Renowned Addiction Specialist, Dr. John F. Kelly of Massachusetts General on Treating Addiction as a Chronic Disease

John Kelly

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Mark Masselli: This is Conversations on Health Care I’m Mark Masselli.

Margaret Flinter: I’m Margaret Flinter.

Mark Masselli: Well, Margaret eyes are on Washington as we wait and see what the
final version of the federal budget is going to look like. The budget deal worked out last
week to end the three day government shutdown included long term funding for CHIP
the Children’s Health Insurance Program. The nation’s community health centers are
still waiting for signs that their organizations w ill see renewed funding moving forward.

Margaret Flinter: Well, Mark I think it’s really important to note that the 1400 community
health center organizations in the United Sates are the essential primary care providers
to some 27 million Americans and th ey’re really on the frontlines of dealing with the
opioid epidemic.

Mark Masselli: The Trump Administration declare the opioid epidemic a national
emergency, but now they are talking about reducing th e budget for the so called Drug
Czars Office by 95%. O pioid overdose is now the leading the cause of accidental
deaths in America, 64,000 in 2016 alone.

Margaret Flinter: The experts predict that the numbers for 2017 are most certainly
going to be higher. That brings us to our guest today, we are going to r evisit our
interview with Dr. John Kelly an addiction medicine expert at Harvard Medical School
who also was the founder of the Recovery Research Institute. He’s been studying best
practices for long term substance use disorder and treatment.

Mark Massell i: We’re looking forward to that conversation along with Lori Robertson
who will stop by, she’s the managing editor of FactCheck.org. No matter what the topic
you can hear all of our shows by going to chcradio.com.

Margaret Flinter: As always if you hav e comments please email us at
[email protected] or find us on Facebook or Twitter we really do love to hear from
you.

Mark Masselli: We’ll get to our interview with Dr. John Kelly in just a moment.

Margaret Flinter : First here is our producer Marianne O’Hare with this week’s headline
news.

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Ma rianne O’Hare : I’m Marianne O’Hare with these health care headlines. Comings and
goings in health policy world, the Director of the Centers for Disease Control and

John Kelly

Pr evention has resigned. Dr. Brenda Fitzgerald the former Health Commissioner for the
state of Georgia was found to have purchased stocks in several tobacco companies
after assuming the home of the CDC. In spite of having made public comments
promising to work on curtailing tobacco consumption. An investigation by the
publication Politico found that after being told by HHS attorneys to divest a number of
her stock holdings and things like large pharmaceutical companies and other tobacco
entities as well as large food companies, she went on to purchase stocks in Japan
tobacco a large exporter of tobacco products into the US. While not illegal it does
present a conflict of interest, according the Matthew Myers President of the Campaign
for Tobacco - Free Kids her resignation was immediate.

The new director of the Department of Health and Human Services has been sworn in
Alex Azar former president of pharmaceutical giant Eli Lilly. The president promising
Azar will, quote “Bring drug prices way down.” Three he avy hitters muscling into health
care in a big announcement this week though lacking in specific details. Amazon’s Jeff
Bezos, Berkshire Hathaway ’s Warren Buffett and JP Morgan’s Jamie Dimon
announcing they formed a consortium whose goal is to disrupt hea lth care specifically
the cost. The announcement came in the form of a press release suggesting that this
disruption would be tech based and would only be used to provide health services for
their specific company employees for now. Effort such as compan y wellness programs
and cost sharing initiatives have not move a needle on health care cost, in fact study
after study shows they really don’t work. The American government provides health
care for more than employers do through Medicare, Medicaid and vet erans programs.
Those entities have not managed either to significantly reduce health care cost. I’m
Marianne O’Hare with these health care headlines.

