get plenty of them but you ain’t answering the phones anymore.

Dr. Nicholas Coangelo:

Well, sometimes.

Rich Hession:

You probably do sometimes, yeah.

Dr. Nicholas Coangelo:

Sometimes, like you, like you.

Rich Hession:

Yeah, we do that. Yeah, absolutely, we do that sometimes. But let’s just say you’re getting a call from Suzie Q Citizen and they’re calling up at Brookdale and they’re saying, “Hey, we have your number, and I have this issue.” Go.

Dr. Nicholas Coangelo:

We have a team, and the intake team, the admissions team is to get as much data for evaluation as we can possibly get and we want dose and frequency. We want previous treatment and we want health and we want etc., etc. By the time they’re calling us, they want to come in because of whatever they’re stuck in out there. You know what, sometimes it’s a pure motivation to get help and sometimes it’s not so pure of a motivation. That’s what happens once they arrive. When they come in, they’re being triaged and detoxed. They’re being evaluated medically. Look, we are what I call a hybrid treatment center. Today, we have a very open mind about the use of medicines, the initiation, the tapers, the step down, the referral, and developing partnerships that will help after they leave.

Dr. Nicholas Coangelo:

But everyone is exposed to and educated on the abstinence and the 12-step model. There’s still a war going on in our industry. It’s either this or it’s that, that is foolish and it’s extraordinarily unprofessional in my opinion. We are listening to the patient, you’re clinically being reviewed, we’re coming up with treatment plans, and we’re talking to the patient and all the evaluations that you were talking about, doc. Sometimes patients agree for a week, and then they change their mind. This opiate deal, because of the deaths, current the way they’re happening, let’s just say 100,000 a year. Patients used to be ignored, “Here’s your treatment program, follow it or leave.” That’s kind of cruel and harsh today also. We evaluate, we try and get them stable, and I really want to say something about whether it’s Suboxone or straight detox.

Dr. Nicholas Coangelo:

You don’t get your mind back in five or 10 days, you don’t get the ability. Then there is the frontal lobe damage, the chronic years of abuse and assault of drugs on your brain has on how you make a decision. Everything we should be doing should be assistive, giving them information and showing them hope, and a window of light of what they can be. Without exception, almost everybody that comes into us has forfeited a piece of their life. The best way that I understand that is that if you walk into a nursery, it’s the brightest light you’re going to see with human beings. They’re all bright, all the children, there’s just a bright light in there. When you meet addicts, whether they’re alcoholics or whether they’re heroin addicts, their light is dim and they’ve forfeited it. Some of the medicines keep that light dim but allow them to stay alive and not OD on Fentanyl or bad dope out there.

Mark Bonnani:

My question, I want to interject because I’m going to lose it if I don’t.

Dr. Nicholas Coangelo:

Go ahead.

Mark Bonnani:

It’s for both of you really because I don’t understand where is the data saying that this is stopping people from overdosing? I’ve taken Suboxone, I know that there is a blocker effect of taking Suboxone. But if I want to get high, I skip a dose. I work on a detox that we do abstinence-based treatment, we really don’t on ramp anybody to Suboxone maintenance unless they’ve come in already on Suboxone maintenance. Which is another point, which I find funny is that you’re coming in and you want to stay on maintenance, but it didn’t work. I mean, recidivism is huge for all of us, abstinence or not. But you have a lot of control with Suboxone.

Mark Bonnani:

I understand the nature of the drug very well, and once it builds up, you might have to wait a little bit longer. I can play devil’s advocate in my own mind because I just had a guy that was living in my sober house that I wish was on Suboxone instead of dead right now. He left and three days later he-

Dr. Nicholas Coangelo:

That’s a great point right there.

Mark Bonnani:

He was 57 years old. But at the end of the day, if you want to get high, you stop taking it and you can get high, or now with fentanyl, you can power through Vivitrol for god sakes. So how-

Dr. Nicholas Coangelo:

You’re right, you and I aren’t on opposite ends of this discussion.

