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Addiction, Aging, and Patient-Centered Medicine · White Coat Black Sheep

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Welcome to White Coat Black Sheep.
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I'm your host, Dr. Elli,
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and today I have with me Dr. Matt Bear.
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Yeah, thank you. Welcome.
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Addiction medicine specialist.
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Yeah, addiction and family and street medicine. So, yeah.
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How's that going? Really
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Well, I feel like ridiculously blessed, to be honest.
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It feels, uh, it feels like I cheated
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to get some bonus in life.
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Like I'm gonna quote you right now. Yeah,
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Yeah. You said,
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my days all look good,
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man. I'm incredibly lucky.
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Yeah. I stand behind that.
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I feel like, honestly, I, I got
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like straight outta residency.
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I just got, I landed like a really good position,
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and Clinica has let me sort of like,
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take every little brain child I had and just run with it.
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And so when I came to them
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and I was like, Hey, I wanna start the street medicine,
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and we're just going to, we're gonna take a backpack
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and we're gonna take medicine out of the clinic,
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and we're just gonna take it into the homeless
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encampments and see patients.
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I thought for sure they're like, the hell you are.
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But they were very much like, yeah, yeah, let's do that.
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Supportive. Yeah. And then it was like, Hey,
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I'm gonna start doing addiction treatment,
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and like, yeah, let's do that.
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So they really, every single step along
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the way, I've just been very lucky.
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And then because of, I think the patients that we serve,
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it's just very like, um, underserved and marginalized.
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Oh, yeah. And so that brings a ton of like,
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just satisfaction day to day satisfaction.
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Yeah. I mean, like, you know,
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if you think about traditional like medicine
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and what that looks like in terms of your relationship
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with a patient and your relationship with their pathology,
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a lot of what you do in medicine, it's like, Hey,
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I'm trying to prevent mm-hmm.
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I'm trying to prevent your A1C from getting so outta control
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that you lose your feet or,
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Right. Like, I see you're
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trending up.
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Let's, what are you doing? Right.
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Let's talk about that. So it's, it's a lot of that like,
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Hey, I don't want you to have a stroke.
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Mm-hmm. When you're 60 and with addiction medicine and,
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and street medicine both, like, that is flipped
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and the interventions you make are having very
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immediate life changes.
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Mm-hmm. So like, when you get someone started,
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and you've probably seen this working
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with like buprenorphine and stuff.
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Mm-hmm. When you get someone started on treatment,
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it's not just like, Hey, I'm feeling better.
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It's like, Hey, I got a job.
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Hey, I saw my kids for the first time in three years.
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Hey, like, I'm not having those legal problems.
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So it's just very like, and that's every day. Yeah.
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Every day you get to see people
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Instant gratification.
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Yeah. Yeah. So it's very, yeah.
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It's like legit rewarding. So yeah,
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It's been great. I just love that
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I, I wanted to experience that.
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I feel like I was looking for that exact thing,
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but when I graduated, I did telemedicine,
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and it just, something about it was appealing to me.
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I liked that it was access to a doctor
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that people wouldn't otherwise have.
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Like, Isabella is pretty far from here,
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and it's as, you know, a very windy path to get there.
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I had a lot of, um, the clinic patients there
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driving out there, no doctors, um, go there.
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Yeah. And so, um,
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but really on the other side of that, seeing
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that population, I, I just felt like okay, nobody was like,
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I was forgotten about number one because I'm at home.
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Yeah, that's fair. But I'm at a standing desk.
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I'm actually like, I was, I was so serious about it,
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you know, I had like 40 people on my schedule
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and I was like, oh God.
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They would load me up and then it would be like 10 o'clock,
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and then nobody is ready, you know?
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Know. Yeah. And,
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and in, in our world, readied just, you know,
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to anybody listening would be, they have called the patient,
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their insurance is there, we have their phone number,
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everything's confirmed.
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So that, and we have their chief complaints, so we know
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that they're not gonna get a surprise bill,
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and like we can properly see them.
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So, um, I couldn't call them ahead of time anyway.
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It was just really, yeah. I don't know.
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It was not, it was not instantly rewarding.
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It was not fun or, uh,
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what I feel like I gave up everything to do
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and I just was like kind of standing there
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with an empty bucket, so to speak. And I was,
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Yeah. That sucks. Yeah.
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That's not, that's very,
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that's like moral injury and Yeah.
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I think like Coming out
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of residency we're also motivated and I
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Was motivated. Yeah. Like,
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let's change the world. Yeah, exactly.
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I give up everything to do this, and like,
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and then you're there like, oh
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My God, I'm so sorry. No
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One cares. Yeah. We
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had the opposite experience.
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It sounds like, like legit out
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of residency was like completely
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Different. Very
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Rejuvenating and like very, like, I feel like I've kind
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of woke up again after residency. Oh,
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That's what I wanted. Yeah.
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I feel like I'm just now
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That's wonderful.
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Just now feeling that that's Really good.
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I feel like I've woken up and I can help people,
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and I want to, I have the energy to, and I know how to,
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and you just need to call me like,
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you know, like, come on over.
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Just like, you're, you are so ready
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and willing to take on my patient.
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Like, that's how, that's how I feel. That's awesome.
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Like, if you need something, you just come on
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in, like, we've got you. You're gonna feel great.
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Yeah. I think it's, it's very easy
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to get dragged down into the bureaucracy of a clinic
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or the bureaucracy of medicine and billing
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and insurance and all that. It
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Was shocking. Yeah.
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So like, I think that's a very,
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that's a very common, um, complaint
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or common experience Right.
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For a lot of physicians. And legitimately, I feel like all
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of that sort of bounces off of me now because,
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because of the patients I'm able to interact with
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and the, and the relationships.
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Like, that's another really critical thing about the way
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I I see patients, is that it,
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it is all about building relationships, whether it's like
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that person in clinic Yeah.
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Or that, you know, patient out on the riverbed
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or, you know, under the bridge or whatever.
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It's just like taking that time
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to build a human relationship. They
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Know you and, and the patients like they remember you.
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They know you. They, they are not worried.
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They know that you're gonna be back. Yeah.
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You know, if you maybe miss them that day.
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Like the, it's just, yeah. It's really cool. Yeah.
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So I think that, I think that sort
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of relationship building medicine is really
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protective towards burnout.
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Mm-hmm. So, yeah. Just food for thought, I guess
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That's such a good thing.
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Yeah. So like for a lot of my colleagues, you know,
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as we get together, which is honestly not often, we're not,
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doctors are really not that social. Yeah.
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How can you be, We're tired.
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I found most of the jobs that I've worked,
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like since graduation just made me tired.
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And so I'm like, why, why don't I love it?
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Why am I not like so over the moon to like,
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just show up every day?
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But then, okay, so fast forward, now
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that I'm here, I feel energized.
