In this episode of Healthcare Americana, Christopher Habig interviews Dr. Joshua Lee, Chief Clinical Advisor at Oar Health and a professor at NYU Grossman School of Medicine. Dr. Lee discusses his journey into addiction medicine and how it evolved throughout his career. He highlights the importance of making addiction treatment accessible and the role of medications like naltrexone in addressing alcohol addiction.

Dr. Lee also addresses the stigmas associated with addiction care and provides insights into the demographic patterns of those seeking help. Oar Health's approach to addiction treatment and its customer base are explored, shedding light on the changing landscape of addiction treatment and the challenges faced by diverse communities in the United States.

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[INTRODUCTION]

[EPISODE]

One of discourages of our society, especially from a healthcare standpoint is addiction. Americans love the old saying, "Better life through chemistry." Too many times, that is choosing the wrong chemistry to improve their lives. Addiction, it affects so many different people in so many different ways. And shame on evolution for giving us the ability to become addicted to so many different things throughout the course of our life.

Today's episode, we're focusing on alcohol addiction. Alcohol is one of those things that changes our brain chemistry, does a lot of different things to us. So to help us through this conversation, and to pride his expertise on this episode of Healthcare Americana, please welcome Dr. Joshua Lee, Chief Clinical Advisor at Oar Health, and Professor in the Department of Population Health and Department of Medicine at NYU Grossman School of Medicine. Dr. Lee, thank you for joining us here on Healthcare Americana to talk addiction.

It's tougher with stimulant addiction, other behavioral addictions. This can crossover to eating disorders, which is extremely complicated. I don't treat that, but that's where – that's kind of the fringe of kind of what I do, which is helping people with some type of compulsive disorder, where the alcohol can't be stopped. They would like to stop it. Despite kind of their conscious knowledge that it would be better for them not to drink, they're unable to. That's the definition of addiction. Kind of repeated use of something that's harming you, or repeated use despite harms that are obvious to you and other people.

Then, as you say, you could fit a lot of activities, behaviors, or substances into that. Keep doing this despite harm. Clearly, alcohol is one of the most common reasons people seek help for, die prematurely, get liver transplants, pressure cars, all the other societal and individual ill effects of alcohol. Yet, a lot of us use it and try and use it responsibly. Arguably, healthfully, you can have that debate too, whether any alcohol is healthy metabolically a little bit.

Say, the Mediterranean diet, red wine with dinner. There's a lot of good new evidence that that is probably isn't the case like any alcohol is mostly helping you accrue harm. Yet, I personally, I use alcohol. So there's something to be gained from it still, and this is despite what I do for work, and my knowledge as a physician, still enjoying using alcohol, hopefully in moderation. Because it's such an age-old substance, and our whole society is built around it in many ways. It's key to fine dining, all that kind of stuff. There's a lot of reasons you can still enjoy it, and not consider yourself addicted. So it's an interesting subject to talk about from that matter.

Then, what is addiction medicine? That to me is kind of practically what can we tell all the doctors at the med school in your family practice residency, in the emergency room, and all sorts of different settings. How can we help our patients in that next patient encounter, what can we do that's practical, safe, effective? There's a lot again for smoking opiates and alcohol. The impetus of addiction medicine is a relatively new board-certified subspecialty, is that we can be experts in it, but that we can all take part and do it. That's a little different than tradition of addiction psychiatry, which was a pretty narrow set of fellowships, and not too many experts graduated per year. That was the original kind of home of addiction treatment, in a medical school or across your country medical society of who's treating addiction. I came from psychiatry, and then narrow band of people within psychiatry, addiction psychiatry.

Nothing against addiction psychiatry, but it wasn't inclusive of all these other specialties, doctor settings, general practice settings, especially where we could be doing a ton about somebody's alcohol use. They may never get to the specialty drug and alcohol treatment center down the road or one county over. But right here, now, in the ED, or in the family practice office, we could start doing something about that, and that's really what addiction medicine is.

I've always been fascinated because I think alcohol is one of those things where people are free to express, there is a dependency on it, but people shy away from the word addiction. In your mind, is there any difference being dependent on a chemical versus being addicted to that chemical?

But most people taking benzodiazepine prescribed by their physician are not addicted to it. There is an important distinction, even though some of those people are physically dependent on it, and will have ill effects if they abruptly stop it. There'd be some type of withdrawal or rebound effect.

But the question is, why? Why is it that we put ourselves into these situations where we're triggered, and that's where we need the drink, right? Or that's where we need to have this thing. What is happening within our brains from what you see that makes us act that way?

