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Something for the Pain

Something for the Pain - ECHO Idaho Podcast artwork

Listen to recorded lectures from ECHO Idaho’s substance use disorder education series archives and interviews with Valley County subject matter experts to find out the latest trends, best-practices and existing resources for opioid and substance use disorder prevention, treatment and recovery in Idaho.

Whether you work in healthcare and want to claim continuing education credit or live in Idaho and want to educate yourself about opioid and substance use disorder treatment, Something for the Pain has a little something for everybody.

Claim Continuing Education (CE)

Something for the Pain is considered an enduring material jointly by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC).

ECHO Idaho uses eeds software to manage our continuing education (CE). To claim CE for listening to an episode of Something for the Pain, please navigate to the eeds website.

Questions? Email us at wwami-ce@uidaho.edu, or call Karley Kline at (208) 364-9910.

Episode 9 – LaDessa Foster Talks Managing Clinical Services for Patients and Providers

Featuring: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise

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Featuring: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise

Didactic Presentation Details

  • N/A

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Cathy Oliphant, PharmD, College of Pharmacy Chair, Idaho State University, Pocatello
  • Speaker: Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC
  • Speaker: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project, Boise
  • Speaker: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 8 – Marjorie Wilson Talks Idaho's Syringe Exchange Programs

Featuring: Marjorie Wilson, LMSW, MPH, Executive Director of the Idaho Harm Reduction Project and Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier

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Featuring: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project

Didactic Presentation Details

  • Didactic Presenter: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project, Boise
  • Didactic Presentation Title: “Needle Exchange and Harm Reduction in Idaho”
  • Didactic Presentation Date:  10 June 2021
  • ECHO Idaho Series: Opioids, Pain and Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Courtney Boyce, Health Education Specialist Senior and Drug Overdose Prevention Project Coordinator, Central District Health
  • Speaker: Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier / Cache Valley Community Health Center in North Logan, Utah
  • Speaker: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project, Boise
  • Speaker: Amber Peace, Latah Recovery Center, ECHO Participant
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Lachelle Smith, Program Director, ECHO Idaho
  • Speaker: Camille Evans, ECHO Participant
  • Speaker: Randi Pedersen, MPH, Program Manager, Idaho Department of Health and Welfare, ECHO Participant
  • Speaker: Cathy Oliphant, PharmD, Pharmacist, Professor and Co-Chair, ISU College of Pharmacy
  • Speaker: Megan Gomeza, ECHO Participant
  • Speaker: Rachael Bazzett, Idaho Harm Reduction Project, Sexual and Reproductive Health Program Manager
  • Speaker: Amy Jeppesen, LCSW, ACADC, Behavioral Health Director, Trivium Life Services, Boise
  • Speaker: Annie Hawkins, ECHO participant
  • Speaker: Jacob Harris, MD, Psychiatry and Addiction Medicine Specialist, Boise VA

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 7 – Monica Forbes Talks SMART Recovery, Stigma, and Reentering Society Post-Incarceration

Featuring: Monica Forbes, Nationally Certified Peer Recovery Support Specialist / Certified Peer Recovery Coach - Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC

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Featuring Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC

Didactic Presentation Details

  • N/A

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Lindsay Brown, CPRC-Supervisor, CPSS, Lead Recovery Coach, Peer Recovery Supports of Idaho, LLC
  • Speaker: Radha Sadacharan, MD, MPH, Primary Care Physician/ MAT Provider, VA Medical Center, Boise
  • Speaker: Skip Clapp, Director of Valley County Court Services
  • Speaker: Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 6 – LaDessa Foster Talks Levels of Care in Substance Use Disorder Treatment

Featuring: Ladessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health and Craig Lodis, PhD, Psychologist, VA Medical Center, Boise

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Featuring LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise 

Didactic Presentation Details

  • Didactic Presenter: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise
  • Didactic Presentation Title: “Levels of Care in Addiction Treatment, Pt I”
  • Didactic Presentation Date: Feb. 4, 2021
  • ECHO Idaho Series: Counseling Techniques for Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise
  • Speaker: Radha Sadacharan, MD, MPH, Primary Care Physician/ MAT Provider, VA Medical Center, Boise
  • Speaker: Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC
  • Speaker: Katy Palmer, Assistant Director, ECHO Idaho, Boise
  • Speaker: Craig Lodis, PhD, Psychologist, VA Medical Center, Boise

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 5 – Motivational Interviewing and Donnelly's The Change Clinic

Featuring: Debbie Thomas, CADC, LPC, CEO of The Walker Center, Gooding, ID; Barbara Norton, LMSW, Program Director of the Change Clinic, Donnelly, ID 

