Dr. Mario specializes in addiction. During this episode, he shares pertinent information about addiction and also discusses how COVID-19 has impacted those struggling with addiction and substance use disorders.
Kate Gosney Hoffman:
Hello, and welcome to the Hope Happens Here Podcast. I'm Kate Gosney Hoffman. So glad you're here. Today I am joined by Dr. Mario San Bartolome. Dr. Mario is a clinically active addiction specialist. He is triple board certified in family medicine, preventative medicine and addiction medicine. He is the Medical Director of Substance Use Disorders, as well as the National Medical Director for Substance Use Disorders and SDOH, which stands for Social Determinants of Health Center for Innovation in Molina Healthcare. And he is also the chair of BeWell OC Substance Use Disorder, Leadership Coalition. And among all of these things, he continues to see patients through his community clinic called KCS Health Center for medically assisted therapies and outpatient addiction treatment services. He is also an expert legal witness on issues ranging from process improvement and quality of control and CMS policy. Hi, Dr. Mario, how are you?
Dr. Mario Bartoleme:
Very good, Kate. Thank you so much for having me.
Kate Gosney Hoffman:
Absolutely. So I wanted to just see what your take is on how COVID-19 has really impacted the work of addiction treatment and mental health. What kinds of changes, what kinds of patterns and shifts have you seen and really what your take on all of this is?
Dr. Mario Bartoleme:
Sure. Yeah. I mean, it's been a drastic 180 in some areas, but as we know the pressures that were brought on by COVID 19 really ... And there's actually a perfect storm that actually happened from the standpoint of folks that struggle with substance use and mental health issues. Because not only is there the actual disease itself where it was showing that folks that have substance use disorders actually have a higher rate of having problems related to COVID-19, so that having the disease by itself predisposes you to having worse complications. But there's also all the fallout from how we managed it in the country. We looked at increases in stress, increases in isolation, increases in economic upheaval.
Dr. Mario Bartoleme:
And all those things, I mean, if you start stacking them together, really, they are the triggers for people that might have been in recovery that then now caused some sort of a recurrence in their disease or made it very difficult potentially to access certain things. So for example, when you're told to stay at home and normally you're supposed to be showing up to say, to some treatment program or to be part of a mutual support group of some sort, along the lines of 12 step or Smart Recovery or other, maybe church-based type of support groups, that makes it very difficult because those were stopped. And it took some time before the virtual aspect of those came to be. We did see some pretty dramatic increases in some areas and others not as much. I mean, I would have anticipated, we'd see a lot more say suicides, it didn't change all that much, for the most part. I mean, there's some pockets of folks in different parts of the world where it did.
Dr. Mario Bartoleme:
But where we did see in the United States, a huge impact, was in overdose rate. And so this last year was the highest recorded rate of overdose ever in the history of us recording it. So we had 81,000 people that died last year from overdoses related to drug and alcohol use. So we went up about 20%. There's definitely ... It's a complicated type of reasoning in terms of what was behind it. But part of that is likely that things like isolation ... For example, we have medications like Narcan that are used to reverse when somebody say is taking an opioid or using heroin or something like that and they overdose. Normally this medicine when given, it reverses it and it saved their lives. It's the antidote for the overdose. Well, imagine if you're socially isolated and don't have anyone around and you overdose. Well, there's no one to administer it to you.
Dr. Mario Bartoleme:
And so we saw increases from the standpoint of access. People not wanting to go to pharmacies or having difficulty accessing programs that they were already in like methadone treatment centers and things like that, until they caught up. So certainly lots of different ways that it impacted people. And again, I think more globally, I think it's those triggers that impact anxiety, depression and then decrease the support systems that people normally have access to, given that the need to socially tend to restrict the places that we go to and who we interface with.
Kate Gosney Hoffman:
Yeah, like you said earlier, it's a perfect storm of things. We know that social isolation is a trigger in itself. I mean, it's something that we talk to people with substance abuse disorders all the time, as one of the number one triggers to look out for, right, isolation. We are not born to isolate. We are not meant to isolate. That is a trigger. That is something that can get you into trouble. And so to connect with your tribe, to connect with other people is remedy. And to not be able to do that or not be able to do it in the way that you're used to, or the way that you have developed in your recovery routine.
Dr. Mario Bartoleme:
Yeah. And I remember talking to one of my patients that had a series of recurrences and relapses that he experienced. And one of the things that he told me was that during this time, and he said it about COVID and about the disease of addiction. He says, "You know, addiction, this disease wants me to be alone. It wants me to be alone to get me." Because every time he's alone, then he has problems. And so when the issues around COVID-19 came up, he said, "Now there's another reason why I might be alone and so I feel less secure." So in that case, we needed to figure out, "Well, how do we intervene? How do we address those issues?"
Dr. Mario Bartoleme:
And you have to think ahead as soon as these reasons why any sort of isolation needs to happen. It can happen for other reasons, right? You can get another medical condition, people that have say cancer, they have chemotherapy, and they might need to isolate because they have low immune system and they want to keep the disease at bay. But whatever it might be that you need to proactively reach out to other communities that you might have access to.
