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Okay, all ready?
- [Charles]
Yep.
- Okay. Okay, great. So I'm Dr. Gloria Baciewicz. I'm the co-PI of this HRSA grant that is producing the Stigma Summit and I am an addiction psychiatrist.
I practice at Strong Recovery at the University of Rochester, and I'm the medical director there. Today, we welcome both our online audience and also our Eastman School of Music audience. And I am pleased to introduce Dr. Charles Morgan, who I have known for a long, long time because actually, we went to college together as well.
And I think Dr. Morgan wrote this part. Charlie Morgan doesn't just believe, he knows that there is no wrong path for recovery. He has dedicated his life to addressing stigma and advocating for people impacted by substance use disorder.
He also celebrates 41 years of continuous long-term recovery this year. An addiction medicine specialist, he has been deeply involved in health equity work, including transforming Philadelphia's behavioral health system and serving on numerous boards such as Friends of Recovery New York and Camden Council on Alcoholism and Drug Dependence. In Georgia in the 1980s, he founded a support group for those affected by HIV at a time when HIV was not openly talked about and there was a lack of support groups. He also co-founded Like Minded Docs, an international organization of addiction specialists who believe that recovery has a spiritual solution and Western New York Project ECHO for chronic pain and medication-assisted treatment.
Welcome, Dr. Morgan. (audience applauding) - So it's great to be here with everybody today. I wanna thank Dr.
Baciewicz for the work that she's done in Rochester. I'm convinced that we would not have the system of care in treating people with addiction that we have today. We certainly wouldn't have had the Addiction Medicine Committee of the Monroe County Medical Society. So her work is extended to the university and to state and to the nation.
And now with this, it's an amazing conference and I'm really delighted to be here. It's kind of a full circle in a way for me. I walked into the entrance hall at Eastman and used to study there when I was an undergrad. And that's the place where we would hear people with perfect pitch start Christmas carols at the holiday time.
I don't know what they sing now, but I'm told they still sing there. And now I'm here talking about science, which is my other passion, and recovery, which is the basis for my life. The most important thing that ever happened to me was when I got into treatment in 1981 for my own addiction. And I like to disclose that because I don't know if you would know that I was in recovery if I didn't tell you, which is why this is so important today.
The other person who's here is one of my bosses, Bob Ross, who spoke yesterday up at Saranac Lake. And it's good to have everybody else here as well. So, anyway, I'm gonna move forward. There's really too much content in these slides to cover today, so I'm gonna get through them.
I'm counting on that. But I also want you to know that they'll be available. We can make them available to you so that you can look at them. There's some text in there that I'm gonna be tempted to read and I don't know if I'll do it or not.
It depends on how things are going. So really good to be here today. So I think this is really important, you know, that which does not kill us, makes us stronger, including it's wrong that we get stigmatized in any, I'm also a gay man, so there's been numerous things where I could have, and I grew up in the '50s and the '60s, so things were much different then. I got sober in 1981 and so things were much different then as well.
But that which does not kill us, makes us stronger. I truly believe that. And when we can get through things, and a lot of times what we have to do is we have to, because people who victimize us won't stop, we have to, as those people who are victimized by stigma, we have to pull ourselves up. And that may be wrong that we're in that situation, but lots of us do it.
And I have admiration for people in recovery. So let me see if I can make, oh, there we go. So when we talk about this, I wanna make it clear that I'm not just talking about it from the point of view of recovery. I'm talking about this as a person who's lived through much of the history, some of the history, let me put it that way.
And also as a person who is a physician who believes in the biological nature of the illness. And I think that helps us when we talk about stigma. So Vivek Murthy is our surgeon general again, but he was our surgeon general from 2016 until 2020 as well. And he did an amazing monograph on addiction and pointed out that 40, four zero, to 70% of it is genetic and that it's a primary illness.
And when you talk about that, diabetes has a genetic component, hypertension has a genetic component, depressive disorders have genetic components, and we don't blame people for getting those other illnesses. So having the genetic component actually could result in some freedom. But there's other ways to get it as well. We certainly believe that trauma is one of the ideologic factors.
But like diabetes, if you had diabetes, one of the things that would happen would be that there's a low carb diet, an Atkins diet. I'm not endorsing these things or anything else, but people who are insulin dependent with diabetes can go on those low carbohydrate diets and need no more insulin. It does not mean that they don't still have diabetes. But if you remove the agent that's causing the problems, the manifestations of diabetes, including blood sugar, can go away.
Not in every case, but in some cases that can be true. And it's the same thing with this illness. The genetics doesn't dictate that we're gonna suffer for the rest of our lives if we've got this disease, they're genetics. The miracle of recovery can occur and it can occur for many, many, many of us.