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Mark Masselli: We’re speaking today with Dr. John F. Kelly founder and director of the
Recovery Research institute at Massachusetts General Hospital and Associate
Professor of Psychiatry at Harvard Medical School. Dr. Kelly is Associate Director of
the Center for Addiction Medicine at Mass General. He is past president of the
American Psyc hological Association and the Society of Addiction Psychology. He has
served as consultant to the White House Office of the National Drug Control Policy. He
earned his bachelor’s of science from Tufts and his doctors of philosophy in clinical
psychology from the University of San Diego. Dr. Kelly welcome to Conversations on
Health Care.

Dr. John Kelly: Thank you, glad to be here.

Mark Masselli: Yeah, I don’t think there’s a community or a family that hasn’t been
touched or impacted by this drug addicti on and overdose epidemic. I’m just wondering

John Kelly

if you could help put in perspective for our listeners the public health crisis we now find
ourselves in, and why the nation’s response seems to be falling so short?

Dr. John Kelly: About 33,000 people died fr om an opioid overdose in 2015 and this has
gone up actually over the last couple of years as well. Of course this is occurring in the
context of a broader public health crisis with addiction alcohol and other drug use
disorders. We’ve seen this very star k and sharp increase in opioid, begun in part by the
over prescribing of opioid medications which has led to increased availability, easy
access ability. The nature of these drugs they are very potent, they are very seductive.
What happens is because the y are so seductive in human brain that they can seduce
people into repetitive administration exposure, and then what’s happened is that as
people have been unable to obtain the prescription medications they’ve gone to
cheaper availability of opioids in the form of heroin.

I think there is a sense of crisis but I think it’s been way too small, it’s really lacked the
sense of urgency that’s really needed. Certainly there is a sense of urgency, I go and
speak to family groups, I’m on the board of a family org anization to help family members
who are affected by opioid addiction among their love ones. You really get the sense of
urgency when you are attending these groups, parents, mothers who’ve lost their kids to
opioid addiction. There is a sense of disconn ection I think that the politicians are
suffering from themselves that is a very apparent when you are living in the
communities affected by these opioid overdoses.

Margaret Flinter: Well, Dr. Kelly you’ve said that the scientific understanding of
addicti on disorders has grown significantly in recent years. I think we’d all probably
agree addiction is still a diagnosis that just carries with it enormous stigma. Can you
help our listeners understand what is the clinical description understanding of addict ion
and how key are the roles of genomics as well neurophysiology in our current
understanding of how addiction works?

Dr. John Kelly: Yes we’ve known for at least a couple of hundred years that addiction is
disease that affects the brain. It’s just that our understanding of clarity and
understanding exactly the nature of the disease in the central nervous system in the
brain has been clarified now because of the tools that we now have. With neuroimaging
in particular that’s giving us insights into just the impact of chronic substance exposure
in the brain, as well as probably several decades now of genetic studies which help us
understand about cause and vulnerability to this particular disease. Now, we
understand addition as a disease of the brain that affects the neurocircuits of reward
memory motivation, impulse control and judgment. These kinds of faculties in the brain
are often radically impaired in moderate to severe substance use disorder. These
neurocircuits when they’re exposed chronically to substances they become changed as

John Kelly

the brain does its best to try and adapt to the presence of abnormally high level of a
reinforcing property in the form of a substance a drug.

The brains attempts what we call neuroadaptation, creates a cascade of neuroch emical
changes which makes it very difficult to stop the substance use. This is what we see
when we see withdraw symptoms, so the brain becomes accustomed to the presence of
the drug, and when you take the drug away people experience very unpleasant affec ts
from that absence of the drug. We can understand much more clearly through
neuroimaging exactly the nature and the neurocircuitry involved, not just functionally but
structurally. When we look at structural images things like magnetic resonance
imagin g, we can see structurally that the brain is also radically affected. The tissue
structures in the brain are diminished and impaired. An autopsy for example, with
chronic alcohol addiction the brains of people with chronic alcohol addiction way about
one third less than the age and gender match counterparts.

