(16 mins) In the second installment of a two part interview, Hackie Reitman, M.D. welcomes back Bankole A. Johnson, DSc, MD, MBChB, MPhil, FRCPsych, DFAPA, Dip-ABAM, Dip-ABDA, FACFEI, who heads the Brain Science Research Consortium Unit (BSRCU) at the University of Maryland School of Medicine, and is one of the world’s leading authorities on the subject of addiction. He is a leading neuroscientist and a pioneer in the development of medications for the treatment of alcohol abuse, and was featured on the HBO documentary series, “Addiction.” They discuss the growing crisis involving opioids, the challenges of battling pain, and what doctors can do differently to discourage addiction.
FOR PART ONE, CLICK HERE
To find out more about Professor Bankole Johnson and the work he is doing with the Brain Science Research Consortium Unit (BSRCU), visit: medschool.umaryland.edu/bsrcu
For Professor Johnson’s personal site, visit: http://bankolejohnson.com/
For the psychiatry department at the University of Maryland School of Medicine, visit: medschool.umaryland.edu/psychiatry
For information about the HBO Addiction project, for which Professor Bankole Johnson was a contributing expert, visit: www.hbo.com/addiction
And Professor Johnson can be followed on Twitter here: https://twitter.com/bankolekolej
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HACKIE REITMAN (HR): Hi, I’m Dr. Hackie Reitman; we’re continuing our conversation with my friend, Dr. Bankole Johnson from the University of Maryland, who is one of the world’s authorities on the brain and addiction and so much more. Cole, welcome to our show.
PROF. BANKOLE JOHNSON (BJ): Thank you for having me on your show. It is great to be here and I’m looking forward to our discussion this afternoon.
HR: I noticed on your, uhh, your fascinating website, BankoleJohnson.com, you’re quite a writer and you write a lot of stories and everything but you also take note of certain, uhh, news stories going on and, umm, I’d like to get your comments on the opioid crisis and the recent emergency that was declared about it.
BJ: Well, as you know, the opioid crisis is upon us and it seems to be deeply rather than getting any better and for the first time, umm, the lifespan of individuals in the United States is decreasing. And that tells you that it’s a powerful, it’s producing a powerful toll in the economy and this is going to be a toll that must be borne by our health system. But there are many reasons why this has happened, but one of the myths to discount, to really dispel is that this is not a simple phenomenon because people are bringing more drugs into the United States. That’s probably true. But this was a crisis, I think, primarily created because doctors couldn’t treat pain very well and being told they weren’t giving enough pain treatment and pain medication to the point where now doctors were overprescribing pain medication and now the number of people who were affected has mushroomed. You know, I can give you a very simple example, I, I was at a hospital; it was about a year ago. I had a chest infection, and I was given some Oxycodone tablets to take to reduce my cough, and even when I left and I was given my discharge prescription, I was given 60 tablets of Oxycodone. Who needs 60 tablets of Oxycodone? But the protocols were I got 60 tablets of Oxycodone. Now, if I took those Oxy-, uhh, as soon as I got home, and I, my, my wife opened the packet and she saw all these Oxycodone tablets, she did the smart thing. She just opened up the, the, the loo and then she dumped all, practically all of them in them and that was it, but you can imagine if you had those sitting on your shelf and now you have something else happened, well, here’s now some Oxycodone for something else, and here’s now continuous Oxycodone. Now, umm, your family now has access to it. Lord forbid your kids have access to it. So there are so many of these tablets that were being dispensed that the level of addiction was being picked up. The second point was, I think, a lack of good medical training. You know, if you in a, almost any university in the United States, I always tease, and it sometimes gets me into trouble, you know, but, you know we had, uhh, a sort of ebola crisis in the United States, and we all had to stop to learn about ebola and how to detect cases, so it actually took probably a week to a month of most doctor’s time to get up to speed. Well, where were all the cases? Yet when you go to medical school, you get probably two weeks of trea-, uhh, work and help on learning how to treat pain. You get a couple of weeks of addiction and no one’s teaching you how to deal with the opioid crisis. Yet it’s what killing 64 to 65 thousand Americans. So in a sense, the medical system and the medical curriculum will very slowly and not responsive in the way to helping young doctors learn how to treat pain and addiction better.
