“Your patients are using drugs, whether you know it or not.”
That was the message from Oluwole Jegede, MD, addiction psychiatrist at Connecticut Mental Health Center (CMHC), at a session of his Addiction Education Seminar this spring. The monthly seminar, a popular offering designed for busy clinicians, promises to build on its success when it returns for another year, beginning in August.
Dr. Jegede, who serves as director of the Medication for Addiction Treatment (MAT) Consultation Clinic at CMHC and is an assistant professor in the Yale Department of Psychiatry, told his seminar audience that substance use disorders are among the most difficult medical problems to treat due to the complex web of “bio-psycho-social” factors facing patients who use drugs, alcohol, and/or tobacco.
Those factors include family history, genetics, poverty, trauma, stress, and often, serious mental illness.
Yet the hard work of treating people with substance use disorders is happening every day at Connecticut Mental Health Center, and Dr. Jegede shared a message of hope for the clinicians in his seminar.
“I don’t want you to think you’re not competent to treat addictions, because you definitely are,” he said. “We all have roles to play—neighbors, family members, community members, clinicians, clients. It takes a village.”
In recent years, the risks associated with using substances have grown across New Haven and throughout the country. Highly addictive laboratory-manufactured substances such as fentanyl are compounding the dangers. As the chemistry of synthetic drugs keeps changing, the professional community scrambles to keep up.
Moreover, the COVID-19 pandemic has created conditions for isolation and loneliness, exacerbating people’s mental health challenges. Substance use disorders had already skyrocketed before COVID; now we have what Dr. Jegede calls a “pandemic within a pandemic” in which many people with substance use disorders are using multiple substances, often at the same time. The danger of multiple use, Dr. Jegede said, is “exponentially greater” than single use. Not surprisingly, overdose deaths continue to rise. It all amounts to a time of serious crisis.
“We understand what cocaine, heroin, and fentanyl are—but when you compound drugs, it changes the chemicals and they become unpredictable,” he explained. “We need to have a more open mind and develop more tools to treat addiction.”
The Addiction Education Seminar provides a space for clinical staff—nurses, social workers, physicians and others—to process all of these factors in a supportive space. They come together to hear the latest in substance use treatments, ask questions about specific patients, and share knowledge with each other. Originally created by Dr. Ayana Jordan, founding director of the MAT Clinic, the seminar is overseen today by Dr. Jegede and led by CMHC’s Addiction Psychiatry Fellow focusing on community outreach and education. Fabiola Arbelo Cruz, MD, now an attending physician at CMHC, made the seminar presentations during the 2021-22 academic year as a fellow in addiction medicine.
“It was lovely, it was amazing,” Dr. Arbelo Cruz said of the experience. “I wanted to make sure we shared the most accurate, up-to-date information, and most importantly, to make that information available in colloquial, easy-to-grasp terms. My hope is that whatever I teach people, they’re able to use it with their patients as well. It’s an exchange of knowledge.”
Dr. Arbelo Cruz grew up in Quebradillas, Puerto Rico and her interest in substance use disorders started before medical school, when she served as a street outreach worker in Ponce, a large city on Puerto Rico’s southern coast. What she witnessed opened her eyes and heart and helped chart her professional course.
“I was shocked to see how much untreated mental illness there was in the community,” she recalled, “especially among the homeless. They didn’t have easy access to treatment.” The situation is not unlike what happens in New Haven, a city around the same size as Ponce, also with high levels of poverty and similarly vulnerable populations.
“I learned that there is so much more to a person beyond mental illness and addiction,” Dr. Arbelo Cruz added. “In conversing with people, I learned about them and their stories. They taught me a lot.”
For her first Addiction Education Seminar last fall, Dr. Arbelo Cruz began with a topic she is passionate about: stigma and language. Words matter, and people with substance use disorders are often characterized in ways that are demeaning. For example, instead of using “dirty” and “clean” to describe urine toxicology lab reports, Dr. Arbelo Cruz recommended the more neutral words “positive” and “negative.” Instead of calling a patient an “addict” (or the even more pejorative term “drug seeking”), she and Dr. Jegede prefer “people with substance use disorders” or “people with addiction.”
In subsequent Addiction Education Seminars Dr. Arbelo Cruz covered all of the most common substance use disorders and their recommended treatments: opioids, cocaine, alcohol, tobacco. The seminar is designed to serve as a resource for general providers at CMHC, many of whom have different backgrounds and training. Because the realities of substance use on the ground change so quickly, it is invaluable to have a space where the latest information is shared by specialists such as Dr. Jegede and Dr. Arbelo Cruz.
Many people use substances (especially alcohol) recreationally; when does substance use become a “disorder?”
“The short answer is when people really get effected in certain areas of their lives,” explained Dr. Arbelo Cruz. “People become non-functional, but non-functional in what? A person can be functional in relationships, self-care, work, parenthood—there are many areas.” Under the current diagnostic manual's list of eleven criteria, she said, “If someone meets two or more criteria for 12 or more months, they have a disorder, whether mild, moderate, or severe.”
For many people, mental illness is an underlying factor in substance use disorder. The genetic component of addiction is also very strong: when a parent has addiction, data shows that the likelihood their children will have it is also very high. Social determinants such as race and gender discrimination also play a role, especially in how different people are treated by the medical establishment. Dr. Arbelo Cruz follows the literature related to substance use disorders and the social determinants of health, and she offered research findings at every seminar. It’s a way, she said, to help “all of us” caregivers raise inner consciousness and avoid stereotyping patients.
In the recent seminar, one social worker asked for advice regarding a patient diagnosed with schizophrenia who uses PCP.
“In this patient, we want to get the addiction under control, but in addition, we want to clarify that it is not the mental illness that is causing them to use,” advised Dr. Jegede. “Many times patients with schizophrenia don’t have enough dopamine in their prefrontal cortex, which is why they are so much more likely to smoke—it helps them feel happy. If we can fix the mental illness, that will also have an indirect impact on the addiction. PCP is a hallucinogen and can cause psychosis.”
As they discussed further strategies for helping the patient, an approach emerged. A difficult spiral began to feel like a problem with a potential solution. Overall, the Addiction Education Seminar is a win-win for everyone: clinical staff benefit in their work with patients, Dr. Jegede shares his knowledge to help patients beyond the walls of his small clinic, and the Addiction Psychiatry Fellow gains experience in educating others.
“Substance use disorder is a chronic disease,” reflected Dr. Jegede. “Many people can have this cycle many times in a single day. Clinicians really want to have tools to be able to provide better care.”
Dr. Arbelo Cruz agreed. “We need to keep talking about addictions,” she said. “People want to hear it. They have questions. For me, just knowing there were questions at the end of every presentation—that made me happy. We all want to help our patients.”