How Medications Can Help You Drink Less with Dr. Paul Linde

Episode 121 July 12, 2023 00:54:17
How Medications Can Help You Drink Less with Dr. Paul Linde
Alcohol Tipping Point
How Medications Can Help You Drink Less with Dr. Paul Linde

Jul 12 2023 | 00:54:17


Hosted By

Deb Masner

Show Notes

Are you curious about the different types of medications to help reduce cravings, drink less and manage withdrawal symptoms? Listen to this episode to learn more. Dr. Paul Linde is on the show to share his expertise. Dr. Linde, a board-certified psychiatrist with 30+ years of clinical experience and Medical Director at Ria Health, an online alcohol addiction program and app that helps members change their relationship with alcohol. 

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Episode Transcript

Dr. Linde Deb: welcome back to this episode of Alcohol Tipping Point. I have a specialist on. His name is Dr. Paul Linde. He is a board certified psychiatrist with over 30 years of clinical experience. He is now the medical director at RIA Health, which is an online alcohol addiction program and app, and it helps the members change their relationship with alcohol. I'm really excited to have Dr. Linde on to talk about. Aspects of alcohol addiction and treatments like anti creamy medications and the breathalyzer check-ins, and he has a wealth of experience. So welcome to the show, Dr. Linde. Dr. Linde: It's really a pleasure to be here and thank you for providing this content to such a large audience. It's a very important topic. Deb: Well, thank you for being here too. And I'm curious about you. You have all this experience, how did you start your journey into this side of things with alcohol addiction? Is that where you always started? Like I just wanted to hear more about Dr. Linde: you. Right. I've always craved variety in my career as a psychiatrist, I worked at the U C S F School of Medicine, seeing patients and also teaching most of that teaching on the apprenticeship model, so medical students and residents in a clinical setting. And I've done. 25 years of psychiatric ER work. I've done addiction medicine. I've done consults both in the hospital and in clinic setting. My last job for the last four and a half years was as a primary care psychiatrist. So seeing more higher functioning people generally. So I've always had a lot of variety. So obviously over the years, every psychiatrist, particularly in a. Public hospital setting the va and in all walks of life see alcohol as part of a presenting issue. I was trained in the era, old school era of that once an alcoholic, always an alcoholic, and that a goal of moderation was really gonna be accessible to maybe 5% of quote alcoholics. The thinking has shifted. Over the years, and for me it's really kind of a relief and a pleasure to work in such a focused way that I've been working with RIA Health for nearly three years. And for me, I feel like I've developed special expertise in, certainly in prescribing a. Anti craving medications, but then also in my understanding of the other aspects of treatment. And one of the strengths of our program is we work integrate really well integrated with kd, a, C and K ssac. So addiction alcohol and addiction certified counselors. They provide the coaching at Rya Health and we work together very closely. We also use a breathalyzer, which sets us apart, I would say that we send breathalyzers to all patients on the front end. And ask them to check it twice a day. So we have some data and we also have some accountability for patients. But really the, the bottom line is I've been exposed to alcohol in my, over my career. And then the other thing about alcohol, as you probably understand is that when you're in training, Everybody with an alcohol problem is like dead drunk on the streets, you know, being brought to the ER with a blood alcohol concentration of 0.4. And so you get very cynical about alcohol and training and then you hear from older psychiatrists, it's like, oh, no. Treat work. Working with people with alcoholism and addiction is, is, is great because when they get better, Their life does a 180. And at the time I was like, I don't believe it. You know, cuz I'm seeing all these guys in the ER who are homeless. So anyway, that, what I've found is that is really true. And so for me, I really like addiction medicine and working with people with alcohol problems in that I know it's a long-term effort and that, but I also know that there's hope and that people get better. So I've really, I've really, really enjoyed my experience kind of focusing on alcohol. And, you know, not to minimize anxiety and depression, which, you know, we can talk more about as well. Deb: Yeah. Well thank you for that and, and sharing your perspective across the time. What kind of stood out to me too was just that stigma and even our labeling, like, we don't use alcohol, alcoholic, or, you know, it's alcohol use disorder. Right? Yeah. Dr. Linde: And of course I use the term, I probably use both those terms, which I don't normally do, but you're, you're right. No alcohol use disorder is, you know, much less stigmatizing than alcoholic alcoholism. But that, those are the words we used, you know, going back now 25, 30 years, alcoholic and alcoholism. And so things have really changed, and I would say that the DSM five, which the DSM is Psychiatry's Guidebook for diagnosis was revised about five years ago. And I have, you know, difficulties with a lot of the changes they made. But I think that the way they classify alcohol and other addictive disorders is a huge upgrade. And they created the alcohol use disorder, substance use disorder nomenclature. And then they also put the criteria in a unified way. So it used to be, it was alcohol abuse and alcohol dependence. And it was very confusing because alcohol abuse really talked about. All the psychosocial consequences and alcohol dependence talked about the physical and physiological. And so they've unified the two in alcohol use disorder. And essentially the criteria include a mix of both. Physiological, physical concepts as well as psychological psychosocial consequences. So yeah, I think things, I do think stigma is being reduced kind of from our side of the equation as professionals, definitely. But I also, I do think there's still a lot of work to do, and in fact, as you probably know, anti craving drugs are. Vastly under prescribed of all the people who might be eligible for medication assisted therapy for alcohol, I mean, I hear different numbers. 