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Featuring Deborah Thomas, CADC, LPC, CEO of the Walker Center, Gooding, ID & Barbara Norton, LMSW, Program Director at The Change Clinic, Donnelly, ID

Didactic Presentation Details

  • Didactic Presenter: Deborah Thomas, CADC, LPC, CEO of the Walker Center, Gooding, ID
  • Didactic Presentation Title: “Motivational Interviewing”
  • Didactic Presentation Date: June 13, 2019 
  • ECHO Idaho Series: Opioid Addiction and Treatment
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Interview Details

  • Interviewee: Barbara Norton, LMSW, Program Director, The Change Clinic, Donnelly, ID

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier
  • Speaker: Skip Clapp, Director of Court Services, Valley County
  • Speaker: Deborah Thomas, CADC, LPC, CEO of the Walker Center, Gooding
  • Speaker: Lachelle Smith, ECHO Idaho Program Director
  • Speaker: Lachelle Smith, Director, ECHO Idaho
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services, Boise
  • Speaker: Patrice Burgess, ECHO participant
  • Speaker: RJ, ECHO participant

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 4 – Harm Reduction and the Valley County Opioid Response Project

Featuring: Brenda Hoyt, APRN; Shelly Hitt and Courtney Boyce

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Featuring Brenda Hoyt, APRN

Didactic Presentation Details

Resources and Publications Mentioned

Interview Details

  • Interviewee: Skip Clapp, Director of Court Services, Valley County

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Abbey Abbondondalo, Security Director, St. Luke’s Health System, Boise
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services
  • Speaker: Cathy Oliphant, Pharm D, College of Pharmacy Chair, Idaho State University, Pocatello 
  • Speaker: Brenda Hoyt, APRN, NP, Raise the Bottom, Boise
  • Speaker: Skip Clapp, Director of Court Services, Valley County
  • Speaker: Lachelle Smith, Director, ECHO Idaho
  • Speaker: Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier 
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Shelly Hitt, Valley County Opioid Response Project Coordinator, Central District Health
  • Speaker: Courtney Boyce, Health Education Specialist Senior and Drug Overdose Prevention Project Coordinator, Central District Health

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 3 – Deescalation Techniques and the Valley County Court Services' Diversion Program

Featuring: Abbey Abbondondalo, St. Lukes Security Director and Skip Clapp, Valley County Court Services Director

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Didactic Presentation Details

  • Didactic Presenter: Abby Abbondondalo, Security Director, St. Luke’s Health System
  • Didactic Presentation Title: “Deescalation”
  • Didactic Presentation Date: April 15, 2020
  • ECHO Idaho Series: Behavioral Health in Primary Care
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Interview Details

  • Interviewee: Skip Clapp, Director of Court Services, Valley County

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services, Boise
  • Speaker: Jeff Seegmiller, WWAMI Medical Education Program Director
  • Speaker: Abbey Abbondondalo, Director of Security, St. Luke’s Health System
  • Speaker: Radha Sadacharan, MD, MAT Provider, Boise VA Medical Center
  • Speaker: Lachelle Smith, ECHO Idaho Program Director
  • Speaker: Skip Clapp, Director of Valley County Court Services

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Other Acknowledgements

  • This Episode was reviewed for content by Jeremy Stockett, LCSW, Social Worker, St. Luke’s Psychiatric Wellness Services

Bonus Episode – Project ECHO Origin Story & The Vandal Theory

Featuring: ECHO Program Founder Sanjeev Arora, MD and ECHO Idaho Director, Lachelle Smith

This episode is not eligible for CE credit.

*This episode is not eligible for CE credit

ECHO Idaho Session Details

  • Featured Speakers:
    • Lachelle Smith, Program Director, ECHO Idaho, Boise
    • Sanjeev Arora, MD, MACP, FACG, ECHO Founder and Director, University of New Mexico
    • Terry Box, MD, Associate Professor, University of Utah
    • Magni Hamso, MD, MPH, Medical Director, Division of Medicaid, Idaho Department of Health and Welfare
    • Abby Davids, MD, MPH, AAHIVS, Associate Program Director, HIV & Viral Hepatitis Fellowship Director, Family Medicine Residency of Idaho
  • Didactic Presentation Title: “The State of HCV in Idaho and Actionable Steps for Change”
  • Didactic Presentation Date: April 12, 2021
  • ECHO Idaho Series: Hepatitis C
  • Didactic Presentation Video 

The Vandal Theory: Season 4, Episode 1: Lachelle Smith – Connecting Idaho’s Medical Communities

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Sanjeev Arora, MD, MACP, FACG, ECHO Founder and Director, University of New Mexico
  • Speaker: Leigh Cooper, Science Writer, Host of The Vandal Theory, University of Idaho, Moscow
  • Speaker: Lachelle Smith, ECHO Idaho Program Director