Mark Bonnani:

No, I don’t think we are. I don’t want to impose it that way.

Dr. Nicholas Coangelo:

The discussion-

Mark Bonnani:

But I hear from-

Dr. Nicholas Coangelo:

… is that I’ll sell my Suboxone too. Well, you know we have been-

Mark Bonnani:

I’ve been in offices and saw-

Dr. Nicholas Coangelo:

They get a Suboxone prescription or they get their deal. They go out, they sell that, they use heroin, then they go back for their Suboxone. Everyone’s trying to outsmart addiction, it cannot be outsmarted. The addicts are smarter than everybody.

Rich Hession:

Yeah, but in that case, the addicts and those examples, they’re not trying to outsmart addiction. They’re just trying to outsmart us. They’re lying to him, they’re lying to you, they’re lying to their parents, they’re lying to the wife and the husband. They go, “Oh, honey, look I’m on Suboxone now and blah, blah, blah.” See, these are the informative, these are the information as far as getting high through Vivitrol, I guess that’s a whole different conversation because that’s a… But I understand what you’re saying but that’s fringy. It needs-

Mark Bonnani:

Yeah, it doesn’t happen often, I agree.

Dr. Nicholas Coangelo:

But you can die, you can be an addict. Again, I go back to that wiliness. I have had patients who have been on Vivitrol and they shot enough. It’s on the warning label, do not do this, do not do that-

Mark Bonnani:

They overturn over power.

Dr. Nicholas Coangelo:

… and addicts do not pay attention to that. They’re on Vivitrol, they overpower the Vivitrol, they OD, and they die.

Rich Hession:

Of course, and it can happen and I’ll sell this to the families and to the parents. Guess what you can do when you’re on Vivitrol? Smoke crack, you could still get high, you’re just not getting high of your drug of choice. But it’s a drug of no choice-

Mark Bonnani:

It’s a close second, anyway.

Rich Hession:

Yeah, you’ll take the second place.

Dr. Nicholas Coangelo:

We are smarter than the people managing us, so to speak.

Rich Hession:

There it is.

Dr. Nicholas Coangelo:

More clever, not smarter, clever.

Rich Hession:

There it is, and there’s also differences in the people. Dr. Ijaz is talking about saving a life and I understand your point.

Mark Bonnani:

I wish that guy was on it.

Rich Hession:

Which he said, that’s speaks exactly to what they’re saying.

Mark Bonnani:

If that would work, but I don’t know.

Rich Hession:

But you also understand Mark’s point as well. There’s two different classes here, too. You quoted one of the studies about, “Well, higher IQ showed that it was bah, bah, bah.” I hear you, like I said, I’m sure that there can be studies telling you a lot of things. But I will say you’ve got your street addicts and then you’ve got your soccer mom addicts. I don’t mean just soccer moms, but you know what I mean. People who were sports people who got hooked on painkillers, and then the painkillers because of the new programs in place now, you can’t get those prescriptions anymore. Now you’re buying them from the street, a lot of them are made in pill mills, and those pill mills have fentanyl and they make them for the potency of these fake pills. They look real enough, some of them even stamp the damn number on there.

Rich Hession:

They look real enough, but here you are you’re buying the street pills that were not made in Pfizer or any of these pharmaceutical, or Purdue who just got sued the balls off of them for billions and billions. But this was made on the street in some pill mill. Even the soccer moms, they get hooked on this stuff and they can overdose. But there’s a differentiation, there’s a different class, and the people who are like the street guys, they’re gaming the system. Mark’s point is you aren’t saving that guy’s life with Suboxone, bullshit. He already knows the game, he’s been in and out, he’s going to use the subs to ride him to where he needs to go with a plan in place. You ain’t saving a life by giving it to that guy because he’s using it as a short-term tool, and it’s not.