4%, 7% of that population actually get these medications. Medications have been around for a long time. Naltrexone was F T a approved to treat alcohol use disorder. Wasn't called that then, but to address heavy drinking almost 30 years ago. I'm sorry. Yeah. I have to do a time check in my brain. What decade are we in? So Naltrexone has been around a camper, eight has been around or campral. And these were, these were innovations, of course, over an abuse. Diam. Deb: Yeah, I would, I would love it if you could take some time to talk about those three, because that's pretty much it, right? Those three meds for treating alcohol use or, Dr. Linde: well, it's, what's super interesting to me is those are the three that are f d A approved. Mm-hmm. But I find Gabapentin, To be extremely useful. I would love to talk more about it. So when I was a psychiatric resident 30 years ago, I used to joke about having a t-shirt that said, ask me about Haldol, which is, you know, the inject injectable antipsychotic, which they're still using in ERs. And now my t-shirt would say, ask me about gabapentin. So but this notion of f d approval is kind of fraught, right? You hear the term, oh, you're prescribing that off-label, like it's something bad. And what I found out recently is that to be f d a approved to get an indication for a specific disorder, the manufacturer, the original manufacturer, needs to contact the FDA and ask for it. And a lot of times these medicines have been around so long, the original. Maker of Gabapentin or Topiramate for example, they don't have any stake in getting an indication to treat alcohol use disorder. So those medicines are not, quote, FDA a approved. And what I understand F D A approval is, is a lot of it's commercial that what's on the label and the label is really for advertising, et cetera. So having said all that, the other medications we prescribe, Have all been researched and vetted in large clinical trials. And they've obviously been vetted for safety. So any medication that's made it to the broader market for any indication has been already safety tested. And then when you have the experience of often of decades of prescribing the medicine's been around, we know if there's gonna be any later adverse events. So, I would say gabapentin and topiramate. We also prescribe pretty frequently. So some of that F fda, a approved thing has to do with sort of the idiosyncrasies of the F D A approval project. So in order of usefulness and how often we prescribe, I'd say Naltrexone one, Gabapentin, two. Topiramate three. So we don't prescribe anabuse. I would say we rarely prescribe anabuse. And the reason is it's a, it's an old drug. It's from the fifties or sixties. It definitely has its place and every once in a while we will prescribe it. It's really meant for people who are need enforced sobriety. And so those would be transportation workers, obviously. Law enforcement, you know, different professions need enforced sobriety. The issue with anus is one, it's, it's, it's kind of a dirty drug. The metabolism is wonky, it has a lot of side effects. It is really punitive. And at the end of the day, a lot of it is about, I don't wanna have people have a punitive experience and not just punitive, but potentially send you to the hospital. And then the other big issue for sure is, is compliance. If you take it, it works great. If you don't take it, then it's not gonna work. So that's true with any medication, of course. So, so I'm not a big fan of anabuse. I do have had patients who swear by it and every once in a while I'll hear somebody gimme a history that says, this really works for me. I know it does, and I wanna be abstinent, and I'll go, you got it. Let's do that. And, you know, have to get liver function tests first. Sometimes an electrocardiogram. So it's not, it's probably the least safe of all these medications that are prescribed for alcohol use disorder. Deb: And Anbu is the one that it primarily works if you drink alcohol or, that's right. Yeah, Dr. Linde: that's right. You have to, it's the DIAM reaction. DIAM being the. Generic name for an abuse is that it inhibits alcohol dehydrogenase. I'm sorry, it inhibits aldehyde dehydrogenase. So what happens? You drink alcohol passes through your liver. There's alcohol dehydrogenase, which turns alcohol into an aldehyde, and I don't know any of you have done organic chemistry in college. But in the lab, and I, I didn't like the lab. That's why I'm a psychiatrist in the lab, in the, not a chemist in the lab. I remember we'd made aldehydes and they were pretty, you know Pretty smelly, and you could sort of feel the, the effect. And so anyway, if you have aldehydes that build up, the aldehydes will make you sick. They're toxic, and so it's the toxicity of the aldehydes building up because you're blocking the ability to break down the aldehydes into the next thing. So, yeah, so it, it, it, it works as a, for relapse prevention. And maintaining abstinence. And for a highly motivated patient or one who really is for enforced sobriety, it's not a bad choice. But honestly, a camper site is very or temporal, very well suited to relapse prevention and abstinence maintenance. It has its own set of side effects and problems, but lot safer than. Than anti abuse. So that's, that's kind of our go-to in that situation where someone's been abstinent for a period of time, they wanna stay abstinent. That a camper, Seder campral is a great choice then. Deb: Thank you. And how does campral work? Dr. Linde: So, camperall works, they all ultimately kind of work on GABA and glutamate which are two receptors. So a camate. Reduces the reward associated with drinking in a different way than Naltrexone. So other than naltrexone, which works on our internal opioid system, or the word I like to use is endorphins. All the other medicines work primarily by manipulating GABA and glutamate. And so GABA's gamma aminobutyric acid, and essentially gaba. When you