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So it really, it's about like, finding exactly
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where you're meant to be, what you're supposed to be,
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and just connecting with the field
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that you can really do what you're meant to do. Yeah.
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That makes, I mean, to me, that makes Yeah, perfect sense.
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If you're not, like, if you're not getting something out
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of it, sort of that emotional feedback
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or something rewarding,
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then what the hell is the point of any
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Of it? People just take pieces
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of you. Yeah.
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Oh yeah. And especially in the field of medicine,
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and this is not, this is not exclusive to doctors.
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Mm-hmm. It's for everybody in the field of medicine. Mm-hmm.
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Like, there's always more to be done. Mm-hmm.
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And like, there's always a call to be like,
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do more, be more, see
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More patient. Your list is never done
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It ever. Never, ever. Mm-hmm.
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So it's very easy to sort
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of lose yourself in medicine.
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I think you have to be very intentional about like, no,
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these are my as, as much as I hate that, I hate
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That I'm a yes person. You're, you're
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Yes. Person. I'm, I'm
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very much a yes person.
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So you have to have like, at some point, like a boundary.
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I, no. Yeah. And I hate, it's not,
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it doesn't come naturally to me.
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Same. But having a, like, having four kids
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and my wife, it makes that much more doable. Right.
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What, you don't live at your clinic. No,
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No. But when
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I'm in my clinic, I am in, like,
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I feel like a piece of my clinic.
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Totally. Yes. But then when I'm at
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home, that's what I wanna be too.
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I wanna be at home and just dad and husband
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and not a clinician.
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So I love that. And I've been very,
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very lucky to do that. So,
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Yeah. I think that
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really shows too.
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I mean, you're always like, so like, my experience
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with you is that you, you've always loved it.
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You are a piece of the clinic and it's just synchronous
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and it's infectious, really. Like, you know, like,
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I dunno if that's good or not, but I don't
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Know. Infectious in
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a good way. Yeah, yeah.
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In a way you don't wanna treat.
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Yeah. So, no. Yeah. It's been really, really good.
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I love the patients. I love this.
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I, you know, I've sort of grown more in love
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with Kern County over the last
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I know. Me too. Five to seven
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years. And today was really gross.
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Like aesthetically Yeah.
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It was very foggy and cold, and everyone sounds congested.
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It's so true. Yeah. But it's also, we don't get this type
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of weather very often, so I'm kind of embracing it. Yeah.
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It's a little moody. Yeah.
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Very moody. I embrace it. I totally
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Agree. Mm-hmm. This is good. Like,
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um, read a good book. Yeah.
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Rather. Yeah. Yeah.
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But you probably read a lot of good charts today.
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No, not too much. I'm not, so, okay.
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I saw like 20 patients. I had only morning clinic. Um,
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That's like a whole day for a lot of people.
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Yeah. But a lot of my visits are, um, follow up.
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So they're pretty quick. And honestly, like,
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I don't even know if I ever want this out on the air,
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but it doesn't feel like I'm working most of the time
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because I'm legit.
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I'm just having conversations with people
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that I genuinely love and care about.
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So it really is, it feels like I'm calling
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and being like, dude, what's
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happening? How's everything? How's,
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That's you and your purpose though? That's
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What it looks like. I dunno. Whatever it
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Yeah. It's really, really,
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it doesn't feel like taxing at all.
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And that's exactly what it should be.
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That's, that's what I'm just now tapping into. Yeah.
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Tell me about that, by the way. Yeah.
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Tell me about this, the functional medicine.
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Okay. So functional medicine I think is such
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a interesting new space.
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So with primary care, where we all started family medicine,
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you can see everybody and you can treat anything.
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And it really gets complicated,
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especially if somebody has trouble getting into the clinic,
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because as a person who struggles to say no, like,
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I'm gonna just like maximize the visit
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and try to see you for everything.
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Mm-hmm. But then the time slot does not allow. Right.
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And then insurance doesn't pay you.
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So really, it's like, I was just creating this burnout
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scenario, like not meeting the goals,
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not really helping a patient fully.
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Right. Um, you can't fix everything.
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It's hard to get people back in timely.
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I, there's a lot of things
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That's horrible. 'cause then you're
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failing everywhere. I felt
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You're failing. I failed everywhere.
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Your employer or the boss,
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you're failing the patient everywhere.
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You're failing yourself. You're failing
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your friends. That's a horrible
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Way to, and then my mom calls
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and I'm like, I fail to answer.
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And then she's now p****d off. Like, what about me?
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And I'm like, oh, well, I just have, I need to find myself.
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I need a minute. Yeah. Fair.
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I'm so sorry. No, I'm so sorry.
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Well, I'm not alone in this, you know, and I, and,
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and so sharing this whole like, toxic cycle,
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really, this is what led me to where I'm at.
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So, um, let's see, 2023, I looked into peptides.
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I went to this conference.
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Um, I was actually, I was in Grand Cayman where I,
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I did med school and um, I, I was just swimming in the ocean
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and I happened to meet this, um, er doctor
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who is a longevity doctor in functional medicine.
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So he's er, and then he specialized into functional.
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And, um, I was like, what is that? Just like you said.
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And, uh, really in his case, he described it, um, in his
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scenario where he had a, um, an aneurysm in his, uh,
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in his brain, like around the pituitary.
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And he almost died. He was saved just in time.
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They put a clip and then he was deficient of a lot
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of hormones including growth hormone.
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And, um, so, but he didn't know that for a while.
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He just was like, I feel horrible.
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Like, I would rather be dead than feel like this. Mm-hmm.
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And he went to all these different doctors
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and including endocrinology.
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They're like, oh, okay.
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You have, um, you have a low testosterone.
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Like really, everything was low, so
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low growth hormone, everything.
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So he got onto replacement.
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He's like, oh my God, I got my life back.
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I got my life back.
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So from that moment, he just like, I have to do this
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for other people, and I don't think I know how to do that.
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I'm an ER doctor. Mm-hmm.
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So he went into functional medicine from that.
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It really is a subcategory.
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It's outside of the scope of what, um, anything
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that we have learned.
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Like we have the primary working knowledge
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of the whole body at different ages,
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but when you are looking at like, hormones
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and like the safety profiles and,
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and it's like, yes, the paper,
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like we're looking at reference lab ranges,
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but then also there's subspecialty labs that you can do.
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There's, um, there's, there's spaces that you can, um,
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I don't know, I guess go more aggressive,
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like do higher doses or lower doses of certain things.
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Mm-hmm. Adjustments that you can make
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or, uh, supplements that you can do
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that really give people their life back. Oh,
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Interesting. Yeah. Yeah. So it's,
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it's a subset
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of endocrinology, or No, it's,
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Yeah. I would say everything.
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Okay. So, so it's in the space that,
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um, that is not the gen general, like health maintenance
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and wellness, like, if you went to your regular doctor,
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they would likely say everything is fine if you're mostly
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fine according to reference range labs.