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 2 – State of Substance Use in Idaho

Featuring: Amy Jeppesen, LCSW

Claim CE for this Episode

Didactic Presentation Details

  • Didactic Presenter: Amy Jeppesen, LCSW, Executive Director of Trivium Life Services (formerly Recovery 4 Life)
  • Didactic Presentation Title: “The State of Use in Idaho”
  • Didactic Presentation Date: February 28, 2019
  • ECHO Idaho Series: Opioid Addiction and Treatment
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Edits/Commentary/Errata/Redactions

  • Throughout the recording, Amy Jeppesen is referred to as the Executive Director of Recovery 4 Life.  Recovery 4 Life recently changed its name to Trivium Life Services. 

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services, Boise
  • Speaker: Coire Weathers, MD, Psychologist, Lost River Wellness, Boise
  • Speaker: Radha Sadacharan, MD, MAT Provider, Boise VA Medical Center
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Lachelle Smith, ECHO Idaho Program Director
  • Speaker: Monte Moore, MD, Pain Specialist
  • Speaker: Cathy Oliphant, PharmD, College of Pharmacy Chair, Idaho State University, Pocatello
  • Speaker: Brenda Hoyt, APRN, NP, Raise the Bottom, Boise
  • Speaker: Steven Kohtz, MD, St. Luke’s Health System, Twin Falls
  • Speaker: Neil Ragan, MD, Health West, Idaho State University, Pocatello
  • Speaker: Magni Hamso, MD, MPH, FACP, Medical Director, Division of Medicaid, Idaho Department of Health & Welfare
  • Speaker: Jeff Seegmiller, WWAMI Medical Education Program Director
     

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 1 – Framework for Addiction as Disease

Featuring: Craig Lodis, PhD

Claim CE for this Episode

Didactic Presentation Details

  • Didactic Presenter: Craig Lodis, PhD, Psychologist at the Boise VA Medical Center
  • Didactic Presentation Title: “Understanding the Disease of Addiction”
  • Didactic Presentation Date: January 7, 2021
  • ECHO Idaho Series: Counseling Techniques for Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Edits/Commentary/Errata/Redactions

  • At about (9:30) Dr. Lodis talks about “a psychiatrist who does a lot of really great work with mindfulness,” whom he names as Peter Seigel; it’s actually psychiatrist Dan Seigel he’s talking about.

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director at the Boise Family Medicine Residency of Idaho
  • Speaker: Craig Lodis, PhD, Clinical Psychologist at the Boise VA Medical Center
  • Speaker: Jason Coombs, MPC, CEO of Brick House Recovery in Boise
  • Speaker: Katy Palmer, ECHO Idaho Assistant Director, Boise
  • Speaker: Radha Sadacharan, MD, MPH, MAT Provider at the Boise VA Medical Center
  • Speaker: Haylee (ECHO Idaho Participant)
  • Speaker: Scott Jones, BS, Chapter Manager at The Phoenix Recovery Center in Boise

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

SOMETHING FOR THE PAIN
EPISODE 1: Framework for Addiction as Disease

Episode Transcript

(31:41 mins)

(0:00)
[somber music]

[Sam Steffen]
The Opioid Epidemic in America claimed 450,000 lives in America between 1999 and 2018.  That means that in the last 20 years, more people have died from opioid overdoses than firearms or car accidents.

[Todd Palmer]
…the mortality rate for people that are using opiates, it’s six times the general population…

[Sam Steffen]
In Idaho, 3.9% of Idahoans age 12 and older reported misuse of prescription pain relievers in 2016

[Craig Lodis]
…It’s important to point out that a lot of the research suggests that 40-60% of the variance, with regards to who struggles with addiction versus who doesn’t, 40-60% of that variance is accounted for by genetics… 

[Sam Steffen]
Among Idaho high school students, 13.9% have taken a prescription drug without a doctor’s prescription. 

[Jason Coombs]
…when I was in high school I had my first soccer injury, I was a senior in high school and I blew out my ACL and was prescribed Percocet, and that was my introduction to pills… (1:04)

[Sam Steffen]
The CDC classified 13 of Idaho’s 44 counties—that’s nearly 30%—in their highest category of opioids prescribed per person. Higher opioid prescribing puts patients at risk for addiction and overdose. If you’re a healthcare professional working with someone who is seeking treatment and recovery options for opioid addiction, or if you are a citizen interested in learning more about prevention, treatment and recovery education resources, ECHO Idaho is here to help. 
[cue music]
This is Something For the Pain…a podcast for Idaho healthcare professionals and citizens working to learn best practices in the fight to prevent, treat and facilitate recovery from opioid and substance use disorders in communities across the state of Idaho. I’m your host, Sam Steffen. (1:56)