You want to be praised, you want to get paid for your success. There's reasons we work hard and do long-term planning, and that has to do with rewards and eventual pay offs. That same reward system deep in our brain momentarily can be kind of hijacked by drugs and alcohol, that wasn't necessarily in the landscape we're born into. But if we discover it, our brain really, really, really, really likes it, out of proportion to other things we're experiencing kind of day to day.

Then, again, think of like rat models, where we have really good animal models for addiction. Because you can, in a lab, get an animal hooked on substance A, cocaine, methamphetamine, alcohol, nicotine. And it will prefer that and hit the lever in opposition to other stuff that you used to like, like food, water, et cetera. It's just random. Why was that one molecule that you gave the rat that much more attractive to the rat. It just hit the right buttons.

Most things that you would try off the shelf in a pharmacy would not do that. But something's due, and then you've got kind of a winner so to speak, in terms of a compound with addiction potential. So if you're trial and error over eons, alcohol that keeps doing it to people, nicotine, caffeine, et cetera, et cetera. You could even get into like overly sugary, fatty, salty food. There's a reason that junk food is junkie. That's more like desirable in the moment to a lot of consumers, even though that's not necessarily good for you or good food.

It's just kind of chance and it's random how we kind of evolve on earth, and how we're experiencing our environment. I think the usual teaching is that it came from a survival mechanism, which is, how would you learn what is good for you through kind of experience: touching, feeling, tasting. Your brain had to have some way of kind of reinforcing what it was going to take to keep going, thrive, survive.

Then in the case of addiction in something like alcohol, it just does a bit too much. For some of us, we are programmed to like it too much, so there is genetic susceptibility variations. We don't have it down to like, "This is the alcohol gene." There's probably hundreds of candidates and it's a complex epigenetics story. But for sure, if you for instance have a family history of sever alcohol use disorder in first-degree relatives, you're more at risk for that yourself.

Then, environment, like when did you experience alcohol for the first time, and what was the context, and was it normalized to drink heavily when you're an emerging adult, versus later in life, where you just became a football fan. "Yeah, I go to these tailgates, and people drink a lot. That was new to me, so I don't – sometimes I'm into it, sometimes I'm not." Versus, "I have been tailgating my whole life. I was raised as a seven-year-old to chug beer at a tailgate." That's very different, probably impacts on that person long-term. Even if genetically those people are exactly the same. There's the whole chicken or egg, and genes versus environment to talk about.

Alcohol is so prevalent that everyone eventually is usually, in a country like United States, exposed to it. But later versus early exposure, and then kind of other social pressures and contacts probably also matters a lot in terms of what people develop in and stick with, and then what becomes a problem for person A versus person B.

It could also be, "I would like to do something I haven't been able to. I think I drink too much. I want to – it's something I want to talk about now with my health care provider, and whatever the next encounter is. Hopefully, that's a way to get good advice and help." Interestingly, alcohol, another good example, a lot of people never get help. They don't all die of drinking or suffer throughout their older age and last decades with a drinking problem. People can naturally make choices. We probably all have a friend who used to smoke cigarettes, and then quit, and didn't do it with any fancy Chantix, plus a patch, plus the gum, and an app. All of which is available and may boost your chances for quitting smoking. But they did it on their own, they did it kind of when they were sick of, and they did it for their own reasons. That's not an unusual story, nor with alcohol, where people have just kind of toned it down as they get older. They got tired of being tired. That kind of sloganeering, but it does happen.

It will happen at greater numbers and with higher probability if people are getting the interventions we have, but it's not to say, people can't kind of self-cure, or sometimes we say it burns out. It's not necessarily a forever state once you're in it. But it is the whole problem with the disorders, it's hard to change it yourself. That's one of the criterias, and what people really struggle with.

That where I just find it so fascinating, because you got this trigger, you got the actions, you got some kind of reward there. Even if that reward is so detrimental to our physical wellbeing, our brain still processes it, just like that cycle.

Again, back to like evolution and how our brains are set up. So then you learn that that rewarding first impulse becomes a kind of learning network. As you say, you can remember it then, you can remember how you got into it, how you accessed it, where you go to get it. It would make sense that we would want to repeat pleasurable experiences over and over.

It's only later that it's like, "Oh, yeah, but that much alcohol is hurting my liver. That much alcohol means I can't lose weight. I keep driving despite all that alcohol." Your brain has to work a little harder to say, "That's not rewarding." Because in the immediate aftermath of a drink, you can still experience the reward. That makes sense that your brain would want to keep doing it.