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Whereas we in functional medicine, might have a different,
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uh, summary mm-hmm.
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Of your, your labs. Okay.
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Like, like, uh, you know, like
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how we'll look at hemoglobin on A CBC
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and the MCV, we can say macrocytic microcytic anemia.
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Right. Um, your platelets, you know, are normal,
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but then you just, there's nothing
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else that that's on there.
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Right. Whereas functional medicine is gonna say, oh,
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I see your basophils are really elevated.
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Or, um, there's calculations that, you know, would kind
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of tell a different story,
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or your hormones, um, oh, your estrogen is fine
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by reference, but then if it's just a E two,
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uh, estradiol mm-hmm.
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That's not adequate. So it's just a very, like a expanded
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in depth, um, management.
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Interesting. Yeah. No, I don't know that I've,
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I've heard the term before, so,
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Yeah. It's,
13:49
so, uh, longevity,
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you'll probably hear that, hear that term a lot.
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Mm-hmm. So, aging is considered, um, a disease.
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It doesn't get that term
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because too many people are affected.
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Everybody ages. If 100% of people are affected,
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then it's no longer considered a disease.
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Mm-hmm. You have to have a subset of the population.
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So everything that is, um, pathologic mm-hmm.
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Is due to aging in a sense. Right.
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So it, like, it used to work and then now it doesn't. Okay.
14:18
Because something inter intercepted.
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So it's kind of just like looking into
14:24
different angles of that.
14:26
I mean, telomere length, have you heard of anybody talk
14:28
About that? Yeah, I remember like that,
14:29
like the, the studies
14:31
and stuff about that back in
14:33
like the early two thousands and stuff.
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But I, you know, it's not a thing I follow. So
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Yeah. So
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you can check the length of your telomeres,
14:40
and then you can see, um, based on that,
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like if you change your different lifestyles
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or supplements, you can extend them.
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You can actually have them measured every three months.
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That's Wild. Yeah. It is wild.
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There's a lot of Harvard studies
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that have made, like these labs.
14:56
Does. What does that look like in terms of like, practice?
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So like, what does your day to day look like as a
15:02
functional medicine physician?
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Short answer is that it's longer visits. Okay.
15:06
Well, that's not a bad thing necessarily.
15:08
No, no. It, it actually is very pleasant.
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And, um, I look into things like, how,
15:13
how, um, are you sleeping?
15:15
And I'm gonna hear what you tell me,
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but then I'm also gonna ask you, show me
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what your wearable data shows you
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and me, for example, so my doctor
15:23
used to ask me, how do you sleep?
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I'm like, good. Like, I think I slept good.
15:27
But really when I started using a wearable,
15:30
I saw I had a lot of light sleep.
15:33
I didn't have enough, uh, deep restorative sleep
15:36
and rem so I, you know, made those adjustments.
15:41
Um, it was anything from like lifestyle changes,
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like stop looking at my phone after six, put it away.
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Um, no bright lights, no decisions, no fights.
15:50
Like nothing after,
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I have no decisions after six.
15:53
Oh my God, no decisions Felix. Like totally. I
15:55
Make all my decisions For real.
15:58
Well, if it, if it's not affecting you. Yeah.
15:59
And, and like, your labs look good, you feel good,
16:02
and your sleep is is great, then, then carry on.
16:05
Right. But for me, it, it was keeping me up apparently from,
16:08
it was preventing me from that deep mm-hmm.
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Sleep, right? Like, I wasn't unwinding enough. Yeah.
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So, and I did that.
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And then I also started to exercise in a different way
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rather than like, hit interval training.
16:20
I would do like heavy lifting and less cardio.
16:24
So for me, that,
16:26
and also I started to have a lot more carbs. So,
16:28
Nice. Me too.
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It's Gone Great. I feel
16:31
great. Right.
16:32
So, so, so like those little changes,
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uh, were pretty impactful for me.
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That's awesome. Yeah. And that's
16:38
When I sleep much better and feel better. Overall.
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I do, I feel strong's. Yeah. That's good. Yeah. Yeah.
16:44
Sounds great. I feel like after the sleep was corrected,
16:46
that corrected like a lot of other things.
16:48
But yeah. And I went through hell, like, 2025 was horrible,
16:52
but I felt fantastic.
16:54
That's good. That's really good.
16:55
I feel like it's easy to, uh, really under appreciate
17:00
how much sleep can affect your day-to-day life.
17:02
Yeah. I mean, there's a lot, I feel like actually there's a
17:04
lot of those little things that can really,
17:06
really affect just how you interact with the world.
17:09
Mm-hmm. Like chronic pain patients, I always think about,
17:12
like, if I have a pain that lasts more than, you know,
17:15
an hour or so, like it affects my whole day.
17:17
Right. It affects my mood. It affects how much I can enjoy.
17:19
Mm-hmm. A meal. It affects
17:21
how much I can engage with other people.
17:23
So then you imagine these people
17:24
who have like, pain all day,
17:26
All the time, every Day.
17:27
And it's just like, how do you, like,
17:30
I would be so, well, I, I mean, you'd have
17:33
to really check yourself.
17:34
Yeah. Because I think I would be irritated.
17:37
Yeah. I mean mm-hmm.
17:38
I think irritated is like just one of a many potential, um,
17:43
emotions to have with that.
17:44
Yeah. It's just so awful.
17:45
Yeah. So, yeah.
17:47
Yeah. So stuff like that. Right.
17:48
Like, so, um, so just checking in with people,
17:50
like if they do have like a, a irritated like symptom,
17:53
and usually it's like the husband and wives come together,
17:56
or I do see them separately
17:58
and I get to learn like what the real
18:00
Oh, the dynamic between them is.
18:01
Yeah. 'cause they tell on each other. Yeah.
18:03
That's, I like that. Yeah.
18:05
But, um, yeah, so it is just looking at data, extended data,
18:08
like, uh, I do gut microbiome tests.
18:11
Nice. Um, longevity tests.
18:12
So you had mentioned like, um, that you had a patient
18:16
who was on, uh, a buprenorphine product.
18:19
Yes. So how does, uh, functional medicine fit into like,
18:23
the addiction space, the, the pathology of addiction?
18:26
Yeah. So we are invasive, I would say, you know, a visit,
18:31
first visit could be like an hour.
18:32
It could be a little bit longer. Just depends.
18:34
Um, but when we're looking into every category of like,
18:37
your sleep, your performance,
18:39
because it's really about, like, you're optimizing a lot
18:41
of people, they show up their, they're healthy,
18:43
they're high performers.
18:44
They're already doing, they look
18:46
like they're killing it in life.
18:47
Mm-hmm. So, but they're like, I just know that I used
18:50
to be stronger, or I used to not have these episodes
18:55
of like, uh, anger or I used to.
18:58
Right. It's, it's, I used to.
