Ask the Expert: Interview with Dr. Brian Fuerlein of Yale University

In our first two posts, we discussed what we can all do to reduce addiction and death caused by the opioid and substance use disorder (SUD) crisis. The first focused on shame and stigma, and the second focused on false beliefs and misconceptions about what can be done right away to help.

In this interview with one of our nation’s experts on emergency medicine, addiction medicine, and addiction psychiatry, Brian from Yale University, Associate Professor of Psychiatry and Director of the Psychiatric Emergency Room at Virginia-Connecticut Healthcare. Listen to Dr. Fuehlein’s story. system.

He is the national expert on what we are doing, what we should be doing, and what we can do better on the front lines of this crisis.

Money: If you could do one thing to save the life of someone with SUD, what would it be?

Fuer line: Eliminate prejudice. Stigma prevents people from seeking help, creates barriers for patients to seek help when they do, and contributes to our attempts to punish illness. Stigma may also play a role in why there are so few treatment options. If we could remove the stigma and view substance use disorders in the same light as high blood pressure, cancer, and heart disease, we could go a long way in saving lives.

Money: anything else?

Fuer line: We need more and better drug treatment options for all substance use disorders. Despite the availability of excellent treatments for opioid use disorder (OUD), overdose rates remain near record highs. At our hospital, we have some medications that are somewhat effective for alcohol use disorder (AUD), but there are no treatments for other SUDs. Compare this to the myriad drug options for most other illnesses.

Detoxification and treatment of OUD patients in the emergency department

Money: Tell us about your experience with opioid overdose patients in the emergency department and how you persuaded them and their families to engage in treatment by administering Suboxone.

Fuer line: The Connecticut Department of Veterans Affairs (Department of Veterans Affairs) has a separate psychiatric emergency room. The emergency room allows the patient to be observed for longer than her normal six hours. Patients may be observed for at least 48 hours to stabilize their condition before discharge. Our typical process for patients using opioids is to monitor their symptoms of opioid withdrawal, usually using the Clinical Opioid Withdrawal Scale (COWS).

Initiate buprenorphine if necessary by discussing with the patient and using the COWS as a guide. We use a standard induction protocol by default (4 mg, then 4 mg immediately, 8 mg on day 1, and 16 mg on day 2). A walk-in detoxification stabilization clinic (DASS) is also available, and patients discharged from the hospital can follow up with DASS the next day. The patient is connected to the outpatient team through her ER and then her DASS for ongoing maintenance. We rarely detox the patient alone. We recommend starting and continuing buprenorphine in all patients.

Why people stop treatment

Money: If the treatment is so good, why do most patients drop out?

Fuer line: This is the million dollar question. Maintaining treatment for patients with SUD has always been difficult. I think the main reason is that for many patients, the desire to use it is stronger than the effectiveness of the treatment (hence the need for additional research and new drug options). Therefore, they stop treatment due to relapse. Sometimes it’s an issue of access or cost. Additionally, for some people, the stigma of being on medication has a negative impact on their lives. Some people may not have transportation to the clinic. Many people have co-occurring mental health conditions that contribute to their ability to continue receiving treatment. For some people, the cause is a chaotic home environment.

12 Steps and Similar Meetings Critical to Success

Money: If treatment with Suboxone needs to be continued for 1.5 to 2 years, will most people be successful? Why?

Fuer line: The data is clear that the longer you stay on treatment and medication, the better your outcomes. At some point, the time for recovery and sobriety is firmly established, and you may need to slowly wean off the drug. These are not necessarily lifelong medications.

But the most important variable is a solid foundation for recovery. Daily NA/AA (Narcotics and Alcoholics Anonymous) meetings, sponsorship, and 12-step work will provide you with the support you need while considering withdrawal from maintenance medications. Without a solid foundation for recovery, discontinuing the drug becomes more dangerous.

Why substance dependence remains a serious problem

Money: Why does the problem of drug addiction seem to be getting worse now?

Fuer line: The human brain has an increased susceptibility to powerful drugs of abuse. For decades, society has developed more powerful and addictive drugs to facilitate the financial drug trade and generate more customers. These powerful opioids lead to worsening dependence, severe withdrawal symptoms, and increased overdose deaths. Unfortunately, this tragedy overshadows the great strides we have made in improving treatment.

New hope for future treatments

Money: How do you see the current situation going forward?

Fuer line: Our group here at Yale, NIDA (National Institute on Drug Abuse), and other researchers are working to better treat patients with SUD. Research into new treatments such as psychedelics, neuromodulation, and other alternative therapies is very active. We appear to be on the verge of a neuroscience advance that could be game-changing, improve treatments, and offer hope for a cure.

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