So the problem is that only one in 10 of us ever get to get to treat, there's something wrong with that, isn't there? And stigma's one of the major reasons that that can happen. So let's take a look at that. The other thing that can happen in medicine is that people, when we tell them that we have addiction, practitioners may not even acknowledge it.
They might say, "Well, you've been sober 20 years. You don't have it anymore. I don't have to do anything." Yes, you do.
You do, if you're gonna take care of me as my doctor, you need to acknowledge that I have this chronic disease. And while I might not have had a drink or a drug in 41 years, thank goodness, you better acknowledge that I got a disease that requires you to do some things differently than you would if I didn't have that disease. I also have hypertension, and you better acknowledge that I have that too, cause that puts me at risk for some other things and we better keep our eye on those things. So there's a lot of meat in this slide here that we don't even have more time to talk about.
So these things are things that we need to acknowledge. That stigma, we've already talked about this causes us, but this is evidence-based stuff that I don't think many of us who are in recovery had a study to show us this. But it's evidence-based that shows that we're actually right, that Dr. Baciewicz is actually right to address this as the principal investigator right now.
So we got these things. And here's some interesting things about healthcare professionals. Addiction professionals can have stigma, can exhibit stigma towards our patients as well. But so can general practitioners and people who are psychiatrists.
General practitioners fared the worst in this particular study. But when we educate people, they can actually get better. They can actually do better. Practitioners I'm talking about.
Isn't that something? So here's some of the other stuff that is true about that. So we looked at some of the medical, some of the providers, some of the different specialties a minute ago and now we're looking at a different, and we looked at addiction professionals. Now we're looking at a different subgroup of people who are really influential in healthcare as well.
Nurses. And do we even think sometimes that nurses need to have education in their curricula? They do a lot of work, a whole lot of work. And as a physician, the truth is that when I entered internal medicine, the first place that I went was the coronary care unit at a place that doesn't even exist anymore, Genesee Hospital.
We have a connection there to Dr. Baciewicz and I and a great place. But I was scared I was gonna kill the people cause I had been a fresh medical student and now I was taking care of people who'd had heart attacks and you know who got me through all that? My residents and my attendings were important, but it was the nurses who would call me up and say, "You need to call the resident about this."
Or sometimes they'd say, "You don't really need to call the resident about this because it's just something we have to tell you about." I learned a lot of medicine from those nurses. So they have a huge influence not only in patient care but in what happens to other healthcare professionals as well. So there you go.
It's across the board what we need to do, the work we have to do. So here's a statement from Dr. Murthy that he made in 2016 and he talks there about the shame and stuff that has made people with substance use disorders less likely to come forward. And he talks about the fact that we don't do that with other chronic illnesses.
We don't shame people that way with heart disease and diabetes and cancer. Let that sink in for a couple minutes right there. But we can do something about this. So let's take a look at this thing.
And I think some of us that are in recovery, and some of us that are addiction professionals tend to still not recognize the enormous impact that having this brain disease of addiction has on our patients or our friends who are in recovery. It influences everything, not just physical health problems, but choices that people make, value systems that they apparently have. So let's take a look at what this is. Well, here are some things that are true.
I have a disease of addiction. I'm not impaired right now, but I still have the disease, okay? However, if I were using chemicals right now, I would be impaired. So there is an agent and there is an underlying illness that we have to consider.
AA said a long time ago when they wrote "The Big Book", the first stories in "The Big Book" are they lost nearly all. The second set of stories in "The Big Book" at the end of "The Big Book", Alcoholics Anonymous is what I'm referring to, are people who didn't go down as far. They realized in AA way back in the '40s, they wrote that book in 1940 something, they realized that people don't have to go all the way down the tubes to get better. And yet, we still hear that some, they haven't had enough suffering.
Well, I don't believe that. My job is to help people get to the point where they can, as a professional, as a person maybe in a mutual support group. It's a program of attraction. But as a person who's a professional, it is not a program of attraction, it is a program of promotion.
One of my mentors said a long time ago, he said, "It is true that you can lead a horse to water, but you cannot make him drink. But it is also true that you can make him thirsty before he gets there." Motivational interviewing, motivational enhancement therapy, cognitive behavioral therapy. In the old days, we used to talk about reality therapy and some of those other things that we talked about.
Those things can help us with that thing right there. And just like a person who might have diabetes, do you think that they wanna stick their finger every single day? Do you think they look forward to that? Do you think they look forward to having to put a a needle in themselves?
And I don't even look forward to taking my antihypertensive pill. I mean, and that's a big thing to really complain about, isn't it? I mean, that's just taking a pill in the morning. So anyway, they don't have to want to do that.
But if they do those things, they will get better. And our patients can have the same kind of dignity. We can give them that dignity that it isn't necessary to want to do this stuff. You can do it and you can get better.