Dr. Mario Bartoleme:
And now these days, I mean, we're far enough into it that you can go onto the AA website, for example, and there are virtual meetings. There's more access from insurance companies that are now allowing for telemedicine services, like medication assisted therapies for medications like buprenorphine and naltrexone, for people that have opioid or alcohol use disorders. And these can be done now through either a telephone or a video chat type of function. We don't know if all of those ways will continue to exist in the future, because in the past, we didn't do them a lot because there were some laws that didn't allow us to, as physicians to be able to engage with people that way.
Dr. Mario Bartoleme:
But that's developing and we're now being able to study it. There's a bigger number now of people that are getting services that way and in fact, that's how I'm seeing folks for medication assisted treatment, is through telemedicine, one of the nice, positive impacts that it's had. We've been talking about all the negatives. What about something positive? A positive one, is that when I was seeing patients face to face and in the world of mental health and substance use, that can be a lot of challenges for people to get to visits. So the no show rate, in other words, you might have 10 patients scheduled and maybe only five would show up and it could be for various reasons. Somebody might've had a recurrence, somebody might be taking three buses to go see you or whatever it might've been. With the telemedicine, I'm getting 90, 95% show.
Kate Gosney Hoffman:
Hmm. Wow.
Dr. Mario Bartoleme:
So, you could argue as well that this has increased access, particularly for people that have social challenges. They don't have a car, they lost their job, they don't have money for gas. Maybe the bus lines are very difficult for them to see you. You've eliminated that just by virtue of offering a new way for them to engage with you and to support them.
Kate Gosney Hoffman:
What a great point. And I appreciate that positive reframe, because it does make a lot of sense that, like you said, we might take for granted that somebody can just go to a doctor's appointment. They might have childcare issues or not have a car or whatnot, and to have the increased access is really kind of a beautiful gift that has come out of this.
Kate Gosney Hoffman:
And I'm curious too, though, I'll be honest with you, I just want your opinion on this, because you have been doing this, you've been in it with a tele medicine, the effectiveness of it. Do you feel that you can connect with the patients in the same way?
Dr. Mario Bartoleme:
Well, not in the same way, right? And same doesn't necessarily equal outcome. So if we say that we connect in the same way, that doesn't also equal that there's going to be of inferior benefit or a superior benefit or even an equal benefit. So they are different things. Definitely, how you connect with someone changes. It's like saying, "Well, is sign language the same as speaking?" Well, no, they're not the same, however, can you communicate that you need a piece of paper and if you can, and you still get the paper, then, then the outcome is equal, but the way you went about it is different.
Dr. Mario Bartoleme:
But there are definitely some rules of engagement, just like we do in face to face. It has to do with norms that we have developed now, really quickly, on how we engage when we're on video calls. All the little things that maybe before weren't an issue, like a barking dog in the background. Or that kind of thing how you're respecting this new space, just like you would normally respect it in a therapeutic environment.
Dr. Mario Bartoleme:
But I definitely think that from the standpoint of connection, that it has all to do ... I mean, you almost, after a minute, you forgot you're on video. I mean, you really have. My patients are able to connect in some cases even better because there's less disruption. They didn't wait in line for anything, they weren't sitting in the lobby. Even the process of how we do the drug testing and all the other things like that. It's separated out. So in some cases they're more relaxed. They might be in their own environment, so they're not as edgy.
Dr. Mario Bartoleme:
And so at the end of the day, though, you are still able to, and I feel from my experience, I'm still able to communicate to them that my goal is to help them with quality of life and this is how we can do it. They can have fast access and still express themselves, and you still get all the same tears and virtual hugs and discussion that you could if you were face to face.
Dr. Mario Bartoleme:
At the same time, I'll say, it's not for everybody. So some people like to see your eyes in person. It's a combination of what the patient needs and then how good of a communicator they might feel in that mode, as well as the provider. There are new things to learn about how to communicate and to not be typing when you're talking to somebody. They're hearing it too and that kind of stuff. But I do think that there's wonderful, wonderful connections that can be had with telemedicine. I don't feel that it's inferior. I just think it's different.
Kate Gosney Hoffman:
Different.
Dr. Mario Bartoleme:
And it lends itself to certain groups.
Kate Gosney Hoffman:
And it's encouraging to hear that from you. It really is because I know that there's been a lot of hesitancy. I guess, even I will admit my bias as a clinician. I'm like, "I don't know if I could connect in the same way." I mean, I haven't been practicing since COVID, but it definitely is something that's crossed my mind a few times. And I mean, I have worked with clients via tele medicine in the past, but that was only because we didn't have our regular meeting and we would resume next week or whatnot.
Kate Gosney Hoffman:
And it's different and I think what I'm appreciating about what you're saying is, that this whole situation, the circumstances being as unfortunate as they have been, it has forced the tele health availability and process and technique, it's refined it, so that it can maybe continue to be an option. Maybe, hopefully in the near future it's not the only way, but it is a certainly an option to grant access to people. And we know how to do it with more specialty and awareness of what works and what doesn't work. We can continue to offer it as an option for people that may need it.