18:59
And then, so that changes the space
19:01
that somebody would see me for.
19:03
Okay. Because you're fine until you're not.
19:06
And it's really, um, so for this, uh, particular patient,
19:10
um, he, I mean, now that I've learned a lot about the,
19:14
the personal life, there's like a lot of social,
19:16
I would say triggers going on, like with his family dynamic.
19:21
And then, um, he had a performance issue at his work.
19:25
He's a self-employed. Mm-hmm. So focus was a problem.
19:29
Um, uh, he just felt tired all the time.
19:33
Uh, just, um, he, he worked out, he could lift heavy.
19:38
He was like doing as much as he could to really stay on,
19:42
um, a schedule.
19:44
Mm-hmm. But his sleep was poor.
19:45
And then I tried different, like sleep aids just to temper
19:49
or behavioral changes.
19:50
Mm-hmm. We checked all the labs. Um, testosterone was low.
19:54
We replaced it. There were just a few things,
19:56
but like finally we realized it was kratom.
19:59
Yeah. But,
20:00
but I, I started out, I would say like
20:03
two years prior to him. I didn't know what that was.
20:06
Yeah. It's sort of, um,
20:07
really taken off in the last It's crazy couple.
20:10
Yeah. So it was, you know, it's been around for a while,
20:12
but it really, honestly, in like the last,
20:14
I would even say the last 12 months,
20:15
we've seen a huge explosion of, um, patients
20:18
who are struggling with Kratom.
20:20
And it's a very strange chemical on its own.
20:23
And it acts like at low doses, it sort
20:25
of acts like a stimulant,
20:26
but then at high doses it acts like an opioid to the point
20:29
where it's like, you can overdose on it,
20:31
and then you can just go buy it.
20:32
Like, you can go at
20:33
A gas station. Yeah. Totally.
20:34
Legally, no restrictions. It's, yeah.
20:37
It's, it's really, really wild.
20:38
So yeah, we've had a lot of great impatience
20:40
and it's really, it's really tragic. So
20:42
I had to learn like c you know,
20:44
whenever you're going over like a medication list, like
20:46
what stands out, right?
20:47
Like, you're kind of listening for certain things,
20:48
like which ones are impactful for this patient?
20:51
So for him, I had to just ask him directly.
20:54
It was not brought up, and I was like, nothing else.
20:57
Makes sense. Yeah.
20:58
And so just, you know, so I have to go, like,
21:02
that's the part where I'm no longer like, primary.
21:05
I'm like, let's go functional medicine right now.
21:08
Let's go a little bit rogue. Tell me
21:09
your supplements and herbs.
21:10
Tell me which teas we're drinking.
21:12
Tell me, like all that stuff. Wow.
21:13
So I had to like learn like all of like the, the language,
21:16
like ashwagandha, rhodiola, like, oh yeah, remember those?
21:18
Let's talk plants and herbs right now.
21:20
So there's a whole like, repertoire of things
21:24
that people dive into.
21:25
And I, I know, I know them all now and that's good. Yeah.
21:29
There's a lot of 'em. There's so many.
21:31
And they're not regulated the same way
21:32
as not at all regular meds.
21:34
So if someone's like, Hey, I'm on this dose, it's like,
21:36
yeah, well, what does that actually mean?
21:37
Because it doesn't, you know, 25 milligrams
21:40
of amlodipine is different from 25 milligrams of, um, uh,
21:44
you know, thistle or whatever it is.
21:46
Yeah. Because it's just not,
21:47
it doesn't have the same
21:47
regulation. Yes. So, yeah. It's a tough one.
21:49
That's a tough one. Yeah.
21:50
So, so like, really learning how
21:51
to speak to that type of patient.
21:53
I mean, I would say that's really the
21:55
type of patient that I would treat.
21:56
Yeah. And, and a lot of them, they're like, well,
21:58
I know I have diabetes, but I don't wanna take this.
22:01
And, and so like, we really, I feel like it's a, a gap
22:04
that I can bridge because it's like, look, here's
22:07
what you're doing by not,
22:08
so we talk like regular medicine first always nice,
22:11
but then the rest it would be like, okay, so go ahead
22:14
and take your, your statin,
22:15
but then let's also add on cozy Q
22:18
because it's gonna give you an extra benefit.
22:20
Maybe they'll, they'll reach like a lower dose statin.
22:22
Mm-hmm. You know, there's, I don't know, it's just,
22:25
it's a language, it's a reframing.
22:26
Yeah. Like somebody, like, they reject, uh, depression.
22:30
I don't have depression. I don't have anxiety.
22:31
That's for other people. And, and I get it. Right.
22:33
Because they, I mean, they're intelligent
22:34
like professionals.
22:35
They, yeah. Doctors, lawyers, a lot of, you know, that type
22:39
of patient, like, don't, don't diagnose me with that.
22:41
That's for other people. Right.
22:43
Well, I don't know if it works that way
22:44
with any other Right.
22:46
Illness, like no profession has spared pancreatic
22:49
cancer or Yeah.
22:51
High Blood pressure. So I know,
22:52
But yeah. Well, well, okay. But it's
22:53
happening. Right?
22:54
So like, a lot of this type of, these types of patients,
22:57
they, I feel like we do a lot of reframing.
23:00
Mm-hmm. Like, okay, this is a nervous system issue, so
23:04
let's, you're too much in sympathetic overdrive,
23:06
so let's get you back over to parasympathetic.
23:10
And so, I don't know, it's just interesting. Yeah. Yeah.
23:12
It's a language. Yeah.
23:13
It's, I mean, what a, again, I, I,
23:15
this is my first step into the conversation
23:18
of functional medicine, but what, what one part I,
23:20
I love this I'm hearing is, um,
23:23
that there's shared decision making
23:25
and patient-centered care.
23:26
Yeah. And so that very much overlap
23:28
And overlaps and a Whiteboard overlap.
23:29
And a whiteboard. Oh, yeah. It makes sense. Yeah.
23:30
A lot of education. So,
23:32
but that, that very much overlaps with addiction medicine
23:35
and street medicine as well,
23:36
because it's not about like, Hey, I'm coming in
23:39
with my agenda for your health.
23:41
Mm-hmm. It's like, Hey, I'm just a conduit to like Exactly.
23:44
Treatment. And what is your plan?
23:46
Like, what is your, what are your goals exactly.
23:48
And how can I help you reach those goals,
23:52
specifically? Not my goals, but
23:53
100%. That's
23:54
the same way I see myself completely.
23:57
Yeah. That's good. Yeah. That sounds fun. Yeah.
23:59
And that honestly, like, it makes sense
24:00
that you're feeling more rewarded Yeah.
24:01
Now, professionally because like, finally, yeah. Mm-hmm.
24:04
Because it, it feels really good to like, I don't know,
24:07
let someone else drive.