In terms of cause, the genetic space we know that we are all – had certain
vulnerabilities to certain diseases which are conferred by our genetic predisposition.
Addiction turns out to be no differen t, people may choose to pick up a drink of alcohol or
another drug and consume it, but the experience related to that initial exposure can be
very different depending on the nature of our gene. For example, if you take a drug like
alcohol to which a large proportion of the population is exposed, only about 15% will
actually become addicted, and that is because of the experience that is modulated by
their gene. Other people may kind of feel like they can just take it or leave it, and other
people will actu ally have an aversive response, they’ll say I don’t like the way that
makes me feel. That is modulated by their genetics, now of course that initial exposure
leads to repetition.

When you have a substance like alcohol being socially sanctioned, people are more
likely to repeat exposure to it and then for that particular vulnerable population they
become hooked, that is the process. They don’t choose to become addicted, and it’s
something that people when they’re on the other side of that, when they cross that line
into compulsive use, they find it very difficult to stop. It’s critically important that people
understand that there is this genetic influence on addiction which changes the brain,
we’re much clearer on both of those things now.

Mark Masselli: Dr. Kelly at Harvard you’ve brought science to the understanding of
what yields good clinical outcomes. You’ve said that with addiction treatment and
substance abuse disorders the pathways aren’t always clear and that from most
addiction disorders relaps e is very much part of the equation and that it takes multiple
attempts for most people to achieve sobriety. I’m wondering if you could address this
aspect of addiction medicine that relapse is almost a certainty.

John Kelly

Dr. John Kelly: Well when you think abou t it trying to change any behavior is hard, right.
I mean people make resolutions all the time to engaging, just going down the gym or
changing their diet. How hard is that for people to actually maintain, usually people start
off pretty well, but they t end to fade quickly, so these are people with generally healthy
brains. Now imagine that compounded with someone who has actually brain deficits,
the impairments in the brain that make it even more difficult to maintain that kind of goal
directed choice. You’re right, people don’t snap their fingers one day wake up and say I
want to be in recovery, I want to stop all this and then jump on the water wagon as it
were, rather it is a gradual process of change where people start to entertain the idea
and real ize that they may have a problem with compulsive use and they can’t stop that.
It becomes important for people understand what it takes to get and stay in recovery,
and it takes a lot of concerted consistent effort.

We know from these studies that after t he onset of addiction takes about four to five
years before people actually starts seeking help. It’s actually related to this issue of
stigma that makes people disincline to actually talk about it, acknowledge it and go seek
help for it. When people sta rt to seek help, it takes about eight years on average to get
one year of full sustain remission. The good news is that people are making a lot of
progress during that eight year period on their way to get one year of full sustain
remission, so someone mi ght get three months of abstinence and have a replace, might
get six months have a relapse. Most of those days are actually abstinence days, but to
get that one year continuous abstinence takes about eight years on average.

After someone achieves one year of full sustain remission it takes on average about
four to five years of sustained remission before the risk of relapse in the following year
drops below 15%. To be no more likely than anybody else in the general population to
meet criteria for substanc e use disorder if you’ve already had it takes about four to five
years of continuous remission. This is why we have placed much more emphasis in
more recent times on chronic recovery management, so providing ongoing, monitoring
and management of people wi th substance use disorder in the same way that we would
address hypertension or diabetes other kinds of chronic medical conditions. We’re now
starting to address this in behavioral health as well in a more long term form.

Margaret Flinter: Dr. Kelly you’ ve launched the research recovery institute at Mass
General to become the go - to resource for stakeholder seeking the best science in
addition medicine. On the frontlines primary care providers feel under siege somewhat
and under - resourced and overwhelmed as they attempt to deal with the opioid crisis
within their patient populations. We’ve use strategies like Project ECHO to bring
training information education to providers across the country focused on how to
correctly assess and managed chronic pain but also how to treat opioid addiction using
medication assisted treatment. How are you sharing your best practices from the
research recovery institute with stakeholders around the country?