The opportunity is that, there's not enough of mes or folks that have heard this podcast, and then treat patients differently. There's not enough docs prescribing what we know works for smoking opiates and alcohol. That is something I've spent my career, I'll write a paper that says, "Hey, colleagues, let's prescribe more to help people quit." Who knows if anyone reads that paper? But that's like academic medicine for you.

I was not a PR professional. I was not working on a national campaign to get people on more treatment. It's just like outside of my own little individual narrow neighborhood. But the idea with Oar is that, "Well, we'll do it. We'll take that as an opportunity. We'll advertise on the radio. We'll do Google search ads. We'll find the patient somewhere, or the individual who is struggling with alcohol." It could be a wide spectrum of really severely ill, to, "No, I should do something about it, but just haven't been able to." All of whom are probably eligible for a trial with naltrexone to help temp down the drinking, suppress cravings, help them drink not at all or drink less.

It's a generic non-controlled substance. Naltrexone is an opiate blocker at the mu-opioid receptor in our brain. So it's a brain drug, but that somehow works with a lot of people with an alcohol use disorder. Helps to not find alcohol as rewarding in the moment, and then long-term, as a kind of relapse prevention, maintenance medication. It's something you could put into this new batch of companies that do kind of direct-to-consumer pharmaceuticals like ED drugs, like hair loss, like all the stuff you've gotten a pop-up ad for in terms of a medication that is not that ad, it's not from your local doctor, someone you already have a relationship with. It's from a company that is going to essentially do a kind of out-of-pocket medical telemedicine treatment episode, and in the mail, you're going to get a prescription and medication.

That's what Oar is doing, and it's working. We're not setting the world on fire, if you've never heard of us, stuff like that. But we founded a pretty solid, month to month, like growing and state by state. Finally, we're able to help many people at this point in a simple and quite streamline business in terms of targeting. One condition with one medication, so we're not trying to be a comprehensive care solution. We can't send you to rehab, we can't switch you to the third medication. So it's really quite simple, but that's what we have started with at least, and that's what's been working for us so far.

[BREAK]

[INTERVIEW CONTINUES]

I was interested in though, kind of public health policy, reading and writing. That kind of steered me towards academics for say, just like full-time private practice. In med school, I was interested in psychiatry, I like that a lot, and general medicine, family practice as well. So I was thinking kind of GP, or psychiatry versus a surgery, ED, obstetrics.

I did a primary care tract, internal medicine residency, and that of course is focused more on out-patient medicine. It also has these blocks, at the one I did at NYU on epidemiology, health policy, and what we call psychosocial medicine. But there was quite a bit of a tension there to addiction, treating addiction, smoking opiates, alcohol. But there was no such field as addiction medicine but you could get a credential after residency, a certificate essentially from the American Society of Addiction Medicine.

There was a national organization, there was kind of people I was getting to know that were internist, or family medicine, but the worked in the addiction space as we were saying upfront formally, mostly a psychiatry-driven field. But you could work at a methadone clinic if you're a family doc, let's say. Then in fellowship, I started kind of research-focused fellowship, but I was thinking about hepatitis C, and I was working a lot in the New York City jails at that time. In jail medicine, there's chronic disease, there's acute injuries and other problems. There's a lot of mental health burden, and there's a ton of addiction. Opiate addiction in New York City, in particular, along with stimulants is something we thought about a lot on the jail side.

Then as faculty, I was kind of hired to build out more addiction at my institution. Then on the research side, started doing clinical trials that were focused on opiate and alcohol addiction with medications. Exactly kind of what we're talking about today. That, I liked it, and I wanted to do more of it. I grew with it, and it became a career. I think I could have gone in many different ways, but that's just how it settled out. Then the advisory, and helping a company grow, that's completely new to me. I'm just learning as we go. I'm not myself a start-up person or a biotech entrepreneur. I'm not an entrepreneur in the healthcare or kind of behavioral health addiction. I've been very much kind of traditional sitting there in my office at NYU, and working at Bellevue Hospital.

But it's been super exciting to do a little of that in the last 10, 15 years with a couple of companies, and then Oar is the deepest involvement I've had, and it's the most practical. We know we got eight solution, it's not for everyone, it's not going to work long-term for everyone, but everyone should give this a shot. There's a lot of area under the curve in terms of helping people along the way with oral naltrexone, and making that kind of this approachable, simple, private, affordable as possible has been a lot of fun. That's kind of what I see as lacking in a lot of our healthcare space. Why can't we just keep the essential, but get away with like, it's going to take you three hours to go to the doctor, or you may not get at your next appointment for another six months.