drink, It, you get more gaba when you drink, you guess get less glutamate. So GABA is kind of like a, well, I, I call it the wellbeing neurotransmitter, GABA's wellbeing. Glutamate in excess is, I call it the aro, or aggravating. It's excitatory, not in a good way. And so essentially alcohol gives you more gab and less glutamate. And that's part along with the release of endorphins. That's part of the pleasure response. I feel better. Right. I mean, who, when we all, you know, myself included, why do people drink, they drink to change their mood, their mindset, et cetera. And I think that's the beauty of moderate drinking is if you can have, you know, literally a couple and get that benefit and that, ah, sort of little sense of relief and comfort if you can, you know, if you can stay there. Great. I mean, you're gonna, you're really gonna be fine in the long run. And so people drink and part of it's that pleasure response is mediated by GABA and glutamate. So by contrast, alcohol withdrawal, right? It mimics fight or flight, anxious, heart racing, sweaty, shaky, nausea, blah. You know, you feel terrible. Kinda like a panic attack. It's funny cuz it's not really mediated by. Adrenaline or, or epinephrine. It's really mediated by GABA and glutamate. And so what happens in alcohol withdrawal is the GABA is diminished and the glutamate is increased. So you have less gaba, which is the wellbeing chemical. You have more glutamate, which is the aggro. So these medicines work on GABA and glutamate primarily, and so acamprosate. Does that as well. I mean, there, yeah, there are other sort of general differences, but that's the short version. Deb: So Camral would be something you would take after you get through the withdrawal period to keep you from going back or, Dr. Linde: yes, exactly. So it, this is its primary use. The sort of the, the number one use for a camp is for people who have at least. Really three or four days of sobriety and wanna maintain abstinence. I mean, obviously if you come to Rio Health and you've been abstinent for a month, it's still a great choice. So really it, it, for whatever reason, it seems to help people. It so it reduces craving and what I hear. A lot of people say is, God, I don't even think about alcohol anymore. The reality is, is it doesn't work that well for everybody. But as my colleague, Dr. John Mendelson, who's a co-founder of Rio Health and our Chief Medical Officer, he said, it either hits our home run or it strikes out. So for a subset of patient, it, it works incredibly. So it's more like for relapse prevention, however you can use it for craving and people are actively drinking. We sort of go with maltrexone for that mostly. Gabapentin, topiramate. So we don't, we don't prescribe it that often, but you can also take it when people are actively drinking. There's, it's, it's safe to reduce craving in people actively drinking. Deb: Okay, so, so let's talk about those top three that you prescribe. Dr. Linde: Okay. All right. So Naltrexone is our bread and butter. Naltrexone has been around, again, like I said, for 30 years. It's been vastly under prescribed, and I can say you know, when I worked in primary care, for example, and earlier I knew about naltrexone. But I didn't really have much facility with it. I didn't totally understand how it worked, and I didn't know how to, most importantly, I didn't know how to talk to patients about it. So I would say the standard dose is 50 milligrams out of the box, take 50 milligrams, and for whatever reason, I'd tell people to take it at night, and I didn't really know that much about it. Now when I get to Rio Health, One of the things, and this is true for all the physicians and nurse practitioners who come to work as prescribers at Real Health, there's an adjustment period, like how do you really prescribe these things? And with prescribing, it's really, at the end of the day, it's more art than science, and you're basing it on, well, what the research says, but you're really also basing it on your cumulative experience and then learning from others who've learned from experience. So Naltrexone. Works by, we think it works to reduce craving by inhibiting the pleasure response from drinking. And it does this literally by blocking opioid receptors. So naltrexone is, you know, little. Brother of Naloxone or Narcan, they're in the same group. And as you and your listeners know that Narcan is the drug that we use either in a nasal form or an injection to reverse opioid overdoses. So particularly fentanyl and heroin can reverse it. And because it goes in and immediately knocks the opioid off of the receptor, and so it reverses the overdose state. So naltrexone is not that powerful. But it, it works by the same mechanism. So the beauty of Naltrexone, several things. One, it's cheap and it also, people need to take the oral form for it to work. There is an injectable form called Vivitrol, which we don't prescribe that much because one insurance often doesn't cover much of the cost. And two, it can be a little bit difficult to, to get. It's great for people who consistently don't take their medications. We just don't prescribe a lot of it. And so naltrexone, it doesn't cause any toxicity to the body. It doesn't have any drug interactions to speak of except for with opioids. And so I always have to tell people with naltrexone, so this is an opioid blocker. So, for example, if you have dental or foot surgery and the surgeon gives you hopefully no more than maybe 10, you know, Vicodin or Percocet or whatever the pain medicine is, you have to go off the Naltrexone for at least a couple of days. Before you take it, otherwise it's gonna, it'll block it. Not only will it block it, you may get a opioid withdrawal symptoms. So I always inform consent with naltrexone to tell people. And then I hate, I kind of always hate to do this, but you have to, and I say, God forbid you break a bone and you're in an ER and you need morphine. If the ER doc knows you're on naltrexone, they'll just increase the dose of the morphine to overcome it. And I'm always like, you know, God forbid you're gonna break a bone. So Naltrexone is re is is really safe. It works best when people are actively drinking. I would say, and I would say, you