24:09
Mm-hmm. And you are just participating and,
24:11
and helping in, in a meaningful way.
24:13
And as opposed to you are dictating
24:15
and composing and finger wagging. Yes. Um,
24:18
Like, you are going to die of this.
24:20
Like, I mean, I, we talk risk, like your risk of Yeah.
24:25
Mortality is high if you don't change anything.
24:27
You know, it's so funny. It's like, that is straight up.
24:30
So when I first started doing street medicine, I thought,
24:33
okay, I'm gonna take like the high quality evidence-based
24:36
medicine that I perform in clinic,
24:38
and I'm gonna take it to the streets.
24:40
And then I got out to the streets
24:41
and the patient was like, what the hell?
24:42
Like, this is what I want. This is what we're talking about.
24:44
This is, this is what I need. Mm-hmm.
24:47
And I, and I had to become, I was sort of forced
24:49
to become patient centered.
24:51
And so then I took that philosophy back into my,
24:54
this is when I was still doing primary care.
24:55
I took that back to like my diabetic patients
24:57
and was like, Hey, here's like your A one C'S 14.
25:00
The guidelines say you should be this, this,
25:02
we should start doing this
25:03
medicine, this medicine, this medicine.
25:04
Maybe some insulin. But really, what do you want?
25:07
Yeah. Let's start there.
25:08
Because that's like a fail, right?
25:09
That's like a hundred percent. That's, that's overwhelming.
25:11
Like, oh my God.
25:12
Like, I just wanna crash
25:13
and like, I'm gonna go to sleep. And,
25:15
And what'll happen is if you do prescriptive medicine in
25:18
that way, Hey, you need to be on these meds.
25:20
I'll send the meds for you. They'll say, okay, thank you.
25:22
And I'll never see 'em again. Yep.
25:24
Because they're not gonna take all those meds.
25:25
It's too much. But they're gonna be too embarrassed
25:27
to come back and not have done what the doc Exactly.
25:30
Yeah. So then I found out, I was like, all right,
25:32
like if the first step you want do is let's talk about
25:34
cutting a tortilla outta your diet.
25:36
Like, cool, let's do that and we'll just follow up.
25:38
And I feel like when you let the patients,
25:40
when you really do all that hokey mm-hmm.
25:43
Patient centered mm-hmm.
25:44
Care, it really has better health outcomes. It
25:47
Does, does, I know I used to laugh at, right.
25:50
It's like the, I don't know the way we're talking really.
25:52
Yeah. Because I'd be like, okay, like marketing. Yeah,
25:55
Yeah. Oh, I remember being
25:56
taught in med school, like,
25:58
all these tenets of good medicine, patient centered care.
26:00
Right. And it's like, yeah, okay. Yeah.
26:01
Like, like I know what to answer on the test,
26:03
but then it's like, no, when you actually
26:06
apply it in a real world experience, it's like, like,
26:09
Let the patients decide.
26:10
Yeah. It's life changing. Yeah. Yeah. Yeah.
26:13
So I'm actually doing that.
26:14
That's, yeah, it sounds like it. So, yeah. That's awesome.
26:17
Yeah. It's pretty cool. Or like diets, I mean, there's
26:19
so many weird diets, and like a lot
26:21
of people like bring out these like very restrictive things.
26:24
I'm like, yeah, you're gonna lose some weight.
26:26
Like, oh, okay, you think I'm going to?
26:27
I'm like, no, I know you're going to, you're going to,
26:29
but like, can you sustain that?
26:32
Right. Like, is that, yeah. Is that good for your longevity?
26:35
No. Yeah. So then that maybe would be,
26:38
when we talk about their telomeres,
26:40
Lots of lots of telomere talk.
26:42
No, we don't talk about it that much, but that's good.
26:44
Yeah. No, I think it is patient-centered.
26:47
That's awesome. Yeah. I think that's, I think
26:49
that's the way to, I think that's what's missing honestly,
26:51
in a lot of, um, uh, uh, medicine as a whole.
26:55
Yeah. It's just like, it's very, we sort
26:56
of get taught to be prescriptive.
26:58
Mm-hmm. We get taught to like, Hey,
26:59
here's the algorithms, here's what you do.
27:01
And it's never like, well, okay, well how do you present
27:04
that to a patient, but then don't do that.
27:07
Mm-hmm. How do you present that to a patient
27:08
and a patient tell you no,
27:09
and you still come up with a plan mm-hmm.
27:11
That's going to have, that is
27:12
Right. So there's
27:13
an action.
27:14
Yeah. Right. So how do you do that? Yeah.
27:15
And I don't feel like that's really focused on,
27:18
it wasn't in my medical, medical education,
27:20
So it wasn't in mine either.
27:21
It's like, I'm the doctor because I said so.
27:23
Yeah. I hate that. I hate that. I hate that. Yeah.
27:26
I don't, I don't like that. I don't like
27:27
that power dynamic at all to begin with. But
27:29
Yeah, it's kinda like parent child, like,
27:31
because I said so Yeah. And Yep.
27:33
No, so we see that. So, and that un legitimately like,
27:36
that does not work in addiction medicine.
27:39
They just, they're like none of that.
27:41
So it's nice because it is, like, it gives me the ability
27:43
to not have to like, I don't know, pretend
27:46
to be someone's parent
27:47
or to pretend to be this force that I'm not.
27:50
So it's really, yeah. It's really wonderful.
27:51
More people should do addiction medicine.
27:53
Well, okay. So on that, like, is there any,
27:56
was there any like moment that you felt like hopeless about
27:59
or hopeful that you're like, I know I can help this person,
28:03
or this one I can't help?
28:05
Yeah. I mean, it's, um, so, you know, we see
28:09
the field itself is sort of crazy
28:13
because you have like these moments
28:15
and they're, they're very routine.
28:17
They're very regular all the time of just like overjoyed,
28:21
uh, experiences where just pa like I said, patients are
28:25
re involving themselves in their lives
28:26
and reconnecting with their family, and they feel alive.
28:29
But then because of the nature of the disease of addiction,
28:33
like we also have a lot of death.
28:34
Mm-hmm. And so we do see a lot of patients where it's like,
28:38
we can start treatment and then we lose them,
28:40
and we start treatment and lose them,
28:41
and then we don't hear from 'em for a while,
28:42
and then we find out like, yeah, they passed.
28:43
And that, that really speaks to the mortality of the,
28:48
the chronic disease of addiction.
28:49
Yeah. Um, but I've never felt hopeless. Yeah. Um, like, so
28:53
Professional. So you believe that there's
28:54
always like, hope for anybody
28:55
that steps into the clinic?
28:57
Like, I'm not gonna give up on this one yet. Yeah.
28:59
Oh, yeah. Yeah. So a lot of, you know, a lot of that, like
29:02
what do we do with, um,
29:06
when when someone is still actively struggling
29:08
and they're not, they're not gonna reach, uh,
29:11
necessarily some goal of, of complete remission, right?