And then when a person experiences what it's like to be free of diabetes symptoms, not the disease, but free of the symptoms of diabetes, maybe then they do get the motivation later to stick their finger and to stick themselves with that needle every day and put that insulin in there. Maybe that could happen for our patients too if we let them experience what it's like to be in recovery. Then maybe they'll want to do some of the things that they have to do. So what did "The Big Book" say about it?
Well, "The Big Book" was way ahead of stuff. It said it was cunning, baffling, and powerful. It tells a story in that chapter where it uses those words of a person who has gotten sober, he's not drinking, he has every intention to go to the business meeting the next morning and he's been free of alcohol for a while. And then he decides, you know, I could go to the bar and have a drink tonight and he does.
And then what happens is he thinks that went pretty well. I'll have another one. That went pretty well. I'll have another one.
And next day after that pattern is repeated, he doesn't show up for the business meeting. That's what happens with this illness. People do not intend to have a recurrence. But if you ask an alcoholic or a drug addict or a person with addiction or a person with alcohol use disorder, however you wanna phrase that, then every now and then they'll get honest and they'll tell you they just don't know why they had the recurrence.
That's a profound statement. And that has to do with the brain circuitry. So this is the previous iteration of the definition of addiction from the American Society of Addiction Medicine. The current definition is much shorter than this.
And I went back to this because it actually tells us what we're dealing with here when we talk about people with addiction. And I'm not using DSM five terminology here for those of you who might wonder about that. I'm using the word addiction, which is the underlying disorder that might cause those substance use disorders. But it's a primary disease.
It doesn't mean there can't be co-occurring disorders. There can be, and maybe sometimes people use chemicals because of those co-occurring disorders. So we don't need to to to quarrel about that or disagree about that because we can all agree that all of that is true. But there's a pathological pursuit of reward or substances.
So there can be process addictions as well, can't there? Gambling, sex, food, shopping. Elton John says he has a shopping addiction. If you watch the, he said it didn't go away.
At the end of the movie, he appears with his Gucci bags, you know? So anyway, diminished recognition, that's a real, I have some things in red. There's so much more I could have put in red in here. But when you have addiction, you don't recognize that addiction is the problem.
We call it denial. But there's actually a biochemical and a biological basis for it. And we need to recognize that that is true. They can't see what the problem is.
And here is some more things. So you could be triggered by exposure to substances, which could be prescribed even. That's why my doctor has to acknowledge that I have this illness. And exposure to environmental cues, which could be spring weather.
We don't know what those environmental cues are because they're different for every different person. Or a heightened stress in the brain circuits, their heightened response to stress. Excuse me. The other point that's really important, while we talk about recurrences a lot, the truth is that reoccurrence is not inevitable.
It doesn't have to occur, but it could occur, all right? So then we go to what can help us to recover. It's personal accountability. So if I could empower my patient as I treat them to have, not necessarily power over their drug, over chemicals or whatever the kind of addiction it is, but empower them to have power over the recovery.
That's a key thing, isn't it? So when we talk about powerlessness, we'll look at a slide about that a little later, but, oh, there were two slides like that, so I forgot about that. So those red things in there are about that there's a narrowing of behavior. So as a person progresses through their illness and it gets worse and worse, there's a narrowing of response and there's an increasing focus on things that will lead to further drug use.
So it comes quite naturally. No one ever showed me when I was a little boy or ever how to be a drug addict. Nobody ever showed me how to per be a person with addiction. Nobody ever showed me how to steal alcohol from my parents.
Nobody ever showed me how to steal drugs from the institution where I worked. And the statute of limitations has run out. I say that all the time. So, you know, nobody showed me how to do, and yet it came quite naturally to me.
Then after I got sober, there was a physician's group in Philadelphia where people used to go and it turned out there were other people at the same time that I was there who were doing the same thing as me who showed up later. And we all had done the same thing and none of us knew anything about each other who got into recovery. That's how we knew about each other. So isn't that something?
So here are some things. As a person progresses, they get increased anxiety, dysphoria, and emotional pain. Things seem terrible to the person. So when they come in and they've had a tiny little thing that you and I might not respond to or I might, but it seems like a crisis.
It's a difficult thing for people to tell the difference between the things that are really big and the things that aren't so big. And then they get this alexithymia, which is related probably to stuff that happens in the insula. So we could talk about other brain regions too. We could talk about the cortex and we could talk about all those different things, but these are things that we actually characterize as behaviors or something like that that are really just part of the disease of addiction.
And we blame people for this stuff and expect them not to behave this way and not to have these feelings and stuff. And yet, that's what we're in the business of treating. And when we don't acknowledge that this is a brain disease and that these are characteristics, pathological characteristics of the disease, it increases the stigma that our patients feel. Now it doesn't mean we have to just let it go.