know, probably three quarters of the patients who come to Rio Health are actively drinking and have a goal of reducing. Which I know we'll get to that topic as opposed to abstinence. So that's why it's a good fit. The, the nuances I learned about Naltrexone though, which I didn't know before, is one, we start at a reduced dose. We start with a quarter tablet for two days. Half tablet for two days and then up to a full tablet, which is 50 milligrams. We do that to let people get used to the medication. We do that to assess side effects. Most common side effect would be nausea or diarrhea. Other people feel a little bit tired on it. And those are probably the mo headaches of course. And so we find that when people start at a really low dose, And then get 'em up to a full tablet. You know, obviously at a half if that half tablet they're having side effects, we say, you know, you can stop it or just stay at that dose. So that's one thing I learned about Naltrexone, cuz if you give somebody 50 out of the box. 50 milligrams, boom. And they're sensitive to the medications, then they're not gonna want to take it. I'm done with that. Oh, I felt terrible. I'm not taking that. Whereas if you start 'em at a, at a, at a baby dose and move 'em up, you have better success. The other thing I've learned is that we don't know the doses in advance. In other words, 50 is the standard dose and 50 works for some people. But I would say frequently we end up going up on the dose to 75 milligrams. So it's one and a half tablets. It's a tablet you can break in half, sometimes two tablets, a hundred milligrams, and sometimes even higher. And unfortunately, it's all trial and error. I mean, it just is, the nature of the beast is like with any medication, it's. We're looking for the sweet spot, so we're looking for the benefit while we're avoiding side effects. And so for people who get to 50 with no side effects, if they're not really having any benefit, Over probably a month or so, then we'll, we'll start going up on the dose and a lot of times that higher dose will start to catch. The other thing that I find fascinating and I just, this, you know, obviously helps connect with patients is to say, can you be specific with me? How does a Naltrexone help? And it's just interesting to hear what people say. A lot of people say, you know, I just, I lost my taste for the next drink and I wasn't interested in it. Other people say, you know, I In fact, I made a drink and I left it on the counter last night. I, after one drink it, I feel full. I'm not getting anything out of it, so I, I'm not continuing. And you'll have a subset of people who try to drink through it. A small subset and that's always difficult cuz they, like, I miss how alcohol made me feel. So I just barreled through and, you know, drank more than usual. And obviously that's not a great sign. So that's kind of, kind of gave you the long version, but what I just told you is very similar to what I tell a patient when we're starting naltrexone. But our evidence is super strong in aggregate. In aggregate, we treated more than 7,000 patients and in aggregate people reduce their drinking by 50% in the first two months. So I know, and most of those people it's because of Naltrexone. Mm-hmm. So I'm kind of self-conscious. That was a long answer. So Gabapentin my favorite topic. So Gabapentin is a really interesting drug in my opinion. One it is super versatile and essentially I was prescribing it as just a primary care psychiatrist a lot. The reason I was is that it works for anxiety, it works for insomnia, and honestly, gabapentin is safer and as effective. As benzodiazepines for anxiety. So that's the Xanax, Ativan, Klonopin, and you know, the Xanax epidemic or revolution. Everybody in their brothers on Xanax. El pram, the benzodiazepine for anxiety and gabapentin works great for sleep, so you don't have to prescribe Ambien and Lunesta. And those drugs, the what we call the Z drugs, they're problematic. Gabapentin works for alcohol withdrawal. So hair of the dog, eye opener. Right? Who hasn't done that? I did in college, you know, had BA basically, and, you know, no, no joke. I mean, a lot of people that come to our program, they're drinking first thing in the morning because they're gonna throw up or they're shaking really badly and they, you know, it's untenable. So. So they're drinking first thing, so Gabapentin can substitute for alcohol. In that situation, I say, listen, try the Gabapentin. It will treat the alcohol withdrawal symptoms. And then so you don't have to drink like you, maybe you'll start drinking at one o'clock that day, but you're not gonna start at 8:00 AM And so Gabapentin treats alcohol withdrawal. You can use Gabapentin to detox people off of alcohol. And in fact, early Covid asam, the American Society for Addiction Medicine came out with guidelines to utilize gabapentin for withdrawal. And so we don't do detox at Rio Health. You know, if people are coming in, drinking 8, 10, 12 drinks a day, the advice always is don't go cold Turkey. A lot of patients come in doing 10 drinks a day, like, and I gotta do something. They have a crisis in their life and they stop cold Turkey. They have a seizure. And they end up in the hospital or they get like a true delirium tremon, which is, you know, alcohol withdrawal. That's pretty unusual but can kill you. So anyway gabapentin also works for nerve pain. So some people who have sciatic or other pain, they'll have a, a side benefit of their pain being better. And then gabapentin, in addition, was studied to see if it helped people reduce drinking. And there was a great study done in 2015 that showed that indeed, between doses of 900 and 1800 milligrams a day, it helped people drink less. You know, and the mechanisms unknown, but I mean, the mechanism, the way, again, I think it were back to that enhancing gaba. You get more gaba, the Wellbeing Chemical and less Glutamate that, that what I call the agro neurotransmitter. I know I'm playing a little fast and loose, but this is just my, with the terminology, but this is just the way that I kind of interpret it and, you know, trying to translate what's going on at the neurotransmitter level to patient care. And honestly, we don't really know