Rich Hession:

Now, some of the other folks, however, that this is maybe not their first rodeo, but it’s not like they’ve been around for everyone where everyone says, “Hey, Butch.” They’ve been around a couple of times maybe, or they could be brandy new. Those people, I would say, maybe you may be saving a life, you know what I mean? You’ve given him the subs. It’s just, for me, and this is where I want the discussion to be, to me, that’s an opportunity is all that is. When you first give somebody Suboxone, it’s opportunity. I’m going to agree with what you said-

Dr. Nicholas Coangelo:

Then what they do with it-

Rich Hession:

What we show them to do with it, right?

Dr. Nicholas Coangelo:

Right.

Rich Hession:

I’m going to agree with you, I’m not saying that my way is the only way. But it’s the only way that I concentrate on. People come to us and say, “Well, I want to be on Suboxone maintenance,” and we’ll tell them, “Yeah, it’s a bad idea and let me tell you why.” But at the end of that conversation if those people say, “Well, I still want to be on Suboxone maintenance.” We’re going to say, “All right, well, this isn’t the right place for you, because it’s not what we do. But here call these guys, and good luck and let us know how things are working out for you.” It’s not only my way, but if you’re going to get somebody to agree to go on subs and you’re going to save that life. Then you can introduce them to people who can walk them on a path because recovery doesn’t happen by accident, or by osmosis.

Rich Hession:

Maybe the accountants and the CEOs, because they’re smarter than everybody else. I’ve actually seen, again, anecdotally, I’ve seen people be a little too intelligent sometimes, and they find it very hard to maintain long-term recovery because they’re too smart for their own good. But that aside, I don’t know.

Dr. Nicholas Coangelo:

Well, what happens here is, and these little cliches, one shoe does not fit all. Yet those of us that know and are part of a recovery system, who have recaptured a life forfeited, have an enthusiasm about it, and know that certain things are possible, and I believe they’re possible for everyone. What is a little bit different today, because of media, pharmaceutical, physicians, money, 200 patients a doctor can have a year, say all of it, and the treatment industry. Is that the patient has more of a say in their initial treatment, at least, when they come into a detox or they come into a doctor’s office. I can tell them whatever and when we get people, and if they want maintenance, we are getting them off of fentanyl, stabilizing them, and then we do a handoff to a maintenance program. That is their call.

Dr. Nicholas Coangelo:

Now we expose them to everything else and all the other choices. But I think it’s once upon a time, it’s improper for us to force feed that as the only way as it would be a maintenance prescriber to say, “This is the only way.” There are many paths to where we’re getting and it’s the timing and the history.

Rich Hession:

I don’t disagree with that, but what I will say is that, for me, I need to be brave and unpopular enough to be able to say I don’t disagree with anything you just said, but the way I know is the way I know and the rest of the stuff I leave to other people. We are good at what we do. I’m not for everyone. My program that we set up is not for everybody, and we have people who call us in and I’m not going to be that. I don’t have, “Well, we do 12-steps, we do… what are the other?

Mark Bonnani:

SMART Recovery.

Rich Hession:

SMART Recovery, and this and that and there’s 15 other things and whatever you want to do, who am I to say? Well, I’m the owner of BlueCrest Recovery Center, and we have a particular way of doing things that we know works in the long run for us.

Dr. Nicholas Coangelo:

That’s why we love you. That is why we love you.

Rich Hession:

It is what it is, but I’m not saying anybody else is wrong, I’m just saying that I’m not for everybody and I’m not trying to be. Further up the stream, you guys don’t get to have that luxury that I do. See, I’m further down the stream, where you guys are, you have to be pliable like that to funnel them where because there’s a willingness, and you’ve got to get them to a place. Then when they do go to that medication-assisted treatment facility that you’re talking about, I know you’re referring them to a good one, where they’re going to do counseling with it. They’re going to try and get those people to come off because mom and dad, and husband and wife, and whoever is out there watching this podcast, the end goal, I think we would all agree, is to be free.