My job is to treat that stuff. So when we say this is a characteristic, it doesn't absolve me of the responsibility as a professional to address this stuff in my treatment plan and in my work. We've already talked about some of that other stuff. So this is where the brain reward occurs.
The first two bullets are from scientists. The last bullet is from the lay people. The last bullet is what people in the 12-step programs say about what it is. And I wanna read that one cause that's one we don't hear.
So this has been known, what's in that last bullet has been known since 1935. And we're still not there yet, are we? So here you go. When men and women pour so much alcohol, we could use drugs, into themselves that they destroy themselves defying their instinctive desire for self-preservation, they seem bent on self destruction.
They work against their own deepest instinct. And that's what it feels like to be a person with addiction. It feels like that. It feels like no matter how important your family is to you, no matter how much you care about the people you're taking care of, no matter how much you wanna be there at your child's graduation, no matter how much you hate turning tricks out on the street, if that's what you're doing, you do it anyway.
I'm getting chills right now because some of those things are the things that I did. It is absolutely chilling and heartbreaking to think that people have to live that way. They don't want to do that stuff, and yet, that's what happens. It will drive people to do the thing that they hate the most.
And that's where they come to us in treatment or they come to us in the rooms if we happen to be in recovery ourselves. So it's pretty interesting what happens as a result of that. I got outta treatment in five weeks. We're gonna use me as the case study right now and they sent me back to work.
I was an anesthesiologist. They sent me back to complete my residency. I ended up doing a fellowship and I ended up becoming on the faculty at the University of Pennsylvania. So that's what I did.
But when I got, so I went back to work, I started pre-ops right away. Back then, that's what you did. Started giving anesthesia, did a good job, was good enough at it so they offered me a fellowship and then a faculty position. And yet, when I got outta treatment that first Sunday, my sponsor, the person who became my sponsor, had a brunch after church with other, and I couldn't even make a toast.
(Charles laughing) So the kinds of thing, and I couldn't manage my own life. So what happened was I could function as an anesthesiologist, but I couldn't manage to stay, I did stay sober. But it was only because those people in that recovery group and those other doctors that I knew and those other people in my mutual support group kept practicing their principles in all my affairs. It was phone call after phone call after, my sponsor would say, "Charlie, when you get to the university, call me."
I'd call him up, I didn't know why I was calling. And then he'd say, "Okay, what are you gonna do? Go see your patients. When you're done seeing your patients, call me."
And I'd call him up. And then he'd say, "What else do you have to do?" And I'd tell him what I had to do and he'd say, "Okay, go do that and when you're done with that, call me." And then he'd say, "What are you gonna do now?"
And he told me to get in the car and come and see him. So that's the level of management that it took to keep me from relapsing or having a recurrence, even though I could do those other things. So it's a deceptive thing. The other thing I gotta ask about, we had an opioid risk tool.
The opioid risk tool defines what we just talked about. The three things that are the most powerful when you're gonna prescribe opioids to a patient is do you have a history of problems with alcohol or drugs? The second one is does anybody in your family have a problem, have a history of a problem with alcohol or drugs? And the third one, and it's for women, I have a suspicion that if we could get history on men that could vet it, it would be the same for men.
But for women, have you been sexually abused as an adolescent or before? Trauma and genetics and personal history. If you have answers to those things, it means when you're prescribing for that patient, you'd better take precautions if you're gonna prescribe opioids. And maybe there are other ways to treat pain.
That tool has been existence for years and years and people don't use it. That's a matter of acknowledging that this is a chronic illness. All right, so here's what a chronic disease is. It lasts for more than a year.
It requires ongoing medical care. It can limit the activities of daily living. And here are some other chronic diseases. And oops, let's go back here.
All right, we talk about relapse, don't we? These are the rates of relapse with other chronic diseases. And you can see in here that for people with addiction, we certainly aren't as bad as people with hypertension. Do we talk about relapse constantly with people with hyper, no, we don't do that.
But that's what we talk about with addiction. And certain groups of people with addiction, like professionals, can have recovery rates that are astounding. 90% of people with addiction who happen to be physicians in the New Jersey Health Program stay sober when they look at the data for 10 years with no relapses. I think we can do better with other groups of people as well.
But even if we didn't do any better, those are the relapse rates. And yet we talk about relapse, relapse, relapse all the time. I don't think it's helpful. I don't think it's helpful when I go out there and I say I'm struggling with addiction.
I am not struggling with addiction. I live happy, joyous, and free. I haven't struggled with addiction for many, many years. Now I could and I could have any number of things happen that I need to talk about with somebody.