how any of these drugs work. Well, you know, at the end of the day, and you know that right? Particularly with antidepressants like collective shrug, so Gabapentin so this is great for people who come in. So specifically people who come in who can't sleep and alcohol jangles your nervous system. And so people who drink to go to sleep, guess what? They usually wake up in about three hours. They might have a panic attack. Sweating, shaking, nauseous. Oh, what do they do? They have a drink to go back to sleep. So if you take gabapentin at bedtime, not only will it get you to sleep cuz it's sedating, but it also will keep you asleep because what's it's doing? What is it doing at three in the morning? Hey, it's treating your alcohol withdrawal and it's the alcohol withdrawal that's waking you up frequently. Now gabapentin is. One of the reasons I'm so passionate about Gabapentin is that Gabapentin use is kind of under attack in the United States currently, and the reason it's under attack is that it's been found in toxicology of people who've overdosed on opioids. So you'll find, you know, heroin or fentanyl in a system. You also find gabapentin. So the narrative is that gabapentin is abusable. Gabapentin contributes to, to death. And so we need to schedule gabapentin as a controlled substance. And so, but the reality is, is a lot of people have gabapentin in their system, so people who use opioids, There's the people who inject heroin and fentanyl, but there's also the people who overuse prescription opioids and think of how many people have gotten addicted to prescription opioids to manage a pain condition. So what happens if you're managing chronic pain? You go to a pain doctor. What's the pain doctor responsible pain doctor gonna do? What are ways I can reduce your opioid? Dependence on opioids to manage your pain. What are, what can I do to do that? So we can get you on lower opioids? Gabapentin is one of them. Gabapentin is prescribed for pain, so a lot of those people with gabapentin in their system may have had it prescribed. And they're utilizing it to reduce their opioid usage. So anyway, Gabapentin has got, you know, a mark against it. Now Gabapentin is currently controlled in seven states. So to prescribe Gabapentin in one of these seven states, and I'm licensed in 10 states, I started with one and, and I'm licensed just in one state. That requires us, you have to get an additional. State DEA registration, right? So the dea, drug Enforcement Administration physicians who prescribe controlled substances need a national DEA number. Guess what? The states who are controlling it, you need to get a state DEA number. And of course, it costs $900 for two years. But so the bo, so the bottom line is there's a consideration currently to make Gabapentin controlled substance nationwide, and it's controlled at level five. Which is the very low end, right? So controlled substance one are abusable drugs, C2 or controlled substance. Two are things like stimulants and opioids, and then it goes down the line. So by be, by being scheduled five, there's an acknowledgement. It's not really addict as addictive as those other meds, but it's an extra step. And if gabapentin becomes controlled on a federal basis, then it's gonna be a barrier for people utilizing gabapentin. For alcohol use disorder. This has been studied. People don't overuse it. People don't misuse it. People don't divert it. And I can say my clinical practice prescribing gabapentin to hundreds of patients now, very unusual. Someone will come in and say, oh, I lost my prescription. I need a new one. Someone stole my prescription. I need a new one. And guess what? In patients I've treated with stimulants and opioids to a lesser degree, not uncommon. It's like the dog ate my homework, you know, my meds got stolen, you know, and, and Interesting. Yeah. And on one time basis it's fine. Give 'em the benefit of the doubt. And so, so with Gabapentin, and this is supporting research, so people who, alcohol is a primary problem. They are not misusing gabapentin. And so anyway, so it's kind of like, you know, Dr. Mendelson and I and the other physicians were kind of fired up on the topic because we wanna preserve access to gabapentin cuz it works well. And for people who drink cuz of anxiety, take a little bit of gabapentin during the day. Non-addictive, super safe. Doesn't cause toxicity in any organ system. Doesn't have a lot of drug interactions. Yeah, there's side effects, mostly sedation. And once in a while people will get really confused on it. Like, you know, one in a hundred, one in 200 and then it's like, whoa, we'll stop that. So there are clearly people who don't tolerate it, but it's usually, it's cuz of sedation and then we just reduce the dose. So interesting. So anyway, I gave you the long version. And then Topiramate. So what are FDA approved for? Alcohol, DIAM and abuse, naltrexone, acamprosate. And if you notice, our most often prescribed medications doesn't include Camra. It's Naltrexone one, Gabapentin two, topiramate three. So Topiramate another. Seizure medicine that's gone to other uses. What happens with, with epilepsy medicines is they often, by the time all the money's been spent to get them out to market, neurologists will go. I don't know. This doesn't work as well as the four that I prescribe all the time. And so they don't prescribe it for seizures much. So these drugs get, you know, quote, orphaned a little bit. And so Topiramate also been around for 30 years, 25 years. And I was there when we tested it for bipolar disorder. And actually gabapentin was tested for bipolar disorder. And as you might know, a lot of the treatments for bipolar disorder are anti-convulsants. Depakote Trileptal Tegretol historically. So we tried 'em. And guess what? They're pretty lousy mood stabilizers, so they're not prescribed for bipolar disorder. So Topiramate and then Topiramate got a bad rap, and in fact, the product name for Topiramate is Topamax and it got this derisive nickname of Dopamax. Mm-hmm. And the reality is topiramate, not uncommonly, makes people have trouble with their memory, finding words confused. Not everybody does, and it's dose dependent. And again, informed consent first visit Topiramate. I'm always