Rich Hession:

To be free of any dependence on a minor mood-altering substance in any way, shape, or form at some point. The end goal is to get free, and to not be a slave to any particular drug or anything that you need to put inside of your body. I think we all agree with that. It’s just a matter of how you get there. Would you think that’s fair?

Dr. Nicholas Coangelo:

I would agree with that and I would also agree that our shoe doesn’t fit everybody in the way that we do it. That we’re closer to you than we are to who we are except we run an emergency room for addiction. It is not a detox.

Rich Hession:

Right, it’s different.

Dr. Nicholas Coangelo:

Detox has a certain connotation. We bring people in at wherever they are, meet them, look to stabilization, and then look to move them on in several different ways. It is a challenging way to treat people. It is challenging to the staff, and what I want to reinforce here at Brookdale, we do individualized assessment and care. It is not a cookie cutter, and I know other treatment facilities that don’t go through the labor that we go through to get that done.

Rich Hession:

Yeah, but it says in the brochure that it’s individualized care. I read that all the time. It’s a catchphrase in the field, individualized care. Then there’s people who put that in that brochure that actually do that and then there’s people where it just says [inaudible 00:42:19].

Dr. Nicholas Coangelo:

You know what, our assessment comes more from our patients, and I’d be remiss if I didn’t talk about the secret sauce that I believe we have. We talked about that a little bit earlier too. Our patients feel loved and cared for. We go out of our way to treat them with dignity, respect, love, and care. We believe that the addict can take a beating better than a drum, and so there’s no need to be harsh, difficult, condescending, or not listen to some of their participation. The artwork is how you take that information and try and redirect them into a direction that they can live with. I will tell you, we’ve probably had 15 patients that we have directed to other people, and quite frankly, when you read your history, unless they get the hand of God on them, I don’t know if they’ll ever get the opportunity that some of us have gotten in recovery.

Dr. Nicholas Coangelo:

My question is, what is our responsibility for that group if our door is open and they come in? What it is, is to pass them on to the best care they can get. Nothing like a doctor with his door open, who’s trying to do no harm and trying to do the best that he can to get them down the road. This addiction wants a very quick fix, and I think what has happened between the age, the availability of drugs, the pervasiveness of it. We have this army of drug, alcohol, chemical medication users that is overwhelming all systems. We have not come together and had a coordinated effort of agreement yet. Things like this are part of that. I think some of the things that we’re doing up there is bringing the best that’s available and that’s saying I’m this or that. I’ve had conversations with you. They couldn’t wait for you and I to meet, Richie, because of the way that we-

Mark Bonnani:

Common background, common recovery I think is probably why, right?

Dr. Nicholas Coangelo:

Well, with the way that we’ve been and how contentious we can be in our belief systems, and yet, it has to be driven by the patient in front of you and do the best you can. Whether they all come to your place, they all come to my place. They go, “You know what, it’s doing the best you can for that patient that sits in front of you.”

Rich Hession:

Let me ask, Vivitrol, different, totally different thing, right? Totally, totally two completely different animals. To me, I’ll just tell you my baseline that Vivitrol, I’m a fan. I don’t know anybody, I don’t know why you wouldn’t be, for what it is, for the tool that it is. It’s not a curative in any way, shape, or form. Like Mark said, if you take Suboxone, and you just skip a dose, you can get high. Vivitrol is just a longer version of that, and it doesn’t get you high, it’s a blocker. Well, I’ll let you explain what Vivitrol actually is, and you can explain it. But, to me, what we look for is right around day 26, their phones go dark. They get Vivitrol and then we can’t get in touch them on day 26, 27, 28, and 29.

Rich Hession:

Because on day 30, they can get high again. Well, somewhere in that window, it’s the blocker stops working, and unless they reup and they get that next injection. It’s not a curative, you can’t get high while you’re on it, putting aside the pushing through it. But you can’t get high while you’re on it, but the difference is now they are longer term… Are there any longer term Vivitrol shots now?

Dr. Muhammad Farhan Ijaz:

I think the window still about-

Mark Bonnani:

Implants.