And I certainly have access therapy in my life and I am one of those people who has another diagnosis. My other diagnoses include dysthymia and post traumatic stress disorder. And I've accessed care for those things. It's been made possible because of the recovery that I have in addiction.
I never would've been able to go through that stuff if it hadn't, but if hadn't done that stuff with my co-occurring disorders, I'm not sure I'd be standing here talking to you today either. I have a brain that's one thing. It's not just PTSD. I don't know if I've got the dysthymia or not.
I'm not sure about that, but I might. If I do, then it's got that and it's got addiction. All of those things have gotta be addressed. So these are some things that relate to what we just talked about.
We've already talked about not disempowering our patients. Even if they do use a step in the 12-step programs, all of the other steps after the first step in the 12-step programs are about empowering people. And they're all about actions that a person could take to actually do something about cleaning up the wreckage of the past and about becoming useful to society or their families or whatever. So I'm not gonna go through that right now, but these are what our core competencies are.
This was from the American Board of Addiction Medicine. Now we have boards through the preventive medicine and through psychiatry, but these are what the core competencies were. And I'm not gonna go through these, but you should if you want to look at them. I think they're things that we all should ascribe and should do.
We should be taking care of our whole patient. We should be increasing our medical knowledge and paying attention to what we can learn through patients. So one of the things that happened in the past was that there was a study that was done that showed that when you prescribe 16 milligrams of buprenorphine to people, 96% of the receptors are saturated. That had an N of six.
There were six people in that study. Recently, there was another study that came out that showed that when you actually increase doses past that to 24, 32, people do better. It's like methadone. We wanna give adequate doses.
So while these study that people functioned on showed 16, I think people like us paid more attention to what our patients told us than to a study with an N of six. Yeah, and then she's shaking her head yes. So Dr. Baciewicz agrees with that one.
So not that we didn't pay attention to the study, I don't mean that, but that other slide is about learning from our patients as well. So this is about that same thing. Then there are these things that existed long time ago that said we better talk professionally to our people. So some of the language I use in here today might be language that I'd use in a meeting if I were in a meeting.
And some of the language that I use in here today is language that I'd use as a professional working in the field. Those two things don't need to be the same. We'll look at some of the studies on that. And then to be a professional, to act professionally.
Also, we're supposed to do exactly what Dr. Baciewicz is doing with this. We are supposed to understand that we're part of a system and address all of these other things that are in this slide, which we might call social determinants of health. We might call stigma.
We might call it criminal justice. We are supposed to be able to do that as physicians who are certified as specialists in this field. Well, here's what stigma is, and it's a terrible, terrible thing. Labeling people is disgraceful or unworthy secondary to a perceived flaw or a negative characteristic.
Why do we have these kind, well, we're humans. So we have a limbic system. My dog has a limbic system. And if you go up to my dog, now, my dog is a gentle beast.
She won't hurt anybody. She'd rather be with a human, even with a human she doesn't know then drink water or eat. I mean, she's a Great Dane and Bob has seen her on camera. So she comes to some things regularly with me when she's with me.
But anyway, if you went up to her in a threatening way, she wouldn't be like that. And if she didn't understand what was in the driveway, she'd bark at it. And that is a survival mechanism to have some apprehension about that which we do not know. So it has an evolutionary value because if we just went up to everything like rattlesnakes and things like that, we wouldn't be able to stay alive.
So there is a reason, evolutionarily, why, if you talk to the evolutionary psychologist why these things exist. Why people might stigmatize other groups of people if they don't know them. But the truth of the human being is we're not just a limbic system. We got a great big old cortex.
We have the ability not to act on feelings, which is a huge, huge difference between me and my dog. So I think that that is a big point. I'm not gonna go into it more, but we'll go back to what happens as a result of stigma. And I would postulate that one of the reasons also that people might have recurrences might be from stigma too.
And the idea that we don't deserve, or I don't know that it's deserve, that's my word. But that people don't acknowledge that we have an ongoing illness which doesn't impair us and you can't tell that we've got it. So this is an interesting study and this study found some surprising things, for instance, that people who take naltrexone to support the recovery are feel more stigmatized than people who take buprenorphine. And that people with higher education levels feel more stigmatized than people with less education.
I don't think the last one, injection, is a surprise at all. So this was an evidence-based study. I think the take home for me is that I don't know which group my patient is gonna fall into. I don't know that just because this study shows that somebody with naltrexone feels more stigma than somebody with buprenorphine that that means that my patient with buprenorphine doesn't feel more stigma than my patient with naltrexone.
I gotta meet those patients individually. But this does open your eyes to a few things like education and naltrexone, doesn't it? To me it did anyway. So where does it come from?