like, here's a downside that if you get anything like this, we either need to reduce the dose or stop it. It's, it's reversible. It's not permanent. However, for those who tolerate it in doses, kind of between, I would say 25 and 75, I'd say 25 and a hundred milligrams a day it can work really well for craving, also mediated by GABA and glutamate. And it's been studied. Also, really good studies show that Topiramate effective in helping people drink less. So it's a great alternative to Naltrexone. So Naltrexone, people don't tolerate it or it doesn't work. We go with Topiramate after that. And you know, often you can stop the Naltrexone and start the Topiramate. Sometimes we keep, keep them all going. So Topiramate. I would say it's next up and the hard part is getting people to tolerate it. So Topiramate Topamax used for migraine prevention was used as an appetite suppressant before this new wave of, you know, obviously Ozempic and Wogo V and Manjaro. This, this, the GLP one agonist glucagon-like peptide. Before this new wave, it was. It was to Topamax and then stimulants, right? And so they're, you know, the newer agents are obviously less problematic than, than the older agents. So Topiramate been around. Doctors were, you know, inveterate. Were like, oh, it doesn't work for seizures. Let's see what it does work for. So, Deb: Really interesting. Thank you. And the, and those, some of those drugs I wasn't aware, had that alternative use to help with, mm-hmm. Cravings and alcohol use disorder. Can some people take just a Gabba supplement, like when they are withdrawing? You know, I know you can even get those o over the counter. Is that. Something you would ever recommend? Dr. Linde: I would say that there's no harm in trying, and in theory it could help. I mean, I think it depends on how bad it is. I mean, I think, you know, a hangover is alcohol withdrawal. I mean, it's the mildest end of the spectrum. I don't think there's any harm in taking GABA for a hangover, but I think if you're sweating, shaking, heart racing and gonna throw up, I mean, I don't think it's gonna work for that. So I don't think there's any downside. And I, but I would say, you know, and I don't know anecdotally gaba for hangovers, whether it works or not. Or not, yeah. But it's, there's, there's no harm in trying. Deb: Sure. And I'm not just thinking about like, hangovers, just like, okay, I'm gonna take a 30 day break these first 10 days, my sleep is off, I'm off. You know, I'm getting back to balance. Yeah. Like, yeah, I, I've. Recommended gaba, but I was curious your thoughts. Dr. Linde: Well, I think as you know, it's, I'm gonna give you two answers. One is I'm very open to alternatives, and when it comes in the form of nutritional supplements, I'm, I'm okay with that. The other thing I'm gonna say, however, is that hasn't been studied. Mm-hmm. For sleep craving anything. It's all anecdotal evidence. And then the reason, you know, pharmacological drugs are prescribed, ideally is because they've been tested and they work and you're gonna get the oomph you might need. So we have people come in on supplements and again, I'm, I'm open, you know, and if it's long as it's doing no harm, it's fine, but, I think if it's a really pretty serious drinking problem, for example you know, taking Naltrexone according to the Sinclair method, which we can talk about, you know, that would be taking a pharmaceutical A couple times a week. You're not taking it every day. So for people who are hesitant about medications or sensitive to medications, I'm happy to have that conversation. But I might encourage you to take naltrexone, you know, on Friday night, Saturday night when you're hitting it hard instead of relying on, you know, over the counter nutritional supplement to do that. Oh Deb: yeah, for sure. Yeah. Yeah. So, and, and this question comes up a lot and since you have all this experience and working in the er, what should people be concerned about with alcohol withdrawals? Okay. Especially those first four days. Dr. Linde: Great, great question. So alcohol withdrawal on the mild end of the spectrum is a really bad hangover. And then alcohol withdrawal occurs on a spectrum. From, you know, a hangover to seizures and delirium, Trumans and being in the ICU and perhaps dying. So it's a very wide spectrum. What's helpful is to understand the time course because these things occur usually in a progressive fashion. So obviously people who drink a lot and drink every day and have been doing so for months. When they stop abruptly, they're at the greatest risk. So that's that 10 or more drinks a day, usually spirits, so like the people who are drinking a, you know, A court of vodka every day for example, and stop abruptly are at highest risk. And then, but you can get it at lower levels, but usually it's people who are drinking six or more pretty consistently that are gonna get into trouble. So here's the progression. So the first kind of, you know, four to. You know, 18 hours after stopping drinking, you're gonna get what I call garden variety alcohol withdrawal. And that is sweating, shaking, nausea, vomiting, headaches, heart racing. If you're in a medical setting, you're gonna have hypertension, you're gonna have high blood pressure, your heart rate's gonna be elevated but you're gonna be not be confused, you're gonna know where you're at, who you are, et cetera, so that it's very uncomfortable. And the reason you treat it is so it doesn't progress to the next level. And also you treat it because it's a way of sort of encouraging a person to perhaps consider going into an abstinence based program. You know, to do a detox, to do a medical detox. So once you get out to 24 to 48 hours, let's say, that goes untreated. So you're gonna be very uncomfortable. Then you get 24 to 48 hours out. That's when the risk of a seizure is particularly at 48 hours. So you can have a grand mal, generalized tonic-clonic seizure from alcohol withdrawal. If the seizure continues, it could kill you. But in general, the seizures are once and they're self-limited. And at that point, people usually will go to an ER at that point. So, The next stage is delirium, tremon dts. That's usually at about 72 hours after your last drink, so it