Rich Hession:

Still, but the implants-

Mark Bonnani:

Some people do the implant now and again.

Rich Hession:

The implants actually work for the lon-term.

Mark Bonnani:

Three months, 90 days.

Rich Hession:

Is it? Do they do in the slow release? But, anyway, having said that, at some point, it’s not a curative. At some point, you’re going to be given an option and opportunity. To me, the question is, see I like for our sober homes. Anytime somebody’s going to come in and they’re going to go live in a sober home. One of the houses because they’re not ready to go back home yet, and they want to live in a sober, supportive environment. If you’re a heroin addict, you should be on Vivitrol, because we know that for that next 27 days to 30 days, you’re not going to be able to get high on heroin. We’re not going to wake up and find you dead in one of our sober homes. If you can avoid being dead, then you have a much better chance of accepting a lifestyle and to having some experience that can take you beyond where you are. Vivitrol, what is it? Explanation to the folks and tell us about Vivitrol?

Dr. Muhammad Farhan Ijaz:

Vivitrol, chemically, is a competitive antagonist. Basically, it means that with your heroin, Percocet breaks down to like a morphine molecule. It inhibits that molecule from activating the receptor, so prevents you from “getting high” basically. It comes in two forms, injectable, which you mentioned, which lasts about 28 days, let’s say. Then it has a pill form also which people take for alcoholism, opiate use disorder.

Rich Hession:

What is it? Isn’t that typically just to help with urges? Isn’t that typically what that’s for?

Dr. Muhammad Farhan Ijaz:

There are some craving, yeah, craving benefits as well.

Rich Hession:

Cravings, okay.

Dr. Muhammad Farhan Ijaz:

But I think Vivitrol, just like any long-term injectable, like any psych medication, and there’s a lot of psych medication because you can imagine psych patients can be pretty non-compliant at times. Just to maintain compliance with the medication, that’s one of the advantages that you give them shine. That they’re good for, like you said, that 24 or 25 days and you have that window of opportunity to get them on a plan and to get them on a program, and stabilize them. Change their outlook and approach on how they’re going to move forward.

Rich Hession:

What’s the rule on getting the Vivitrol shot? How many days removed do you have to be from… I don’t know if there’s rules around Vivitrol, like you can’t take Vivitrol if you’ve been high within the last X.

Dr. Muhammad Farhan Ijaz:

Right.

Rich Hession:

Most people have taken out Traxolin first pill form to make sure they don’t have an allergic reaction to it.

Dr. Muhammad Farhan Ijaz:

Right, so typically, you’ll get a smaller dose. Typically, you should not have used any opiate within the last seven to 10 days so that’s the drawback. Like you said, somebody calls me and says, “Hey, I want to come. I want to get off what I’m using.” I can’t tell them, “Okay, I’ll see you in a week and a half.”

Rich Hession:

Right, works better for his level of care. If they’re going to be in detox rez for 28, 30 days-

Dr. Muhammad Farhan Ijaz:

Absolutely.

Rich Hession:

… if he can get him to plan and see the sense in Vivitrol. For parents, for husbands, wives, Vivitrol doesn’t suck. If we can do our job and we can get them to agree to do Vivitrol, you don’t have to worry, at least, mom and dad don’t have to… the thing I don’t like, the negative part of that is because we see this happen sometimes, they just want to go right home. Because mom and dad are like, “All right, well, you said he can’t get high for the next 30 days so what difference does it make?” Well, because it’s not just time, time is not going is not curative either. Just putting a safe distance between the last time you used and later, that doesn’t make you more well. It just means more time has passed. It’s the work we do while it’s there, it’s not just burning time.

Dr. Nicholas Coangelo:

Again, we’ve been here before. But it just, whether you know the history or not, there used to be Antabuse for alcoholics. In its design, it was for someone with intact family, intact job, with high motivation to give you enough time to get further down the road with counseling. In our infinite wisdom in America, we gave all alcoholics Antabuse, and when you drank Antabuse, it was a horrible show of illness and sickness. We tend to do this, we have the answer, so let’s give everybody everything. What it basically denies is the will of the addict. Why would somebody know that they’re going to get sick and drink.