[Theme Song Verse + Chorus]
…in the rurallest of places where the resources are scarce
They’re calling ECHO Idaho an answer to our prayers
ECHO Idaho—

[Sam Steffen]
Something for the Pain  is brought to you by the Idaho chapter of Project ECHO, or, Extensions for Community Healthcare Outcomes—an innovative strategy to increase the capacity of the local healthcare workforce to improve lives for patients and providers in the here and now.  Using video conferencing and adult learning techniques, ECHO Idaho connects community providers across the state with specialists in live on-line collaborative sessions.  The sessions, designed around case-based learning and mentorship, help healthcare professionals gain the expertise required to meet the needs of Idaho residents. 
Project ECHO has now been replicated throughout the United States and around the world to address a number of special health areas, including programs focused on increasing healthcare professionals’ capacity to better respond to Substance and Opioid Use Disorders. (3:00)

[Theme song]
…You can earn CE credit while you sit and eat your lunch
[End Music] 

[Sam Steffen]

(3:13) In today’s episode—EPISODE 1—we’re going to be hearing a lecture from Dr. Craig Lodis, a clinical psychologist at the Boise VA Medical Center who specializes in Substance Use Disorder and Post Traumatic Stress Disorder.  Dr. Lodis is going to be speaking on “Understanding the Disease of Addiction” and will be looking at some different narratives surrounding how we conceptualize addiction. The lecture we’re going to be hearing was recorded live during an ECHO session that took place on January 7, 2021 as a part of ECHO Idaho’s Counseling Techniques for Substance Use Disorders series.  Without further ado, let’s turn it over to Craig. 

(3:50)

[Craig Lodis]
So, my name’s Craig Lodis, I’m a clinical psychologist, I work at the Boise VA, I did my post-doctoral fellowship there I think it was about eight years ago, now? And I’ve been working there ever since. I work in the in-patient Substance Use / PTSD program, used to work over exclusively on the Substance Use side and within the last year I’ve moved over to the PTSD side.  

So, today, we’re going to be talking a little bit about how to conceptualize addiction. So, some learning objectives: I wanted to just kind of explore this question, we hear this so much: “Is Addiction a Disease or is it a choice?”  I think there’s overwhelming evidence to support that it’s much more of a disease process than a simple choice. It is very far from a simple choice, especially once we are active in our addiction. So I just want to explore a little bit the implications of how we conceptualize our answer to that question, how does it apply to our direct clinical care, how does it apply to kind of…on a larger, societal level in terms of legislation and how we respond to people who are struggling with addiction, and then more specifically for Substance Use Disorder Techniques for clinicians, look at how can we use this conceptualization and the information that we have regarding how addiction is a disease…how can we use this information to help our patients move through themes like shame and guilt that often are a barrier to treatment and often kind of complicate things or make it so that people aren’t able to receive the treatment that they need.

So, just some recommended resources: In the Realm of Hungry Ghosts is a book by Gabor Mate, which, he’s a brilliant physician who lives in Vancouver. “Everything You Know About Addiction is Wrong” is a TED talk by Johann Hari. Hopefully many of you have seen that.  If not, I would strongly recommend you check that out today. He wrote a book called Chasing the Scream among other books, but he’s got some very interesting views, and I think very helpful views, regarding addiction.  And then last but not least there’s a documentary called Pleasure Unwoven that we show in our program. A lot of the information that I’m going to be covering is coming from that documentary. This is by a physician, Kevin McCauley, who is in recovery himself.  I believe it is available for free on YouTube and I would strongly encourage you to check that out.

So I wanted to start by just acknowledging the huge amount of stigma. Substance abuse tends to evoke even greater negative attitudes even than schizophrenia.  And I think that if we kind of start to unpack this question a little bit, I think a lot of this has to do with where do we fall on the ‘disease vs. choice’ question. And if we’re honest…you know, if you’ve ever had a friend or family member who’s struggled with addiction, it can be very hard to be accepting and compassionate and set boundaries. In some ways it can feel easier to say, “oh, this is a choice, I watched the show Intervention, I know what I need to do, I need to make my relationship contingent upon their sobriety…” It gives us a sense of power.  I think it also perpetuates guilt and shame and some really unhelpful narratives surrounding addiction.
So the disease question: basically, we have this kind of dichotomy, and this seems to just be the way that our brains work and prefer to have “it is a disease” or “it’s a choice,” it’s one or the other. We have a harder time with more nuance and complexity. So basically the “choice” argument would say, if somebody’s struggling with addiction, if I go—and this is a blunt analogy, excuse me—but this is from Pleasure Unwoven—if I go to somebody who’s struggling with addiction and put a gun to their head and say, “stop using!” they will probably stop using, right? And our thought is, “they’re choosing to stop using.” But in reality I think more what’s happening when we’re active in addiction is we’re thinking, “Can I smoke this, snort this, inject this, drink this, before that bullet hits my brain?” because that just seems to be the way that addiction works. It kind of grabs hold of the more primitive parts of our brain.