drives me crazy. People use the term DTS very casually, and they shouldn't. That's why I use the term garden variety alcohol withdrawal for earlier withdrawal. But DTS Delirium, Trumans is a very specific syndrome where people have confusion, they don't know where they're at. They may be seeing things, they may be feeling things crawling on their skin and. The thing that gets people in trouble medically is that you get an inability to control your vital signs, so you get autonomic instability. So, and that's what kills people in the I C U. So these people are delirious, totally confused, admitted to the I C U. It's been diagnosed alcohol withdrawal. So they're getting benzodiazepines, they're getting iv. Medications to treat the withdrawal, and then they're getting supportive care, right? They're having their vital signs monitored, et cetera. So what happens is that literally blood pressure and heart rate become unmanageable like in an I C U setting, let's say my blood pressure goes low. There are things you do medically to increase your blood pressure to a normal level. But if you do that, and then it goes up to dangerous hypertension. Well, there are ways to bring that down, but basically what happens, people get yo-yoing of their heart rate and their blood pressure, and the ICU's great at bringing one up or down. But if it's yo-yoing, then people, people die from that. And so of people who develop dts, the mortality rate is about. I think it's 30%. It's high. So that's not to scare anybody. I do think that just the, the message, the single public health message is like, if you're drinking every day and you're drinking six or more, don't go cold Turkey. Honestly, probably four or more, we're gonna be very uncomfortable. I've had people who've done tender drinks today and gone cold Turkey, and for whatever reason got through it. And didn't have a seizure. And then started, you know, on a path of, of recovery. But I've also had probably more patients who said, yeah, I had a seizure, I had a withdrawal seizure, and that scared me. And so they got the appropriate medical treatment and they start on their path of recovery. And unfortunately, humans, you know, we're. Notorious for not making changes unless we're faced with adverse consequences, right? I mean, if we're like, oh, I'm doing it to make myself a better person, it's like, God bless you. You know, you're rare. It's when we, the shit hits the fan. You know, your partner's gonna leave you. Your boss is gonna fire you. You're alienating people. You're depressed, you're anxious, you're a mess cuz your life is falling apart. You know, that's when people get help. I guess I veered off there, didn't I? Deb: No, you, I mean, you walked us through what happens and you're right, like it is something people are really scared of and it keeps. I think it keeps people stuck too, like, yeah, oh, well I don't wanna quit drinking because I could die from withdrawal. And yeah, I mean, yeah, just emphasizing. The signs. Mm-hmm. And then knowing there's ways to get help and then yeah. And that it is not, it is more rare mm-hmm. Than we think, but like, be medical professionals, you have to just say, Hey, these are what we get concerned about and here's why. Dr. Linde: Right, right. And then of course, the other negative health effects of, of chronic drinking. You know, On multiple organ systems, you can blow out your liver, you know, with drinking. It's true. It impacts your heart. It's commonly associated with atrial fibrillation, which is, you know, dysrhythmia of your heart, which can lead to strokes, which can lead to heart disease. It affects our brains, obviously, causes depression in heavy, long-term use can cause dementia. It affects our bone marrow. So in long-term, heavy drinking it, you can have anemia and reduce white blood cells and reduce platelets. It affects our endocrine system. Adversely, it affects our sex organs adversely. It inhibits a production of normal sex hormones testosterone and estrogen. And so people have consequences from that in their sex lives and in their health. I'm probably forgetting some organ system. It's, well, Deb: I mean, it's every Dr. Linde: and your nervous system, your peripheral nervous system. So long-term drinkers, you get numbness and tingling in their extremities. So, yeah. Deb: Yeah, it, I mean, it's every system of your body, right? Yeah. And when you were talking about the meds and you're like, they're safe. They've been studied. And I just, it kind of makes me chuckle because I, I know a lot of people who are really like conscious of. What they put in their body. Maybe they're eating organically and they're going to yoga or whatever and and also maybe they're concerned about these meds and they're concerned about taking these meds to help them decrease their drinking when it's like, okay, but the alcohol is the poison. Like this. Dr. Linde: Exactly. Toxin. A lot of people say, I don't want to take Naltrexone cuz it will impact my liver and. The fear of naltrexone causing liver damage has been kind of overblown. Yeah. And liver specialists prescribe naltrexone. It, it gets problematic when people have what's called decompensated cirrhosis, literally end stage liver disease. But even people with early cirrhosis, it's one of the drugs of choice to help people reduce their drinking so that, so they say, well, I don't want to take it cuz it'll affect my liver. And I'm like, Yeah, very. You know, rare chance, but I mean compared to alcohol, so anything. Exactly. Deb: Yeah. Dr. Linde: And then the other conversation I have all the time, it's like, listen, these medicines are not lifetime, right. They're really are transitional. And that's conversation at Rio Health. I have with patients all the time, like, how long do I have to be on this? And you know, it varies from person to person, but it's not meant to be a lifetime. What really changes people in the long run are not the medications it's making. The behavioral changes and the habit changes. And that's where for us, the coaching comes in. You know, obviously the doctors and nurse practitioners, we spend time talking to people about behavioral change, but the coaches really focus on that. I mean, they use cognitive behavioral therapy, they