29:15
Mm-hmm. So that's where harm reduction comes in.
29:17
And that's where it's like, all right, well if you're still
29:18
like, I like that term using illicitly.
29:20
Mm-hmm. Like, what can we do so
29:22
that you're using safely, right?
29:24
Absolutely. So then there's a lot of,
29:25
a lot of what we do mm-hmm.
29:26
Isn't necessarily medical.
29:27
It's like, Hey, how can we educate the patient on like safer
29:30
injection injection practices mm-hmm.
29:32
Or safer used practice, right?
29:33
If you're gonna use fentanyl,
29:35
like you should probably use with a partner.
29:37
And if you can't use with a partner, here's a phone number
29:39
where you can call and just have someone
29:40
on the line while you're using.
29:42
So if you overdose, like someone can call 9 1 1.
29:45
And we talk about Narcan and things like that.
29:47
So even if someone is in the throes of active addiction,
29:51
like we still want them to be safe.
29:53
Right? So even if it's like, Hey, I'm not ready to stop, um,
29:56
using, and a lot of people
29:57
Are not. 'cause they, the future of
29:58
them would want
29:58
to live a hundred percent.
29:59
Like they, the person wants to live hundred.
30:01
It's such a chemical, like demon, like
30:05
a dopamine deficiency. Yeah,
30:07
Absolutely. Yeah. So,
30:08
and again, like our goal isn't
30:10
to have everyone come in and, and be like, Nope.
30:13
Like the way we want is we want you to be a hundred percent,
30:15
um, in remission, or else it's a failure.
30:18
That's nonsense. We don't do that for other diseases, right?
30:20
Mm-hmm. Like my patients who have high blood pressure, many,
30:24
many of them will have great blood pressure for months
30:27
to weeks to years, all of a sudden
30:29
to like lose that control.
30:30
Mm-hmm. And that happens in addiction.
30:31
And no one like gives the blood pressure patient a bunch
30:34
of s**t for like, dude, this, it's like,
30:36
oh my God, no one's in tears.
30:38
Or it's like, yeah, that's how this disease works.
30:39
That's how all chronic disease works. Yeah. It's just there.
30:41
Yeah. Waiting for a moment to pop its head up again. Yeah.
30:44
Fine. Until it's not. Yeah. Yeah.
30:46
It's the same with addiction. It's just like, um, you know,
30:49
it's, it's kind of always
30:50
there for the vast majority of people.
30:51
It's just always kind of there in the background.
30:52
If you can get it into that state of remission, hallelujah.
30:55
But if, if you lose, right.
30:57
If you have an episode of use
30:58
or you kind of have a return to use it,
31:00
It doesn't mean, or some, some trigger
31:01
Right. It doesn't mean it's
31:02
over. It doesn't mean
31:03
like you lost anything.
31:04
It's like, yeah, that's the disease
31:06
Man's like, yeah. Like a speed bump.
31:07
That's it. That's all it has to be. Yeah. And so,
31:09
Yeah. So you get right back on
31:10
it. Yeah.
31:11
And then there are other patients who are like,
31:12
look, I don't wanna stop.
31:14
Mm-hmm. I want to use less. Mm-hmm. Or I wanna use safe.
31:16
It's like, great, let's, let me help you as best can, let's
31:20
Do that. That's interesting. Okay.
31:20
Yeah. Oh, no. We have plenty of patients who are like,
31:22
still actively using.
31:24
And so it's like all, well, what can we do to like,
31:28
prescribe in a way that keeps you safe?
31:30
And what, what are other harm reduction principles
31:32
that we need to help you utilize so
31:34
that even though you're still actively using
31:36
illicit substances, like mm-hmm.
31:38
Oh, you're gonna be here mm-hmm. Right.
31:39
Next week or the week after, so
31:41
that we can continue this battle together. So,
31:43
So like all of that stuff is just really, it's good
31:46
to, I don't know.
31:47
I guess it's good for me to hear loud
31:49
because like, imagine so fast forward a decade, I all
31:53
of those patients that were yours,
31:54
like now they're mine in the nursing homes, right?
31:57
So like, if you're 65 plus, you can't, uh,
32:02
you're not, you're still some like enough dysfunction
32:04
or weakness or whatever.
32:06
So you can't live on your own.
32:07
You have to be a skilled place.
32:09
There's they at this facility now
32:11
where every single thing is controlled
32:13
and there there's just, there's nobody
32:16
who knows really how to handle it.
32:17
There's no guidelines for it. And that's interesting.
32:20
And, and like a Norco five every, you know, say four hours,
32:24
maybe a max of Norco 10,
32:25
that's really all that they're gonna get.
32:27
Yeah. And so if they're, if they're going straight cold,
32:30
they're, they end up cold Turkey.
32:31
Right. Like straight from the hospital
32:33
where they're getting like IV morphine, you know,
32:35
from the street to the hospital for whatever reason.
32:37
And then to the, the sn f like, there's no, there's no
32:41
Bridging, there's no like taper.
32:42
That's awful. No.
32:43
And I had so many, um, pharmacies,
32:45
like say somebody's on a suboxone program.
32:47
Mm-hmm. They, they would, you know,
32:49
they have their usual dose,
32:50
but then they're not gonna get that
32:52
because the pharmacy, the, they would tell me,
32:55
I don't feel comfortable with this many MMAs.
32:58
I'm like, I'm sorry, what is your
33:00
Name? Yeah, no,
33:01
it's, it's really unfortunate.
33:02
And I don't, you know, we have, we have issues
33:04
with pharmacies and physicians sort of have their, um,
33:07
concepts of opioids and
33:09
It's Horrible. It is
33:10
horrible. And I get it.
33:11
Um, the problem is, a lot of pharmacies, they have to answer
33:14
to the DA and if they're prescribing a certain amount
33:17
of controlled substances versus
33:19
non-controlled, they can get hits.
33:20
People also have their own inherent biases
33:23
and they can treat patients a certain way.
33:26
I will say like, just sort of, kind
33:28
of touching back in on the,
33:29
the patient who's exiting the hospital on opioids
33:32
and having zero, um, like tapering nothing.
33:35
Right. So that's horrible. Yeah.
33:37
Like opioid withdrawal is
33:40
the way we're taught it is like, oh, it's a bad flu.
33:42
Like, you get the sniffles and you get like body aches
33:45
and goosebumps and you're gonna feel a little anxious.
33:48
That's b******t. Like every patient I've ever had,
33:51
describe me opioid withdrawals is it feels that you, like,
33:54
you cannot survive it.
33:56
It's, so, it feels like you're going to die.
33:58
And imagine having that feeling,
34:00
but also being post-op from a femur, right?
34:04
Mm-hmm. Like a, a femur surgery or something. Yep.
34:06
And you're 70 years old and you just got kicked out.