So the “disease” question, it really helps if we’re able to conceptualize and really look at some of the neurobiology of addiction, it really helps to paint a different picture, and a picture that helps us understand why we see some of these behaviors and why we see people acting in ways that seem 180 degrees the opposite of their normal values and behavior…why do these occur when we’re active in our addiction? So, according to Kevin McCauley in Pleasure Unwoven, it is a disease and it’s a disease of choice. So, “a disorder of the very parts of the brain that we need to make proper decisions.” 

At this stage I’m going to give a caveat and say I am not a neuropsychologist, I am not a neuroscientist, I am a clinical psychologist, so I have some knowledge of the brain but there are people who are much more knowledgeable than I am, so I’m going to be speaking kind of in generalities…

(9:00) So focus is on the role of communication between the frontal cortex and the mid-brain via dopamine and glutamate. Don’t I sound smart? So, what do we take from this? The important things to take from this: the frontal cortex and the mid-brain, if you’ve ever done DBT (Dialectical Behavioral Therapy), this maps on really nicely to the reason-mind or the rational-mind versus the emotion-mind, the emotion-mind being more the mid-brain or limbic-system and the rational/reasonable-mind being our frontal cortex. Again, in general. Also, if you’ve ever seen Peter Siegel (sic) who is a psychiatrist who does a lot of really great work with mindfulness, he has a conceptualization for children where he talks about…he says, if my fist is my brain, you’ve got your upstairs brain which is the pre-frontal cortex and then we have your downstairs brain which is, in generalities, your mid-brain and your limbic system. So I think finding a language that is palatable for our patients and that they can really kind of understand is really important to keep in mind.

So, according to Dr. McCauley’s framework, addiction is a disease of “genes, reward, memory, stress, and choice.” So I think the first thing that’s really important to point out, especially when we have a patient who’s struggling with shame and guilt, it’s important to point out that a lot of the research suggests that 40-60% of the variance with regards to who struggles with addiction versus who doesn’t, 40-60% of that variance is accounted for by genetics. And variance is a statistical term, for those of you who aren’t stats nerds, it’s basically a statistical way to determine why do some people fall into addiction while others don’t and we can control for other variables and kind of isolate and say, it looks like genetics is responsible for 40-60%, so that’s a pretty big number.  The analogy that I like to make here, partly because I work in the VA system, and this is a little cheesy, but I make the analogy of body armor and say, you know, some of us have a different amount of body armor when we go into deployment or into a combat situation and that is based on our genetics and our early life experiences. Some of us are going to be much more flexible and able to bend and adapt, others are going to be much more rigid and likely to fall into that cycle of addiction.

And the way that this is presented in Pleasure Unwoven, he uses Russian nesting dolls, I don’t know if you guys have ever encountered those, but they all kind of fit inside of each other, and I take that to be…I think he’s saying this is kind of a cumulative process, it’s kind of additive, so each layer is impacted and passes that impact onto the next layer. So reward is broken and passes that deficiencies onto memory areas in our brain.

So: reward. Some things that I’ve found really important and helpful for me for conceptualizing addiction (12:00) Reward, the role of dopamine.  So the way that it’s described that has really resonated with me, and again this is in Pleasure Unwoven so if you’re interested please check that out…dopamine is released to tell us when things are better than expected. That’s the way it’s been described to me.  So the analogy is if I go to a gumball machine and I pop in a quarter, I turn the knob, I get one gumball, there’s probably going to be a little squirt of dopamine. It’s not better than expected but it’s still good.  If I put in my quarter and turn the knob and by some miracle I get two gumballs, there’s going to be a larger squirt of dopamine. And we believe the function of that dopamine is to say, “Hey, this is rad. I like this. We should do this.” And part of what is helpful to remember is, when people talk about that idea of ‘chasing the dragon’ so to speak, or you know, the first high, or the first effect of your substance abuse was the best, it’s because you have expectations after that first use. I think it’s also important to remember that the levels of dopamine that are found in our brain when we ingest substances are much, much higher than our brain was designed for. So it’s kind of this huge spike in dopamine, and that helps us understand why I could be passed out on the bathroom floor and my brain is still like, “This is the best night ever!” There’s obviously still significant repercussions once our brain realizes, “oh, there’s way too much dopamine,” and it starts to push back. We’ll get to that when we talk a little bit about stress.