use motivational interviewing, but at the end of the day, it's tips and strategies. For drinking less, a lot of that. So yeah. And I always tell people the medications can be super helpful and we're gonna maximize them, but at the end of the day, it's gonna be on you to change your behavior. And it's tough. And I'll be here with you during the process cuz you're gonna have times you do better, you're gonna have times you do worse. There are times you're gonna want to give up, but it's a process and I think it's hard for us to bite off sort of chunks more than. You know, a day or an hour. Deb: Absolutely. Oh yeah. It's definitely mindset. Can we talk about how you use a breathalyzer, how that might be a tool? Dr. Linde: Yeah, great question. And you know, again, when I came to Rio Health I was like, what's this about? In fact, you know, I'm friends with Dr. Mendelson who started the company and he was nagging me to come work for Rio Health for years, but, When you work for an academic institution, they have you kind of wrapped up. So he actually brought a breathalyzer to dinner at our house a few years ago, and we were drinking wine. I mean, we weren't getting wasted, but we were drinking some wine and passed the breathalyzer around the table. And and, and he explained this and I'm like, I don't know what you're talking about. So what we do is we, we ship a breathalyzer to all the new patients. And basically the instructions are, is to blow on the breathalyzer. So the breathalyzer is linked via Bluetooth. To the app. So everybody downloads r app when they enter the program. And so you blow into the breathalyzer automatically registers in your app. So when it registers in your app, you can see what the numbers, you see the number anyway, but you can see the number recorded. And then let's say in fact later today I'm gonna be seeing patients I'm reviewing their breathalyzer data before I see them. So it's another point of data for us and it's outcome data. Some people don't like to breathalyze cuz they feel ashamed and. Other people feel like it's, they love having the data and really what I hear a lot is they like the accountability and they like the habit it builds in. So I have people who've stopped drinking for a month and a number of 'em still blow zeros every day because it's a reminder. They're in this for the long haul and they like to see all those zeros. Other people, like, I'm not, I haven't drank in a month. Why am I gonna continue to breathalyze? So people use it in different ways, but basically it's data for us and it's data for the patients. And a lot of the patients we have are, you know, work in tech or their quantitative in their careers. They really like it. Some people just. Because what happens is like, well I was blowing 0.1, oh 0.12 in the evening, so we have people blow first thing in the morning and at and, and at night before they go to bed. And then they're sort of drinking, reduce their drinking. And it's like, you know, I'm, now I drink to 0.0 4.06, so they know how much alcohol it would be. To get a 0.0 4.06, so, you know, maybe coming in, drinking six or seven and now they're drinking two, maybe three. So people do use the data and I don't, I think it's unique. What I hear all the time is how do you know that they're. The one blowing in it, and it's like we don't do enforce sobriety, so there are ways to measure that and increase the cost by about two, $300 a month. And so we don't do it for that. But essentially my experience, people come to Rio Health, they're motivated. They've done a lot of things already and what appeals to them is sort of the collaborative nature of the work that we do. The fact that it's convenient, the fact that it's private on the fact that we're not doctrinaire, we don't tell you, we don't shame you and say if you don't stop drinking. You'll be an alcoholic forever. I don't have any problems with aa. I think AA is wonderful for so many people, and we have patients who use AA in addition to our program. I don't have any problem with a, but AA does not work for everyone. It is not it's not the only way to recovery. So I Deb: appreciate that. Well, I, I really appreciate what you're doing and coming on really turned into like a class about different medication options. And like you said, there's more than one way to change your drinking and what that looks like for you, whether that's drinking less or not at all. We're all on these different journeys and mm-hmm. So I think it's great that Ria Health is out there. How can someone find it or find you? So Dr. Linde: probably easiest on the internet. And so we have a phone number you can call and speak to an enrollment counselor if you like. And I guess what I'd like to emphasize is we really. Believe what we say, it's for people who want to change their relationship with alcohol. And I would say the majority of people come with a goal of reducing, and I've seen it over and over again. People can reduce I, so I don't necessarily believe the old school teaching about it. People can reduce and stay reduced for an sustained period of time. So, so that's best way is check out the website. You can make an appointment, talk to an enrollment specialist, and then the goal is to get people to talk to both a doctor and a coaching supervisor within a few days. Awesome. Sometimes even, sometimes even same day, but certainly within three or four days. Have a first and, Deb: okay. And would this only be available in the United States or worldwide or like does insurance cover it or, Dr. Linde: yeah. Great question. So it's, we are only in the United States currently, but we have licensed and credentialed doctors and nurse practitioners in all 50 states. So it's available nationwide. We do have contracts with multiple insurance companies and it's often covered by insurance. If not, there's a self-pay option, which is certainly reasonable compared to, to residential treatment or an i o P. And we're always working on, in, in increasing our payer network. It's it's good, but we want to have more contracts. Deb: Wonderful. Well, thank you. Thank you so much for taking the time to talk today. Dr. Linde: Thanks so much. I really appreciate it.

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