34:09
And, and that's my patients. Yeah. That's so sad. Mm-hmm.
34:12
It's so, so sad. Mm-hmm.
34:13
So that feels like bad medicine to me. So
34:16
It is so bad, and I don't know who can fix it.
34:19
'cause I feel like, yeah, I, I, I don't know.
34:23
I I'm one person. Yeah.
34:24
Oh yeah. Yeah. No, it's a systemic thing and mm-hmm.
34:27
Um, yeah.
34:28
I think, I think there just, I mean,
34:29
more conversations about what about opioids in general.
34:32
We kind of all, you know, we had this,
34:34
the huge opioid epidemic, which we're still sort
34:36
of on the tail end of a whole other one. I feel
34:38
Like it's not over at all.
34:39
No. I don't know that it ever, we're in a whole other one
34:41
now, like with the fentanyl era and all that.
34:43
Mm-hmm. But like, you know, the pharmaceutical company,
34:45
the medical community played this huge role in the
34:47
opioid epidemic.
34:49
And I honestly feel like we sw swung
34:52
too far in the other correction.
34:53
Totally. And too many doctors got very scared of the d
34:56
So now they're like, pa neglectful.
34:57
Right? They're like, sorry, I
34:58
can't, you just have to look away. I can't do that. There
35:01
Are many, many practitioners, doctors mm-hmm.
35:04
Um, NPS PAs who just draw a line in the sand
35:07
and say, I do not prescribe these medications.
35:10
Yep. Again, that's crazy. 'cause we don't do that.
35:12
Imagine any physician who's like, Hey,
35:14
I don't prescribe metformin.
35:15
I don't prescribe stat. Like, period. That's like,
35:17
It feels so unethical your job.
35:19
Yeah, it does. Yeah. But what is it that you do?
35:20
Yeah. So, yeah. Yep.
35:22
It's like, and, and I think it's good for all of us
35:24
to have a healthy appreciation for the risk associated
35:27
with opioids, but it doesn't mean that
35:29
They're often, you can't just abandon. Right?
35:30
No, absolutely not. I think that's bad. Yeah.
35:32
That's bad medicine. Every, every medicine we prescribe,
35:35
every intervention we enact, like has risk and benefits.
35:39
Mm-hmm. And like, you have to weigh those
35:41
and have those conversations with the patients.
35:43
But like, taking something off the table completely just
35:46
feels like a bad idea.
35:47
So Yeah. I feel like PMR doctors do pretty good. Yeah.
35:50
I actually got to work with them at, um, acute rehab. Yeah.
35:53
Palliative hospital also do palliative
35:55
docs are where it's at. Those guys
35:57
Are so good. Yeah. Yeah.
35:58
I got to work with one of, um, one of our, uh,
36:03
um, attendings as well.
36:05
Really? Yeah. Yeah. Learned a lot of good little tricks.
36:08
You should, uh, at some point, if you ever get the chance,
36:10
you should have a conversation with, uh,
36:11
Rishi Patel, Dr. Patel. Oh, I
36:13
Would love to. Yeah. He's
36:14
a palliative doc.
36:15
Street medicine. I wanna be better at it.
36:17
He's so good. He's, he's a good dude, good human,
36:19
and like really good advocate for his patients.
36:22
I would love that. I mean, I feel like, um,
36:24
I don't know if it was, uh, PMR or palliative,
36:26
but I learned, you know, like four fentanyl patches.
36:28
Mm-hmm. You know, 'cause it does get kind
36:30
of like crazy if you're chasing pain
36:32
and you've got like the short acting
36:34
and the long acting pain control
36:36
and then, you know, your pain's still not under control
36:38
and you can't do IV based on the setting.
36:41
Um, and then so fentanyl patches were pretty good option
36:46
for a lot of people, but you have to have a little,
36:48
you know, chubbiness to you.
36:49
Yeah. Yeah. Oh, that's a problem. Yeah.
36:51
One of the problem with fentanyl, um, yeah.
36:53
Chronic pain's a difficult one.
36:55
And the problem, you know, opioids in chronic pain, again,
36:59
they are necessary for many patients.
37:02
And I think, uh, many patients
37:04
need to be treated with opioids.
37:06
And I'm, I'm very happy that we have those as an option.
37:08
Again, it's not to say they don't have their downside.
37:11
One of the ones that sort of I always butt heads
37:13
with in the pain world is the hyperalgesia.
37:16
Mm. The patients who have been on opioids for a long time
37:19
and now they're like hypersensitive to pain stimuli.
37:22
And it's really unfortunate.
37:24
'cause that's a very difficult thing to combat.
37:26
You can't just take 'em,
37:28
It's like a sensory Yeah. Increased sensory
37:30
Like hypersensitive.
37:31
Yeah. So then things
37:33
that would normally like not hurt them become mm-hmm.
37:35
Very like, you know, like a nice little like mm-hmm.
37:37
Someone just kind of socking, Hey man,
37:38
how you been becomes exquisitely painful.
37:41
Mm-hmm. And so, and then every, like,
37:43
every pain stimuli just becomes sort of amplified.
37:46
They're more sensitive to it when they've
37:47
been on opiates for a long time.
37:49
It's like, yeah, well, you can't just stop opioids.
37:51
So then you have to, that's one
37:52
of the nice things about buprenorphine as a whole, is
37:55
that you don't typically get that hyperalgesia effect.
37:58
So if someone's on long-term buprenorphine, oh, that's good
37:59
to know for pain, then you don't get that effect typically.
38:03
Okay. The downside is like, buprenorphine
38:06
as a pain medicine hasn't proven
38:08
amazing, you know what I mean? It hasn't been like this.
38:10
Is it like a bandaid or like
38:12
No, I mean, bandaids are great overall,
38:14
but I mean, no, just like umaid, it's just not as powerful.
38:18
Right? Yeah. It's just not as like, um,
38:19
you're not gonna get the same level of, of, uh,
38:21
pain relief mm-hmm.
38:23
With, with say like a Suboxone mm-hmm.
38:25
Or belbuca as you would with like a Percocet or something.
38:28
Mm-hmm. But that, that being said, there are plenty
38:31
of patients who are on buprenorphine for pain mm-hmm.
38:34
Long term. And it, you know,
38:36
that they're doing really, really well.
38:37
And, and I think in Europe, they're much more likely
38:40
to start patients on buprenorphine than they will on other
38:43
full agonist opioids.
38:44
So there's just room in the US for us
38:46
to be a little bit better about it.
38:47
Oh, I know. And really, I think that's like a,
38:49
along the lines of the podcast, um, you know,
38:53
what, what are we doing well?
38:55
Where is the space to improve?
38:56
Because I mean, I just can't accept that.
38:58
Like, we've nailed it in every category.
39:01
Which category did we nail?
39:02
See? Yeah, you reacted, right? Yeah.