[musical interlude]
[Sam Steffen]
Dr. Lodis makes the case that addiction takes the form of disease, not choice, and that some of us are predisposed to addiction through genetics and early life experiences. The framework of addiction as disease has major implications for approaches to patient care, as well as on a larger societal level and in legislation and policy when it comes to conceptualizing treatment for people who are struggling with addiction. Let’s hear more from Dr. Lodis about the connection between cravings, stress and recovery.

[Craig Lodis]
So, we were talking a little bit about memory.  This helps us understand a little bit why people have these very vivid memories associated with use, it’s in large part because we are flooding our brain with dopamine and glutamate and that helps us also understand and normalize the experience of cravings. Research suggests that cravings are a natural part of the recovery process. They may never completely go away, and so one of the things that we need to do is if people are responding to cravings, thinking, “Oh, this means there’s something wrong with me,” or “I don’t really want to be sober,” or “What does this mean?” you know, and they start to struggle with that craving, that’s really problematic. So we want to use things like mindfulness and urge-surfing to help them just kind of observe and do their best to wade through that experience and then get back to living their life. (15:00)

Then we go on to talk about stress and the role of stress. We talk about how our brain kind of resets once our brain realizes that there’s excess dopamine, it’ll start to release CRF or what they call Corticotropin Releasing Factor and it will push down on the dopamine levels. And after repeated or binge use, or if we kind of go on a runner, so to speak, it can really upset the balance of our brain and what they call the hedonic setpoint, so what it takes—what amount of dopamine does it take—for me to feel good. This helps us understand a little bit of why is it so difficult, especially in the early stages of recovery when you’re doing everything that people are telling you, and you still feel crummy. It can take some time, and depending on our substance abuse that time may vary, and depending on our individual biology that time may vary as well.

The other piece of research that I think is really fascinating that I would encourage people to talk about with patients—they have hooked electrodes to parts of mice and rat brains, they keep them alive, but they hook them to the areas involved in the pleasure center and response, and then they have a lever that they can press. And every time they press that lever, they get a little electric shock that’s a release of dopamine. It feels good. It kind of mimics the effects of substances. What research has consistently found over and over and over again is that these rats and mice will consistently press that lever obsessively, seemingly coming into that cycle of addiction. They don’t eat, they don’t sleep, they don’t socialize. They do this until they die. They will even continue to do this if we put an electrified grate underneath that rat or that mouse.  They will stay on that grate and hit that lever to get that surge of dopamine until they die. So if rats and mice can have addiction, I don’t think this is about will power as much as some narratives suggest it is. I don’t think this is about morality and being a bad person as a lot of our narratives suggest. I think also, if we put a metal, electrified grate under them and shock them, and they still do it, that suggests to me that punishment isn’t always going to be helpful.

[musical interlude]
So the formulation that Kevin McCauley uses is that the majority of the population falls on the left-side, here, as a non-addict, and I…personally I don’t like that term, I wouldn’t use that term, and that’s something I want to touch on, too, real briefly, but before that…so, they’re either a non-user or they experiment, they use, they abuse, but to them and to their mid-brain, the drug is the drug. Somebody who goes into the cycle of addiction, their mid-brain is saying the drug equals survival, and it’s saying the drug is as important as things like eating, breathing, sleeping. Our mid-brain is responsible, in the simplest terms, for the next ten to fifteen seconds of our life and with keeping us alive.  And if my mid-brain thinks I need to keep using my substance to stay alive, I’m probably going to do that.

Okay, so the last thing I want to talk about, getting back to that upstairs-brain/ downstairs-brain, in a nutshell, the way that I explain this to patients is part of what happens when I am active in my addiction is the communication between my downstairs brain and my upstairs brain has been really damaged if not cut off completely. My upstairs brain, my prefrontal cortex where I have things like moral and executive functioning and I’m able to control my impulses, all of that is almost in someway off-line. So that helps us understand: this is what’s happening when you’re active in your addiction. It’s not that you’re a bad person or you don’t care about your family or your job or your other responsibilities, your brain, in essence, has kind of been hijacked.

So before we get to the key points, the other thing that I want to say is because of the amount of shame and guilt that we see in this population, it is imperative that we are really mindful and thoughtful with what language we use. So don’t call it their “substance of choice.” It’s not a choice. And if I say it’s a “substance of choice,” I’m implying that it is a choice. So instead I prefer to say “substance of use.” Other things: I don’t like the label of “addict” or “alcoholic,” even.  Personally I would rather say “I am” or “You are a person who struggles with addiction,” or “you are a person who has an alcohol use disorder.” Really just trying to humanize…and any way that we can chip away at some of that shame and guilt and treat them with that unconditional positive regard that Carl Rogers talked about, that’s going to be beneficial for our treatment.