It comes from all over the place. But I capitalize addiction professionals and recovering communities cause I think, I don't wanna stigmatize us, but I think we have less of a reason to have stigma and maybe more of a responsibility to deal with whatever stigma we've got. So I was a little gay boy, like I told you about, growing up in upstate New York in a small town. And a few weeks ago, my mask broke at work and I went to get another mask.
And I'd been out for decades and decades and decades, okay? But the only color mask that they had at that institution was a pink mask. And they said, "Do you mind wearing a pink mask?" I said, "No, no, it's fine with me."
I put my pink mask on and I went. But we had a medical staff meeting that day and I had to go into the room with all of my colleagues who also know that I'm gay. They don't have any trouble with it. If they do, I don't know it.
But anyway, so I go in there, but I'm wearing my pink mask and all of a sudden, I feel this twinge inside of self-consciousness about wearing a pink mask. And I think, Charlie, after all of these years, you've still got some internalized homophobia, don't you? Gave me a chance to work on it. It was good to know that.
I was surprised by it. But that's what we're talking about here. There could be things that I don't know that I have and when I find out about 'em, I can do something about it as a person in recovery and as an addiction professional. So here's some stuff that came from, I think it's a 20, yeah, it's a 2014 paper.
And they talked about language and one of the things that they said is we need to use person first language. We don't need to use slang terms and stuff like that as a professional. But then it goes on to say, ultimately, the respectfulness and inclusivity of language about a particular group should be determined by the group itself. That means that if I want to go into a session with a therapist or a counselor as a person who needs therapy or is a counselor, and I wanna say I'm an alcoholic, I'm an addict, I shot dope, I drank liquor, if I wanna use that terminology as the patient, I have a right to do that.
If I wanna go to a mutual support meeting and use language like some of it that I've used today, I can do that. And ultimately, as a person in recovery, I have a right to tell people what I want them to call me, who are working with me as a patient. Now as a professional, I don't have those same rights. I need to use person first language.
I need to talk about people with addiction, people with opioid use disorder or that kind of thing. I don't need to use words like dope fiend or things like, I must not use those words, but I can't judge my patient if my patient uses those words. I can get information. I might think, oh my goodness, there's a problem with self-esteem here.
But maybe there's not. In 1992, I was living in Philly. We marched down the street, down Spruce Street, which is a major thoroughfare through the Rittenhouse Square neighborhood, which is the high rent district. And our chant was, we're here, we're queer, get used to it.
Queer was not in LGBTQ at that point. It was a word that people used against us in that day and age. We reclaimed that word. If the people with addiction choose to reclaim certain words, we can do that too if we want to.
We may not want to. I mean, I think when I go speak publicly as a person in recovery to public groups, it is important for me to use language like I'm Charlie, I'm a person in long-term recovery, and for me that means I haven't used a drink or a drug in 41 years and because of that, this is possible, all these things. So it depends on the venue that I'm in, but it makes that point right there. And these are some other things about language that you could read about.
if you want to from that paper. (Charlie clears throat) Excuse me. These are characteristics that I think we're probably aware of and if we're not aware, this conference certainly is making us aware of these things right now. And this is more from a different source.
This is the National Association of Advocates for Buprenorphine Treatment, NAABT, which says that people have a right to choose the language for themselves that they want to have used in their sessions. There was a paper that came out of the University of Pennsylvania, my old stomping grounds, a grad student did great work and found out something about stigma and language. But the conclusion of that paper was that when people who have addiction go to their sessions, if they use that language, then the therapist responds differently to them. And that people with addiction should stop using that lang, well, that's horrible.
Absolutely horrible conclusion in my opinion. I'm the professional. I'm the one who has to make the adjustments, not my patient. So this is saying something quite different than that paper from the University of Pennsylvania says.
Here are some stigmatizing words. And some of them are surprising, like addictive, there really is no real addictive personality. We are all different. And our premorbid personality seem to be different than, and for me with the, if I had the diagnosis of PTSD or, and I do have that one or dysthymia, I might have certain personality characteristics because of that dysthymia or I might get triggered because of my PTSD, which could lead to some different things.
But I don't think these are, but high dose and low dose, that's stigmatizing. Patients wanna compare their doses of methadone a lot. But that's not necessarily for us to say you're on a high dose or a low dose. That's not helpful.
What we're interested in is adequate dosing. Here's some other stuff that we use all the time. Non-compliant and unmotivated. Think back to the brain thing that we talked about before.
All those characteristics, unmotivation, that's a characteristic of their disease. They appear to be unmotivated. That's what that definition said. We didn't read that part by the way.
But it is in there if you choose to look at the slides. So they appear to look that way. Medication replacement, we used to use that term. It is embedded in the literature.
We use that term. But the truth is when Nyswander and Dole developed methadone, they thought it was treatment. It is also harm reduction, but it can be treatment. And I know for a fact that when they do it at URMC, they may do some harm reduction as well, but they are also treating the underlying illness.