Mark Bonnani:

And still do it, still do it.

Dr. Nicholas Coangelo:

Why would somebody on Vivitrol shoot heroin on Vivitrol before the 27 days are over? Because it’s a fundamental misunderstanding of what the addiction interior is of an addiction. But I’m going to do it once my brain says I’m getting high, I’m getting high, period. Without support, counseling, repetition, repetition, so we want control. We want control of the attic, you can’t have it.

Rich Hession:

I know it’s bad that I completely understand your thought process just because I’m a sicko.

Mark Bonnani:

As the panel idiot, because I don’t have credentials of any kind except for a long time in recovery. I think I like-

Dr. Nicholas Coangelo:

Life value.

Mark Bonnani:

Little life experience.

Rich Hession:

I think College of Hard Knocks is [crosstalk 00:50:50]-

Mark Bonnani:

Having done Vivitrol, naltrexone implants, Suboxone, all that stuff.

Dr. Nicholas Coangelo:

How did it, Mark?

Mark Bonnani:

You already know my answer.

Rich Hession:

Well, he cut his [inaudible 00:50:59] out with a steak knife so he can get high, but anyway.

Mark Bonnani:

But I think it just seems to me, from observation only, that for the person to be successful, it’s about motivation. It’s about their motivation, and the motivation level to be successful on maintenance versus abstinence is the same. It requires the same motivation level, so why use something? This is just one of my things, I think about this stuff. Why use something that they’re going to have to kick down the line, and it’s going to be a kick, no matter how low you go. I would get down to shavings, back when they were still sublingual pills. I would shave a side of a credit card and snort it because that’s… but I could not make the jump off.

Mark Bonnani:

But if the motivation is there and all things being equal. The reality is too, I think, none of it works all that great. If you look at just raw numbers of people that actually get and stay sober, specifically with opiates, I think it’s those that stayed clean and sober over a year is 1%, 1% gets saved. That used to be what the number was. But, anyway, the point is if the motivation level needs to be the same for both, why? I just don’t understand. Do you know what I’m saying?

Rich Hession:

If we could create a national index, if we could create a national decision making index too, we have just a standard where someone comes in, and we test their IQ, we test all these different things. We ask them the way we do an assessment, but if somebody comes in motivated, right away, I would say that should disqualify them from even being on Suboxone, because you’ve already got the motivation. If you’ve got the motivation, you have a much higher chance of actually-

Mark Bonnani:

I know where you’re going with it, it makes sense.

Rich Hession:

Right?

Mark Bonnani:

Yeah, I know where you’re going.

Rich Hession:

For sure.

Mark Bonnani:

Because the job of the treatment center is to motivate.

Rich Hession:

Boom.

Mark Bonnani:

That’s all it is.

Rich Hession:

And to get them willing to accept an alternative lifestyle, to the lifestyle that they’re living now. The people who are not motivated that don’t want to do it, maybe you do save a life for a period of time until, guess what, we have to do our job then. Our job is to get you motivated. That’s our job. Our job is to be a cheerleader to get you motivated, to get you do the stuff that you don’t want to do. To get somebody who’s highly resistant to 12-step recovery. Jim, our clinical director, says it all the time, we specialize in highly resisting clients. Yet we still find ourselves getting aggravated at people because they’re not seeing things the way we’re hoping by a particular time.

Rich Hession:

But, guess what, that’s what we’re supposed to be good at. We’re supposed to… Oh, look a chipmunk. That little guy he comes all the time when we do this. I love it, I wish you all could have seen that. It was very cute. Take my word. What are your thoughts?