John Kelly

Dr. John Kelly: Well, we’ve created a website at RecoveryAnswers.o rg that people can
go to, to access the most current up - to - date information on what we know from a
scientific perspective about effective implementation programs. A research has been
done in a field regarding new innovations in clinical care. We also hav e our social
media channels is one way that we communicate now to about a 100,000 people
around the country. We also publishing monthly free recovery bulletin which
disseminates this kind of information on a monthly basis using synthesize, contextualize
s ummaries of the current scientific literature. Those are some of the ways that we have
tried to get the latest signs out on opioid addiction treatment as well as ongoing issues
M ethamnetamine and alcohol and other disorders.

Mark Masselli: We’re speaking today with Dr. John F. Kelly Founder and Director of the
Recovery Research Institute at Massachusetts General Hospital and Professor of
Psychiatry at Harvard Medical School. Dr. Kelly we’ve had a number of mental health
and addiction advoca tes in our show including Obama White House Drug Czar Mike
Botticelli whom address the critical need for more resources to confront the opioid
epidemic. Wondering from a public policy initiative and addiction focus where do you
see limited resources been best invested?

Dr. John Kelly: This has been the top public health problem for a long time. It’s just that
we have seen this opioid crisis now kind of hit everybody’s radar screen. This is in
context of an endemic public health problem. I think what we need to do is training our
clinical work force to address the number one public health problem, so educating our
clinical workforce would be one strong policy initiative that needs to be implemented,
how do we train best train nurses and physicians other clinicians who are coming into
contact with people historically have not been screened for these high volume high
burden diseases because these disorders do affect the efficacy and effectiveness of
whatever else we try to do in clinical care. We started t o do that with making some in
rows but we have to move more quickly I think.

Also on the other side, so the populatio n overall in terms of education, educating young
people do a better job in schools about educating young people about the dangers of
substa nces and what it can do to their health. We would not allow this kind of thing to
happen in many other kinds of health that we’ve allowed to happen with this current
opioid crisis. These disorders tend to onset in late adolescence and young adulthood,
an d we do a poor job o really targeting when it’s most likely to onset. If this was cancer
we’d be spending a lot more money to making sure that we prevent onset, historically
what we’ve done in the addiction field we would say to people go away and come ba ck
when you are ready, and of course that’s at the stage four level of addiction, this is not
good enough.

John Kelly

The other thing is that we need more effective and smarter ways of treating and keeping
people in remission. We had a very short sighted acute care approach to a chronic
illness, we need to target much more effectively the true nature of this disease which
tends to be a chronic disease that is susceptible to relax for many years. We need to
do a better job of supporting people for over a five year pe riod, doesn’t have to be
intensive treatment, but it needs to be extensive treatment. Much like we would treat
other kinds of chronic diseases. We need to support mutual health groups, recovery
community centers, recovery support services and educational settings like recovery
high schools, police recovery programs which are shown to be highly cost effective so
that we can have intensive, more expensive intensive treatment for these conditions to
stabilize people but to enable and to sustain remission ove r the long term and build lives
worth living we need to support them in maintaining that remission overtime.

Margaret Flinter: We’ve been speaking today with Dr. John F. Kelly Founder and
Director of the Recovery Research Institute at Massachusetts Genera l Hospital. You
can learn more about the Recovery Research Institute at Mass General by going to
RecoveryAnswers.org. Dr. Kelly thank you so much for your work and for joining us on
Conversations on Health Care today.

Dr. John Kelly: Thank you so much f or having me I appreciate it.

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Mark Masselli: At Conversations on Health C are, we want our audience to be truly in
the know when it comes to the facts about health care reform and policy . Lori
Robertson is an award - winning journalist and Managing Editor of FactCheck.org, a non -
partisan, nonprofit consumer advocate for voters that aim to reduce the level of
deception in U.S. politics. Lori, what have you got for us this week?