I know that, and I know that happens at St. Joe's up in Saranac Lake where we work up there as well. So here's some other terms. We've got those down.
I'm not gonna go through all those. But recidivism is an interesting term. I do work with the criminal justice system too. And that is a term that we use in criminal justice because it means a return to illegal activity, but it doesn't mean a return to drug use.
And yet, we use that term. So there're two different things. I think relapse is not a term we commonly use in medicine either. We might use recurrence, we might use exacerbation and words like that.
But I don't think we talk about relapse with other illnesses. So here are some comparisons of ways to change some of that terminology that I think are important. Drug seeking is something that I hear a lot. You know, my patients are actually supposed to be drug seekers, aren't they?
That's what they do. So if I use the term in a way that, oh, he is just drug seeking, that's pretty pejorative if I say that and why am I collecting a paycheck if I'm upset by that. It doesn't make any, unless I'm upset because I worried about the patient's condition or the consequences that that could have. But if I use that term pejoratively, there's something wrong with me.
If I use the term in a different way to describe a characteristic of the disease, that's a different story altogether. But I don't think most of the time when I hear that term used drug seeking, we're not using it as a characteristic of the disease. We're using it in some other way. Talked about powerlessness already.
I think all of us probably are interested in doing strength based approaches to working with our people. I know my experience with step work in my own life has been the same kind of thing. I am one of the people that the literature says it is the process by which the depressive becomes even more depressed for personal inventory, taking that step. And if I hadn't had a sponsor to help me get through that and realize, Hey, Charlie, this is about looking at positive stuff too, I could have developed a crisis.
So strength based approaches happen in the recovery community and also as professionals. I think that's a really important thing. Here are some stigmatizing attitudes that addiction is a choice. I didn't make that choice.
I do make a choice to work my program of recovery every single day, but I didn't make a choice to get addiction. And my addiction resulted in me making what appeared to be some terrible choices, terrible choices that made people wanna smash my living room window and stuff. And we won't go into what I did to make people wanna do that. But those are the kinds things that happened.
But it was a result of the brain circuitry. That doesn't mean I'm not responsible for fixing the living room window at that point. It doesn't mean that at all, okay? Some people say that that's a problem with some of the concepts of recovery that we're absolving people of responsibility and we're not.
I don't know of a single method of helping people with addiction, whether we're talking about MET or CBT or TSF or any of those things, motivational enhancement therapy, cognitive behavioral therapy, or 12-step facilitation, which are three evidence-based practices that we can use for treating people. None of them absolve people of responsibility. So are we winding down, Gloria?
- Well, so it's my job at this point - Okay.
- to stop - Ah, good.
- and ask for some questions.
- Okay, good.
- So maybe we can get some audience questions going. Any questions from the in-person audience here? Okay, I have another question.
- [Charles]
Oh, good.
- As a treatment professional and as a doctor, you've talked a lot about stigma and all the aspects of stigma and language and everything. What was the hardest thing? What is the special stigma that doctors in recovery can feel, do you know?
- Oh, I should have known better. When I got sober, I started giving lectures to the residents at Penn back then in the '80s. That was one of the things that I did. And we worked on some policy for the American Society of Anesthesiology and stuff.
But what happened was, there was a point when I was diverting drugs when I thought I had taken fentanyl from the university. And what had happened was that they had filled a syringe with five CCs of naloxone. And that's what I used. And I became immediately sick and went into withdrawal.
And later, when I was giving the lecture to the residents and did some self disclosure, one of the people that I was talking to, one of the residents, I was now an attending said, "Oh my God, that was you that did, we wondered what happened. We always thought it was one of the cleaning people."
- Ah.
- And so, you know, those kinds of things like that that other colleagues think that because you're a doctor, you should know, this is the great leveler of all humankind, addiction, and some of those things. But you know, for me, my recovery was the best thing that ever happened to me. And I had to learn maybe it's not always appropriate to tell everybody about it all the time, you know? So anyway, but that was a big deal.
Yeah. But I gotta tell you that the stuff that I did to my family was so painful at that time that being a doctor did not absolve me from those other feelings as well. And I think that's important to remember cause a lot of times as physicians, we get dehumanized in some ways. We get desensitized or whatever, and we have to maintain professionalism.
But that doesn't mean we don't have all the underlying feelings too, so.
- Sure, no, that's a good perspective on it. Yes, we have a question from the audience. Do you mind come down here and just speak into the microphone?
- [Audience Member]
Thank you, I first wanna just thank you so much for your talk today. It's incredibly inspirational and I'm just wondering if you have any advice for us clinicians, I'm a nurse myself on supporting people with stigma and some of the shame that they experience when there's a recurrence of use and helping them separate from that and move forward in their recovery? We oftentimes see people kinda disappear for months at a time and there's an exacerbation, right? And I feel like if we could better address that stigma and shame when there's that first return to use, we might be able to get them back on track and better support them.