Dr. Nicholas Coangelo:

All treatment isn’t the same, see you’re talking as if treatment is treatment and there’s an inconsistency of what people believe. How they do it, how they take people on, how they don’t. In an ideal world, MAT, a detox med, a stabilization med. If everybody was in treatment for 90 to 120 days, and whatever level they went into, and everybody practiced the same thing, I could almost guarantee you outcomes would be different, with the exception of some of the physiological and other comorbidity situations of addiction. It’s we can motivate, but you know what, what happens when the motivation’s removed and it hasn’t been internalized? You get that through practice? It’s just like sports, it’s just like music. You’ve got to practice doing the things that you’re supposed to do. Medication isn’t going to help you with that, it only buys you time.

Rich Hession:

Buys you time, I agree. I agree. What do you think Mark, are you good?

Mark Bonnani:

I’m good.

Rich Hession:

We covered Vivitrol, we covered subs-

Mark Bonnani:

What about this, Sublocade. What do you guys think? See, that’s one that’s starting to get me a little off the MAT thing, Sublocade.

Rich Hession:

But isn’t Sublocade just long-term Suboxone that gets [crosstalk 00:54:55]-

Mark Bonnani:

Yes, and doctor, I don’t know if you use it at all, I don’t know if you have any experience, Nick? But the difference is there’s a couple things because we all know behavior’s huge. You’re not reliant on taking something every day.

Rich Hession:

Fair enough.

Mark Bonnani:

It’s a lower dose.

Rich Hession:

That, and just so-

Mark Bonnani:

It’s kind of a big deal.

Rich Hession:

… I will say that the act of, right, when you quit smoking, for example. It’s the hardest thing is what you do with your hands. We become a slave to the process of getting high as much as the drug and the feeling itself, so I’ll give you that. Although, to me, I’m still not there at Sublocate. But go ahead, I just wanted to-

Mark Bonnani:

Well, it seems to me my very small sample size, the one person I knew that was on this stuff stopped taking it and the withdrawal was easy. I don’t know that it was in-

Rich Hession:

That’s very anecdotal. I don’t know that I can… The one person you knew, I don’t know that I could go there with it, but fair enough.

Mark Bonnani:

I just wonder, I don’t know.

Rich Hession:

I’m not saying, like I said, I’m not dismissive of anecdotal stories like that but-

Dr. Nicholas Coangelo:

All of this is, all of this is, look, everything we’ve talked about so far is an outside-in job.

Rich Hession:

There it is.

Dr. Nicholas Coangelo:

You know what, anybody that knows anything about human beings knows that it’s an inside-out. It’s how you get there, and what gets your insides to do the switch to make a committed effort to a different direction. All of this either buys you time, helps you reduce pain. But what we’re supposed to be doing is getting people to do something inside-out. If we don’t get there-

Rich Hession:

That’s it, that’s-

Dr. Nicholas Coangelo:

… inside-out.

Rich Hession:

… but you’re talking about the core of my 12-step beliefs speaks to that, but I’m with you 10,000%. I just realized that as we come to the end of our time that we spend together, the term was used, I think, Dr. Ijaz used the term harm reduction. One of you guys used the term, and as a part of the conversation we have, which the term harm reduction would fit well into the conversation about Suboxone or methadone. Which is, was the preferred treatment.

Dr. Nicholas Coangelo:

But that’s not treatment, that’s not treatment.

Rich Hession:

No, it’s not treatment.

Dr. Nicholas Coangelo:

That’s not treatment.

Rich Hession:

What I was going to say is harm reduction, we could do a whole, and probably will. As a matter of fact, I’d like to do a panel on harm reduction, where I’m going to have a TV set up in the back. I’m going to go out with some people and videotape places that you can see what harm reduction actually looks like. See, to the sheriff and to the local politician and to the townspeople, I get you, I see the allure of harm reduction. I get it because the crime stats go lower short-term, this appears to improve. I then go, if you ever go into the city, I remember the first time I was driving across town on 57th, I think, it is. You come up to the light on 57th and 10th, right around there. Then, all of a sudden, you see, it’s early in the morning, 6:00 in the morning and you see a line of people.