All this kind of stuff, we actually experience as healthcare patients and consumers, which are super annoying and it takes a lot of time. You got to be really on the ball, scheduling all your own stuff at this point as the patient. But with this approach, it's like, all right, this is a problem, this is a solution. This part, at least, we're going to push button and we're going to start that and it doesn't stop until you think it's not working.

There are some side effects, here they are. Like you might have a little bit of tummy trouble, or kind of loss of appetite, and flew-like symptoms when you first start naltrexone, and we'll want you to know that, and talk about it upfront, but we think it works. I'm not here kind of selling you snake oil. The reason I'm talking about these particular treatments are, we think we have compelling experience, patients before you, programs where other people are doing the same stuff and it's working for them. Then of course, clinical trials from wherever that indicate, this is something we should be spending our time.

Then, do you still want to talk about it? That's not going to convince everybody. The irony can be something like – one really interesting part of what we do now is vaping, so e-cigarettes. I'm not talking about cannabis; I'm talking about nicotine. That's gotten a lot of negative attention obviously when middle schools have a lot of kids running around vaping. For an adult smoker, it does look like a really successful way to smoke less or to quit smoking. It's not FDA approved as such in the United States. It has more of approval status in the UK and parts of Europe.

But I'll talk to my patients about vaping, and they'll have those same questions, like, "I don't know. What's in that fluid? It was made in China. I've read it can really mess you up." And you're talking to someone who's smoking two packs a day, you're like, "What? What do you think you're getting out of two packs a day of cigarette? You're tying yourself to an exhaust pipe every day of your life. That's not good for you. You know that." "Okay. Maybe the vaping, maybe we got to talk about the gum, or the patch, or the Chantix."

Just trying to be grounded in what's happening to you now is really not good for your health. We have these healthier choices, and you're trying to present multiple options of course, and these are like motivational interviewing. And then just see what the patient is going to willing to consider, able to sign up for. You don't get too super pushy, and you're not disappointed when people don't choose what you think is tier one, and they go for tier four. Like, "Okay. We'll come back to that discussion next time we talk," that kind of thing. I mean, that's how I deal with it in a real time, like patient interview in my office. It's what you would like to sit there and talk about with people for a long time. You don't always have time, of course, and then many people are never getting to the point where they're talking to a medical professional at that level. And that's another kind of real gap that people just don't get any teaching ever about the stuff, and they go through it largely alone.

The women vs men is interesting. Probably nationally, men still have a higher burden and drink more in terms of consumption, and then the prevalence of alcohol use disorder. But one of our – and we've known this really to kick in since COVID, drinking rates, and drinking problems, liver transplant, tests related to alcohol among women have really been accelerating faster than in men, and that's quite troubling. As traditionally in the United States, in our culture, women drink less, men drink more. That's more normalizing, but it's producing a lot of negative consequences for women.

But now, fentanyl is everywhere, alcohol is obviously everywhere. There's no lack of nicotine and smoking products. If anything I think in my career, especially thinking about opiates, and how there was a pill problem, like at this high school, but then this one didn't have it, and then this one was closer to like inner city Philadelphia, and there was some heroine there. It's kind of all over now. I'm originally from Tennessee, and there was no heroine in Tennessee, and there certainly wasn't anything like fentanyl, which is now contaminating most heroine in the United States.

But pretty much in any country, rural, suburban, urban in a state like Tennessee, there's now the availability of heroin, heroine/fentanyl. Illegally, illicitly manufactured, and distributed fentanyl, and fentanyl like analogs. That's driving the opiate overdose rates that we're dealing with year in, year out. It's become kind of a fentanyl epidemic. That's like totally new, totally different, and we would have not necessarily predicted that 30 years ago based on like Tennessee versus Rhode Island, let's say. But now, they've started to look more and more similar, kind of county by county, and state by state, red versus blue, north versus south, east-west. And that just means, in a sense like culture and people's experiences got more similar than different.

Again, back to like, well, we grow up on our phones, and we watch the same TV, and we go to the same chain restaurants. It's not hard to believe then, that like, whatever was working in Iowa will quickly get exported to Nebraska, and then down to Georgia. In terms of the illegal drug markets, that seems to be the case, especially with opiates. You see more disparity, and dissimilarity with stimulants. Methamphetamine versus cocaine, cracked cocaine versus powder from different parts of the country. That does not seem to be kind of equally available, or used in the same way everywhere. But I would say, with alcohol and adults, and then teens at risk, and then emerging adults, like college age, and kids just entering the work force. People generally have the same stuff going on state by state with alcohol.

[OUTRO]

[END]