So, key points: Addiction is a disorder of genes, reward, memory, stress, and choice and I think a bigger point is, how we answer this question: “Is Addiction a disease?” is going to inform how we interact with people who struggle with addiction, it’s going to inform our treatments, it’s going to inform our legislation. It’s going to inform whether our government is supportive of things like safe injection sites or supervised injection sites, it’s going to determine whether our legislators are supportive of things like suboxone and naltrexone and medication assisted treatments, so I think it’s important to say the message and let people know that this is much more a disease than a choice. 

Dopamine, reward, and glutamate, memory are heavily involved in that self-reinforcing nature of substance use disorders.  You get this quick almost immediate response depending on your substance of use, that is incredibly reinforcing. 

Living life on life’s terms is not always incredibly reinforcing. So setting realistic expectations for our patients I think is very important.
Guilt and shame are ubiquitous in substance use disorders. So stock up on kindness, compassion and non-judgment. We can use this framework to help assuage overwhelming guilt that may be a barrier to treatment.

And last but not least, part of our role is to offer unconditional positive regard to our patients, so be very mindful of the language that you use. And I think it’s really important, too, to distinguish that, you know, if they engaged in some shameful behaviors, using the qualifier, “You did this when you were active in your addiction,” versus “you were active in your recovery,” and just kind of letting them know that this does play a role. It doesn’t absolve you of accountability, but it plays a significant role.

[transition music] (21:58)
[Katy Palmer]
Are there any questions for Craig? Thoughts? Follow-up?

[Sam Steffen]
That’s the voice of ECHO Idaho’s Assistant Director, Katy Palmer. 

[Katy Palmer]
Yes, please!

[Hayley Brown]
Just thinking about Dopamine, and in the brain…

[Sam Steffen]
This is an ECHO participant speaking, Hayley. ECHO sessions like this one bring a myriad of professionals together virtually. In our Counseling Techniques for Substance Use Disorders series, we often have psychologists, psychiatrists, social workers, addiction specialists and counselors present on the same video call.

[Hayley Brown]
You know, long-term use generally results, if I’m correct, in less receptors for dopamine, it’s its way of coping with too much dopamine in the brain. Is it natural in [people who use substances] to already have a lower level of dopamine so then when they get a higher amount, that brain goes into their survival mode of wanting to get more dopamine, or how does that…work?

[Craig Lodis]
That’s a wonderful question, and to be totally honest with you, I’m not sure. (23:00) But one thing I would say is there is a lot of evidence that things like neglect or childhood trauma make us much more susceptible to addiction.

[Hayley Brown]
Okay, so I have one more question, then, on that line, um…thinking about preventative healthcare for children who have strong lines of addiction within their family how do you intervene or help families give resources to try to educate these children about possible risks but then also prepare these children for being more resilient?

[Radha Sadacharan]
(26:30) Craig, do you mind if I pick that one up, just as a family doc?

[Craig Lodis]
Yeah, of course. Please!

[Sam Steffen]
This is Dr. Radha Sadacharan, Primary Care Physician and MAT Provider at the Boise VA Medical Center. Dr. Sadacharan was one of the panelists present for this lecture.

[Radha Sadacharan]
One of the things we think about are ACES, just like you’re pointing out, Hayley, in terms of Adverse Childhood Experiences and that’s our way of quantifying trauma that people undergo, and you’re totally right, like, everyone knows this. The more trauma that someone incurs, the more likely they are to struggle with things like addiction, to struggle with incarceration, and so a lot of this really focuses on then what can we do to prevent these kinds of situations. And so, we don’t have much control over this, right? And so, we should be identifying problems, and so in pediatric practices, we should be screening for ACEs, if you’re working with kids you should be screening for ACEs and then based on that, you’re identifying the weak-points.  And so I actually really like SAMHSA—the Substance Abuse and Mental Health Services Administration’s—four pillars of recovery as a way to identify preventative, protective factors, and they talk about (1) health, (2) home, (3) community and (4) purpose. And I think that can start from when kids are really young.  And so identifying the things that they love in their life or the things that make them feel safe in their life, and then spanning out from that, like, are there people in your life that you feel like you can go to if there’s something that’s going on? They might not be the people that live in your house but is it your neighbors or is it your grandma? Is there someone else? And so identifying those points and then over time being able to work on that is resiliency. We can’t predict who’s going to be struggling with addiction later on, but we have a good idea of the risk factors that predispose someone to it, so can we modify those risk factors? (28:15)