Lori Robertson: The Federal Centers for Medicare and Medicaid Services is sued a
letter to state Medicaid programs in January providing guidance on why of a proposals
that would impose work requirements for Medicaid. By indicating that the administration
was open to such proposals from the states CMS was reversing course from p revious
administrations but haven’t approved such waivers. Medicaid is the state federal
program that provides health care coverage to low income individuals including adult,
children, the elderly and people with disabilities. So far one waiver from Kent ucky has
been approved and nine other state waivers on work requirements have been
submitted. Some Medicaid enrollees would likely be exempt from such requirements
including the elderly and disabled. What do we know about the non - disabled, non -
elderly ad ult population in Medicaid?

There were 24.6 million non - disabled, non - elderly adults with Medicaid coverage in
2016. 42% of them worked full - time according to the Kiser Family Foundations analysis

John Kelly

of data from the current population survey. Another 18% w orks part - time. Among the
rest 14% are not working due to illness or disability, 12% are caregivers to family
members, 6% are attending school and the remaining 7% are not working due to
another reason. The not working for other reason category includes those who are
retired and those who can’t find work among other reasons. Kentucky’s waiver program
would apply to both expansion adults, those who gained coverage under the affordable
care act expansion as well as traditional adults who had qualified prev iously. The work
requirement is 80 hours per month, an exemptions to that requirement would include
those age 65 and older, the medically frail or disabled, students and those providing
care giving for a relative. Work activities in addition to employmen t would include job
search, job training, volunteer service, education and drug treatment. The federal
guidance says states must evaluate the impact of these demonstration projects. That’s
my fact check for this week, I’m Lori Robertson Managing Editor o f FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you ’d like checked, email us at
CHCradio.com we ’ ll have FactCheck.org’s, Lori Robertson, check it out for you, here on
Conversations on Healthcare.

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Margaret Flinter: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and to everyday lives. Tel Aviv Computer Scientist
and developer Oded Ben Dov has been coding since he was six years old and he's
always been interested in hacking systems to make them better. W hen this young
entrepreneur unveiled a hands - free gaming system on Israeli TV local quadriplegic in
t he viewing audience took notice. The former Israeli naval officer contacted Ben Dov
and urged him to think about adapting this hands - free gaming system to help
quadriplegics interact with their smar t phones by using simple head movements .

Oded Ben Dov: The guy in the call said hello my name is Giora [ph] I can’t move my
hands or legs, could you make me a s mart phone I could use . T hat really caught my
ear, c aught my heart, it was a chance to apply a ll my tech knowledge towards greater
good.

Mark Masselli: The two h ave partner ed together on the project deciding to call the
device, Sesame Phone as in Open Sesame .

Oded Ben Dov: Someone could opt for big head movement or very small head
movement. You could use all ex tended voice commands or you could use a built - in
Google dictation capabilities. We really try to make it as wide as possible for audience.

John Kelly

Margaret Flinter: Ben Dov says he has seen both children and adults formerly locked in
by paralysi s literally come alive .

Oded Ben Dov: It feels emotional, and every user use it differently. Someone
immediately called his wife, children you know rushed to the most popular game and
played th ere, our family being able to play what all other classmates are playing.

Margaret Flinter: The Sesame Phone now has hundreds of users around Israel and
Ben Dov says, they have got bigger plans for developing this and other systems that are
geared to assist the handicapped community.

O ded Ben Dov: We brought in ou r vision which is currently equality through technology.
I feel a lot of technology that can really be life changing for some people but knowing
necessarily it’s working in bad direction. As the time goes by we see we’re positioned
well within the specia l need space .

Margaret Flinter: Sesame Phone ’s tagline is touch is overrated. Sesame Phone a
simply devised hands - free interface that allows the paralyzed and physically handicap
to interact with their world through their s mart phones allowing them a new level of
independence, now that’s a bright idea.

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Margaret Flinter: This is Conversations on Health Care I’m Margaret Flinter.

Mark Masselli: I’m Mark Masselli, peace and health.

Conversations on Health C are broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health Center.