- I did a lot of work with physicians and I haven't really worked with physicians in New York, but in Pennsylvania, Jersey, and Georgia actually. And with the docs, when they would relapse, there were some people who we needed to stop them from practicing right away and get them into treatment. But there were other people that we didn't have to do that with and that we could, they could even almost, maybe not take a couple days, something, you know, and get an evaluation, but we could let them go right back to work and keep them involved in the recovery program. So the individualization of care, I think, is critical in that group and for nurses the same.
And if we individualize care, I think it opens the door for people to be more honest about us. So it's a great question. I think one of the things to remember about nurses too is I've never worked with another profession that takes, and I can't get into this today, although I have a lot of feelings about decriminalization of a nurse error that recently happened. It's awful thing, awful.
But when nurses make errors, I've never met anybody, any other group that takes it more personally and it breaks the nurse's heart when he or she does that. So I think that there's an added layer of that that I think we have to take into account for nurses that is different than some of the other professionals. Does that make sense? And you're a nurse, so I'd be interested in what you think as well.
I mean, I'm glad to have you impart your expertise in this.
- [Audience Member]
Yeah, I mean, so yeah, I've worked with a number of nurses who have made mistakes and I've, you know, I practiced as a nurse for a couple years and then I moved into management. So oftentimes, I was the one sort of dealing with the disciplinary action of errors or if we had nurses on staff who were using substances and stealing from pharmacy and, you know, most of them ended up leaving the field ultimately. So I think to your point, you know, we need to better support these professionals. We're running into a very scary shortage with nursing staff that's only been exacerbated by the pandemic and how hard that work has become for our nurses.
So I don't know what exactly it looks like, but what I personally do with my own staff, and I work with peer recovery specialists now too, and I've had, you know, many staff have returned to use over the last several years. And the thing I've just tried to do is be as loving and kind as I possibly can be in the moment where they're picking up the phone to call me to let me know that this has happened. And I've put protocols in place in the organizations I work at where we protect the position and we take corporate responsibility for supporting the individual in seeking treatment and support.
And then there's a whole protocol with returning back to work where, you know, there's expectations to, you know, sort of work their recovery program and engage in the recovery community. And so I don't know if there's other things that we should be doing, but that's sort of my own approach and what I've done.
- I think that's really important, you know, and the other thing, I think, that's been true traditionally with nurses programs, not so much in New York with SPAN, but in others they've been a lot more punitive than the doctors programs have been and that's not helpful.
- No.
- Yeah.
- So just time for one more quick question from the online folks. From a provider perspective, how would you suggest to approach providers who don't wanna hear it when it comes to working with people who use drugs and discussing stigma?
- Hmm. Don't wanna hear about stigma?
- I guess.
- And the importance of getting rid of it?
- Yeah, the importance of it of getting rid of it.
- Well, I don't know what else clinical supervision could be about that would be more important to them.
- Okay.
- You know, to tell you the truth, but I hope we're all using clinical supervision and have open doors where people can come to us and say, "Oh my God, that patient, I wanna care for them so much," which needs clinical supervision too. Or that patient annoys me so much. I mean, I hope we have the ability to do that. And that's a big, big question.
So it's not okay to put up with it, that's for sure. It is not okay for people to stigmatize people for whom we're collecting money. And that's a big question though. Boy, maybe do more of these kinds of conferences.
And I think one of the things that is true too is when I approach somebody, I tend to have a really passionate reaction to that. And I get angry when I see that. And that's not helpful if I'm gonna go talk to somebody about their attitude, that anger may motivate me. But being open about that as well to try to talk about, I think us, as recovering people, have things we can do later on in this presentation, I'd encourage everybody to read what George Vaillant wrote.
George Vaillant was a Harvard psychiatrist who also served as a class, a non-recovering trustee for the Board of Alcoholics Anonymous. And he writes about how we have a responsibility to disclose to our doctors because they won't know it. They won't think they know us. So - Right.
- as a recovering community, we can do some things as well, I think. For New York, it has stuff to address that. Friends of Recovery New York and the Rochester Recovery Organization, I think probably does as well, so.
- Okay, okay. Well, thank you very much Dr. Morgan, and we appreciate your perspective on these things.
- Sure do appreciate you too, - Yeah.
- Dr. Baciewicz.
- Well, thank you.
- Thanks for doing all of this and all of the work - Yeah.
- you've done over the years.
- Okay. (audience applauding)
Charles W. Morgan, MD, DFASAM, FAAFP (Charlie)
Health Equity Advocate & Addiction Medicine Specialist