39:04
No, so like, I feel like I, we should be able to say that.
39:06
Like, where can we improve and like, let's try to do better.
39:09
And it's, it's more than just like academia.
39:13
It needs to be like, on our side too,
39:14
like in real life for real time.
39:16
Yeah. There's not all this evidence to support it,
39:19
but we know that we can do better
39:20
and it's like we have to try, like where's the time
39:24
and space to make that shift? Yeah,
39:26
I agree with that wholeheartedly.
39:27
Yeah. There's tons and tons of room for improvement.
39:30
I think the numbers would show it, uh, as well,
39:32
But Oh, yeah. Yeah.
39:33
Because I mean, I, I see suffering every day.
39:36
And so like, uh, I don't know.
39:39
I just, it getting old looks horrible.
39:42
I'm so sorry. You feel that? I don't feel
39:43
that way at all. I mean, feel Well 'cause you're not,
39:44
You're not old yet.
39:46
I'm, I think I'm older than you by
39:48
Pretty good. You're
39:49
older than well, I don't know.
39:50
Yeah. I'm 46. Okay. I'm 42. Yeah.
39:52
I'm older than you, but I'm talking like eighties.
39:54
Yeah, I mean, that's fair.
39:56
Like, you know, I, I sort of watching my, um,
39:59
my grandparents sort of in the, you know, the last decade
40:04
or so I would imagine of their lives.
40:05
Mm-hmm. And it is really, really, really tragic.
40:09
It's to sort see the amount of suffering Yeah.
40:12
Day to day, especially with like cognitive decline
40:15
and that that's huge.
40:16
Not having insight into your own, like,
40:19
what's going on, right.
40:20
It's like things are happening in my body and in my mind,
40:24
but my mind is not capable of understanding those things
40:27
and how frustrating that is and how
40:29
Yeah. So, so inflammation
40:30
is said to be behind a lot of that,
40:33
like Alzheimer's dementia.
40:34
So that's a lot of what I'm really Oh, interesting.
40:37
Diving into, um, I can,
40:39
so there's a skin test that you can do.
40:41
I haven't done any yet, but I just learned about it.
40:44
You can, um, really profile Alzheimer's by a bunch
40:47
of the different proteins.
40:49
Oh, interesting. Um, there's blood tests that I, you know,
40:52
that I do currently order to look
40:54
for different proteins in the blood for Alzheimer markers.
40:58
Um, you know, like the A p oe
40:59
and there's, uh, a bunch of other things.
41:01
Um, we don't go as wild as like getting CSF fluid, but Yeah.
41:05
That's pretty Invasive. Yeah. We don't go. Yeah.
41:08
I mean, I'm sure some patients would, but like we, we Right.
41:11
We wouldn't. Um,
41:12
but still there there's profiles that you can, um,
41:14
biomarkers that you can look for in the cash pay world,
41:17
where it's like, if money is not the issue,
41:20
then let's look for it.
41:22
So, so now we know that like the science is there to find
41:26
and diagnose anything.
41:27
Mm-hmm. Can you treat it well? It depends on the cause.
41:30
Yeah. So, um, you know, like it's just, it's, there's
41:33
so much that, um, I'm obsessed with it.
41:36
That's kinda the direction. That's good.
41:38
You know, that I want to be like, like, uh,
41:41
Alzheimer's dementia, it tends to start in the forties.
41:44
You're, you're in your forties
41:46
and they're just kind of trending it, you know,
41:48
and all these studies and it's so preventable.
41:52
So That's crazy. It is. They're finding, yeah.
41:54
This is news to me. Yeah.
41:55
All of these like, uh, neurofibrillary tingles,
41:57
they're just found in the brains
41:59
and they're finding these on these scans in the studies, so
42:02
That's wild. Yeah.
42:03
Well, at least we're doing that, right.
42:05
At least we're still like for now, um, doing, um,
42:08
pretty good research out there. So,
42:10
Quick question. Yeah. Because
42:11
I know we're almost outta time, um,
42:13
on the premise of, uh, like addiction medicine and,
42:17
and everything like addiction related, that area
42:20
of the brain that registers addiction.
42:22
Um, even something as simple as like food
42:25
or, um, or smoking.
42:27
Like, do you think it's okay
42:30
and do you agree with the principle that you can,
42:32
you're just, you're substituting a lesser evil
42:34
for, for something else?
42:36
Like the addiction part of the brain is still active mm-hmm.
42:40
But you have to take away something
42:42
that creates a dysfunction in the personal
42:44
or professional life, so you're substituting
42:47
Yeah. I mean, I,
42:48
Is it still an active sight?
42:49
So I think the way I view addiction, I think,
42:52
I think the most accurate view to take on addiction is
42:56
that it is a very nuanced, complicated multifocal, um,
43:01
neuro biological, uh, illness, chronic disease that's so
43:05
Proper Re relapsing and remitting disease.
43:08
The, the simple way I like
43:10
to think about is the way we've sort
43:11
of always been taught is, you know, environment plus
43:16
or minus bad choices equals addiction.
43:19
And the real reality is like having a better understanding
43:22
of the neurology, neurobiology of the genetics is
43:26
that it's actually incredibly complicated.
43:27
And that, that equation is really like genetics
43:32
and, uh, environment and socioeconomic status
43:35
and childhood trauma and like a myriad of things.
43:39
Choices are a part of that. Mm-hmm. Whole equation.
43:41
But it's one part of many, many, many,
43:45
and that's what equals addiction.
43:46
We like to focus on like, hey, the choices need to
43:50
Be, we wanna simplify it into one bucket.
43:51
Right. We like, what we like to do is say like,
43:53
this is your fault because you made choices.
43:55
Yeah. But that's not accurate.
43:56
And it's, I think it's the world could benefit from seeing
44:00
addiction as a more nuanced does.
44:02
And it's the same with like thing about diabetes.
44:04
It's like, yes, your dietary choices play a role in that,
44:08
but so do your gen genetic like massively.
44:10
Yeah. Your genetics play a role in that. Yep.
44:12
And your, your your where how you were raised as a child.
44:15
Like it's not just as simple as one thing. Yeah.
44:17
And so that's how I view, um, that's very helpful.
44:20
Addiction as a whole. I don't know if that sort of fits No.
44:22
Answer that question. No, it's complex and,
44:23
and I think we need to do a lot more work to,
44:26
to address it from multiple different points.
44:28
Yeah, I agree. Angles. Yeah. Yeah. You gotta attack
44:30
All those things. Well, thank you
44:31
so much Dr. Bear. No, thank you.
44:33
You're such a champion. Enjoyed, I
44:34
enjoyed, I was so impressed.
44:35
Yeah. You are an example of success
44:37
and I just am so like, I'm grateful.
44:40
Yeah. Thank to have you on. I'm so fun to be here.
44:42
Thank you. Until next time. Yeah. Thanks. Ah.