[Katy Palmer]
Thanks so much, Radha.  So I actually think this is a great time to tee Scott. So Scott, if you can introduce yourself, tell us who and where you are, I’m wondering if you can talk a little bit about some of the services that the Phoenix offers, and the importance of resilience-building activities and kind of how people navigate and find those. (28:35)

[Scott Jones]
Great, thanks. So, again, Scott Jones, I’m in Boise, Idaho, I’m the chapter manager with The Phoenix. The Phoenix is a national organization, we’re a non-profit, we work with anybody who has struggled with substance use disorder or chooses to live a sober life.  We do an assortment of programs, most of them are based in fitness, so it could be yoga, mountain biking, we could be doing some strengths training, or whatever that event looks like, and it varies a little bit by each location.  We also throw in things like social and art and various things like that as activities. The only thing that we require for people to attend is 48 hours of continuous sobriety, or more. And again, those events are free. By people participating in these activities, it’s not so much about like how much weight we’re pushing up over our head or if we’re doing the perfect Warrior-III yoga pose, it’s more about the connections that are created by the people that are participating together. There’s levels of encouragement. And folks can maybe understand what someone else is going through, so there’s a lot of relatability. And we see that folks have a longer journey in recovery with a community of people that help and support them along their journey. So I know…Katy, you had a lot of questions in that one question, and I’m not sure if I hit all of them, but…

[Katy Palmer]
No, that’s great. Thank you so much. 

[Sam Steffen] (30:45) [Cue mellow transitional instrumental guitar]

That, again, was a didactic presentation by Dr. Craig Lodis titled “Understanding the Disease of Addiction.”  That lecture was recorded live during an ECHO session that took place on January 7, 2021 as a part of ECHO Idaho’s “Counseling Techniques for Substance Use Disorders” Series.

[End music]

If you’d like to watch the Zoom recording of that presentation, that video is currently available on the ECHO Idaho YouTube channel, which you can access through our website. The Powerpoint slide deck that accompanied that presentation is also available on our website: www.uidaho.edu/ECHO  
The recommended reading and viewing materials that Craig mentioned in his lecture are currently available on our podcast webpage.  For those, and instructions about how to claim continuing education credit for listening to this episode visit our podcast webpage: www.uidaho.edu/echo-podcast

[cue banjo music]

If you’re interested in joining our free, live ECHO sessions to receive Continuing Education credit, learn best practices, ask a question, or grow your community—please visit our website where you can register to attend, sign-up to receive announcements, donate, and find out more information about our programs.  
Something for the pain is brought to you by ECHO Idaho, supported by the WWAMI Medical Education Program and the University of Idaho, and is made possible by VCORP, the Valley County Opioid Response Project. 

[Fade banjo]
[Guitar strum and guitar and theme song w/ words in background]

We here at ECHO also want to hear your feedback.  We welcome your questions, comments and suggestions and invite you to email us at echoidaho@uidaho.edu.  And don’t forget to subscribe to Something for the Pain using your podcast app.  And if you have a moment, write us a review!
That’s about all the time we have for today, but join us next time when we’ll be exploring the topic of “Substance Use in Idaho” with LCSW and Director of Recovery 4 Life, Amy Jeppesen.  Until next time, Idaho, take care of yourself! 

[Bring up lyrics to first “ECHO Idaho” then fade and continue theme song]
In the rurallest of places where the resources are scarce
They’re calling ECHO Idaho an answer to our prayers
ECHO Idaho!

Something for the Pain is made possible by Grant Number GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDI-1 or HRSA.”
The voices you heard at the beginning of the episode were those of Todd Palmer, Craig Lodis, and Jason Coombs, respectively.

Big thanks to everyone who contributed to today’s episode: Craig Lodis, Radha Sadacharan, and Scott Jones.  We’d also like to thank the other members of our “Counseling Techniques for Substance Use Disorder” Series expert panel: Drew Holliday, Case Management Team Coordinator at Recovery 4 Life in Boise; Sara Bennet, Executive Director and Owner of Riverside Recovery in Lewiston; and Lindsay Brown, Lead Recovery Coach at Peer Recovery Supports of Idaho, LLC.

And a big thanks to all of our listeners without whom none of this would be possible.  Without you, we’d just be talking to ourselves.

Lachelle Smith is the ECHO Idaho Program Director; Katy Palmer is our Assistant Director; our Marketing Manager is Lindsay Lodis; our Program Coordinators are Kayla Blades, Jessica Whitlock, Karley Kline and Sam Steffen. 

[Theme song]  

 

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Something for the Pain is brought to you by Idaho’s chapter of Project ECHO and the University of Idaho, supported by the WWAMI Medical Education Program, in partnership with VCORP, the Valley County Opioid Response Project. Something for the Pain is made possible by Grant Number GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDI-1 or HRSA.

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