HR: And, you know that I consider pain a neurodiversity and that neuroplasticity changes the wiring in your brain as you go. Umm, American medical schools and residencies give very little training for pain, for autism, for Alzheimer’s. It just isn’t unless you sub-sub-subspecialize. The other thing I would like just want to mention is that the, the, the other elephant in the room is I remember when Oxyc ontin first came out, Oxycodone and everything. The, umm, the drug rep was saying that it’s unlike Percodan and Percoset, it’s not addictive, it doesn’t give you a buzz. You don’t have to worry about that, and I was always of the ilk that I would educate the patient, like before I did arthroscopic surgery: I’m going to give you a cryo cuff; you’re going to come in the day after the surgery; you’re going to be walking; I’m going to give you maybe three pain killers but I don’t think you’ll need them. I put all the positive things in. Some of my partners thought I was a little bit draconian that way, but I rather have the patient call me because you’re not supposed to have pain, you know, and so forth. So at the time, I was boxing and I was down at the gym in Miami, down at the old 5th Street Gym, and, uhh, a lot of times, some of the fighters, you know many of them have been in and out of jail and they’re all nice in the gym but you know, they’ve been around and they’re trying to hustle, so, “Hey, doc,” they would come up, “Can I have a Percodan, my back is hurting,” and I tell them, “Come on you know better, I’m not going to do anything like that.” So one day, after the drug reps were around and everything and “You can’t get a buzz from this,” and “Just give it every 12 hours,” I’m down at the gym and one of the usual suspects comes up and says “Hey Hackie. You know, my back’s really hurting. Can you get me some oxycodone?” And I said, “You know I’m not going to do that.” I said, “But by the way, the drug rep told me that you don’t get a buzz out of that, it doesn’t get you high, and it’s not really like that.” And he said, “Well, you ask the drug rep why I’m getting $5 for a Percodan and $10 for an Oxycodone.” And I notified the drug company. I tried to get through, because you know I was very idealistic about it and I thought maybe it was an honest mistake.
HR: But the fact of the matter is these, as you well point out, these prescriptions for 60 strong pain killers or 90 or whatever.
BJ: They’re unnecessary, and that, but people are following protocol and I think you know one of the important aspects of pain management is everybody thinks that pain is simply a sensation. Pain is very complex and is represented in most of us, umm, in the parts of the brain that are also associated with mood regulation and that’s why various people have various levels of thresholds and appreciation of pain and therefore the treatment of pain leads to be more, I would say more complex. Not everybody requires an opiate because they have pain. Some people may require behavioral treatments, some people may benefit from talk therapy, some may benefit from yoga, some people will benefit from electrical stimulation, some people will have various complications including their medicine… but to simply have an opiate narcotic as the only armamentarium to treat someone with pain is pretty poor treatment of pain indeed and patients don’t tend to be satisfied by that approach either.
HR: Can you talk about some of the, umm, organic or biological pathways that are expressed when one is taught breathing exercises for pain which seem to help quite a bit?
BJ: Well most of the breathing exercises are associated with reducing stimulation through our suppression of activity and activation of more vagal stimuli. So then the person feels calmer and the person is able to take deeper breaths. That actually has an impact on brain neurochemistry. More recently it has been suggested that deep breathing exercises and such do tend to affect also other neurochemicals in the brain, specifically dopamine. And those produce, if you like, umm, because dopamine is also linked and correlates with opioids in the, in the brain, it actually produces a sort of euphoric effect. Now people won’t feel pure euphoria but they will feel relaxation; they feel a reduction in tension… and then the use of either deep breathing exercises or actual physical exercise: riding a bike or being in the gym, might also be important for the modulation of pain and the modulation of addictive processes, and that is actually being studied quite actively now in the national institutes of health because the more we can incorporate our understanding of more natural ways to improve our mental health, the better actually it is for everyone to be able to, uhh, prevent, uhh, mental illness and mental disease. You know, one of the jokes as I came as I told you this morning, I said, “You know, not many people wake up and say, ‘Gosh what am I going to do for my brain today? How am I going to optimize my brain today and make sure it’s in great working order?’ You know, the same people who’d get out of bed and say, ‘Gosh I’ve got to go for my five mile ride.’” They never think about, you know, what to do with your brain or what nutrients to, to have.