Rich Hession:

Definitely homeless, people who are like they’re all over the place, and you see them doing the shuffle, the methadone shuffle, and no one is out of line. Now, when it’s over, and you come back later, and they all go in, they’re all waiting to get their methadone dose. But if you screw around on line, they’ll throw you out. You never saw people more, no one’s going to yell at each other. Later on, you see them all and they’re fist fighting in the streets over a half a cigarette that was in the gutter, and who has a beer and they’re out of their minds. But when they’re ready to go get their dose, no one’s going to take the chance in getting thrown out and they do the methadone shuffle, and they stay in a neat line.

Rich Hession:

That’s harm reduction. That’s what you can see, like it’s visceral. You can see the point of the whole thing is that if you can keep them all and control the addiction, and you keep them a slave to the addiction, it does what the neighborhoods want. Which is to have them not seen and have them not heard. They’re just written off into that subculture that you don’t see because you give them the synthetic heroin that they need to survive, and I think that sucks.

Dr. Nicholas Coangelo:

We did this with alcoholism, we had the conversation earlier. Thunderbird was harm reduction, Wild Irish Rose was harm reduction.

Mark Bonnani:

Was there a time they thought [crosstalk 00:59:05]-

Dr. Nicholas Coangelo:

They never used that word but medicate the masses, keep them quiet. Don’t let them burn the neighborhood down.

Mark Bonnani:

But legit for alcohol, didn’t they think that the silver bullet at a point in time… somebody said this, I don’t know for sure, was Valium, was that a thing at some point? [crosstalk 00:59:20]-

Rich Hession:

Yeah, I think that is true actually.

Dr. Nicholas Coangelo:

Valium used to be referred to, alcoholism was a Valium deficiency.

Mark Bonnani:

Yes, right. That was a real thing.

Dr. Nicholas Coangelo:

Thank God Betty Ford became evicted to Valium and Dr. Purse changed all that. By the way, Valium was non-addictive in case you didn’t know that.

Mark Bonnani:

So was Oxycodone, wasn’t it?

Dr. Nicholas Coangelo:

Yeah, and so was Oxycodone and so is everything that we use.

Rich Hession:

Listen, Coca Cola put cocaine in soda back then.

Mark Bonnani:

Cigarettes. Cigarettes are not addictive according to the execs.

Rich Hession:

Yeah, well, tell that to the pregnant lady. Has anybody ever seen the movie Dazed and Confused? There’s one of my favorite parts in Dazed and Confused where he’s going in to buy beer illegally, because he was under 18. He’s standing in line with the six pack and there’s a pregnant lady buying and the guy is putting cigarettes and vodka in the bag for it. He goes, “And remember to eat a green thing every day. See you tomorrow.” I’m like, “Oh, my God.” But we’re in a totally different time than we were back in the ’70s, man. We’ve grown up in some ways and gotten even worse in others. But, listen, I think that we’ve covered as much as we can cover. We could go on and on and we could talk about different aspects of this forever. But I appreciate you all guys and at least becoming part of the conversation.

Rich Hession:

Anybody who’s interested to have… Sorry, we didn’t go to if there were any questions I didn’t even ask but we got on a roll. Anybody who did have any questions, we’ll get back to you via email and answer them and I’ll even direct them to these characters, if it’s one that’s more appropriate to someone else than to me. Other than that, I’m going to say that from BlueCrest, we’re going to be signing off. Anybody have any final parting words that you want to give to the 53 people that are signed on and watching us? Anybody?

Mark Bonnani:

No.

Dr. Nicholas Coangelo:

No.

Rich Hession:

No?

Dr. Nicholas Coangelo:

Thanks for having us. Thanks.

Dr. Muhammad Farhan Ijaz:

It was a pleasure [crosstalk 01:01:12]-

Rich Hession:

Thanks for coming guys. I appreciate you all very much, and we’re signed off.

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