But I think as awareness advances, people will realize, I hope, that having a healthy brain is just, perhaps, I would argue, even more important than many aspects of physical strain because your brain conditions really how your body reacts and how your body can actually help you understand the world and to appreciate and enjoy the world. So one of the other things is and I tell this to my residents, and, uhh, if, if, if, if a patient came to you and you were an esteemed psychiatrist, you took out your pen and your wrote out on your prescription pad “This patient is completely free of all mental disorders and I declare the patient to be completely sane, logical, and fully responsible.” and you sign it “Dr. X” and you gave it to the patient to present to someone at work every day, people are going to laugh at it because they are going to say it sounds ridiculous for us doctors to write notes saying “This person is completely free of physical illness, physical pain, and is absolutely able to do their job.” So our understanding of this dichotomy between our physical health and mental health is very important. The second, uhh, piece of this is most people don’t think about prevention, you know, especially psychiatrists. Psychiatrists think more about mental illness and I’m beginning to try and work with my old faculty at the University of Maryland to focus on mental wellness because if you can get people to be able to look after their mental health, regulate their stress, take in the right nutrients, be able to appreciate when they have risks to their medical health and what to do about it long before they become mentally ill, then that is an important step to be able to improve the wellness of the community and a well community performs better than one that is not very well and that is stressed out.
HR: Cole, what is the single most important message in your view that you can give our viewers regarding addiction?
BJ: The best advice is that if you feel you have a problem with addiction that you should see your f-, your family practitioner or your doctor. And the reason is if I’m your practitioner doctor I’ll be able to take a full physical and medical history from you and be able to determine whether you need appropriate treatment. One of the other things we found is that most individuals who have an addiction have all sorts of other disorders that are not being attended to, whether it’s their heart, their lungs, their blood pressure, or diabetes and so getting a good health check is important. The best message for hope is that addictive disorders are treatable and people do get better and worrying about being stigmatized by going to see a doctor is the wrong worry. It is better to be treated and well than to die of ignorance or to be harmed by ignorance. So it’s much better to go to your doc and get the treatment.
HR: Does the average doctor know about this stuff?
BJ: Not as much as they should, to be honest. I think it’s now behooving on a lot of specialists and the national institutes of health and also universities who have people who are knowledgeable to spread this knowledge and also people like you who are spreading this knowledge through the neurodiversity programs that you have. It is very important for that pressure to be put on for people to have public education. Uhh, take, for example, smoking. You know, before, umm, you know, Sir, Sir Richard Doll came out with the, uh, epidemiological study, a lot of people smoked. Doctors smoked and look how much has been achieved by public awareness of smoking and preventative health, and smoking rates have gone down so much so that tobacco companies have to find different populations to influence and basically different parts of the world to, to sell their, to sell their tobacco.
HR: Sure, and the Mothers Against Drunk Driving or the men’s one, wi-, the reason that driving drunk became not cool to do. When I was growing up it was cool to drive drunk. Then Mothers Against Drunk Driving came out.
BJ: It is not cool to drink and drive at all.
HR: That’s for sure; that’s for sure. It’s been a pleasure having you here. We’ve been speaking today with Dr. Bankole Johnson again. Thanks so much for returning; you’re terrific. Keep up the great work and thanks so much for being here at Different Brains.
BJ: Thank you so much Hackie and I admire everything you’re doing, uhh, in neurodiversity and it’s a pleasure to haven been on your show and good luck with everything. You’re really doing a stellar job educating the public. Thank you.