Dr. Mario Bartoleme:
Yeah. I mean, there's definitely a workflow issue to it and the type of technology that's used. Those are all always improving types of things. I could tell you that a lot of my patients do appreciate them.
Dr. Mario Bartoleme:
For example, one of the things that I do is, even though I might give you a time for when your appointment is, it really doesn't matter when you show up, either way you are going to be seen. So if somebody happens to ... they don't have that stress on them about the specific timing. They might just have to wait until you're done with the patient, but it takes off that stress. So it can be this kind of block and so they always know that they're going to they're going to be seen, they're going to be treated.
Dr. Mario Bartoleme:
And so it also decreases some of the stress that comes around, like you mentioned before, maybe they have childcare issues or work, they have to get off of work. But imagine during the pandemic where jobs are hard to come by, that the one you do have, you're asking to have to leave all the time for various things. It can create increased stressors that normally in a telemedicine visit, I can see somebody even on their break.
Kate Gosney Hoffman:
Right, so it really does open things up if we look at it from that perspective. It opens up instead of limits.
Dr. Mario Bartoleme:
Yeah. And imagine if you're in a rural population. Imagine if you're in an area that guess what, the nearest addiction medicine doctor, for example, or therapist, might be 50 miles away, or sixty miles away. You might be somewhere where you're really isolated, just because of geography, well, imagine that. There's no barrier then, to be able to deliver what that person might need. It is modified, it is different.
Dr. Mario Bartoleme:
There are even virtual groups now that get together, that meet, whether it's through mutual support or the therapy that you talked about, that can still happen even in groups. I've even had family meetings with some of my patients when we have major changes in their treatment plan, for example. And I say, "Hey, you know what? I really need for your parents to buy into this because they seem to be a problem here in helping us for you to get well, because they don't understand. Let's get them involved. Let's put them on." And we have a call where we have everybody on at the same time, and they really appreciate that. And in groups where there's people in different geographies, it doesn't matter.
Kate Gosney Hoffman:
Doesn't matter. It really is an awesome thing when we talk about it this way. How it just opens up the channels of availability. Like you said, we can have somebody in all different countries, altogether in one space. And I mean, that really is the beauty, I guess, of the internet and social media and bringing everybody together in that way.
Kate Gosney Hoffman:
But if we're doing it in a professional clinical way, it can really be ... I mean, I'm thinking of, I actually have a neighbor who is in recovery and struggles with a lot of mental health, and he's very plugged in to his meetings, his 12 step meetings and his therapist and everything. And when the pandemic hit, you could see it in his eyes. He did not know what to do and I was so worried about him. He finally connected online, his meeting, like you said, took a little bit of time, but got it together and his meeting met online. He shared with me that he was thinking it was not going to be the same, but once he was in the quote unquote "rooms" with his peers, even if it was virtual, they forgot that they weren't in person after a while because they were connecting. And like you mentioned before, connection is really what we're talking about, ultimately.
Dr. Mario Bartoleme:
Once that connection happens and the person can still do it as an individual, it can help. So these things, they're little things, they're not even medical prescriptions of sorts. But to stay healthy in this kind of an environment where there is this need to socially distance, that keeping the routine, for example. Making sure to keep a routine, making sure to keep up with personal hygiene. These are the little things. Again, these aren't medical prescriptions, and I wouldn't write this on a prescription pad, but these are things that actually still matter the idea of that routine.
Dr. Mario Bartoleme:
Including things like regular exercise or being mindful of the kinds of foods that you're eating and allocating the right time to rest and to keep up with some of the hobbies, if you like to garden, to continue those things. All of those things improve mental health and give somebody a sense of stability.
Dr. Mario Bartoleme:
Because besides the stress of COVID-19 and all these things, you know what? One of the things that hurts people the most is uncertainty, particularly the young people. So the younger, kids, they're processing all of this too. They might not worry about the financial problems to the degree that maybe an adult might, but the fact that there's uncertainty for anything. And this last year, shepherded not only COVID-19, but a very tumultuous, presidential handoff, and a lot issues around racial inequities in law enforcement. There were so many things that the perfect storm got even more perfect in the sense of increasing stress. So these little things can become actually quite important to try to be able to keep people on track for staying in recovery or maintaining the treatment activities that they were already doing during the time everything was started.
Kate Gosney Hoffman:
So with all of the things that are really out of control, they're feeling out of control, uncertain, unknowable, it's really important to pay attention to what is knowable. And you can bring that back to you and your routine and what you have control over. Like you said, your hygiene, start there. The routines and rituals that really bring you peace and stability, gardening, whatever it looks like, like you said.
Dr. Mario Bartoleme:
And frankly, there's an idea of having ... There's a skill that has to do with being able to be more selective about how you approach consuming information. That's the other thing. So if you get stressed out, because of a lot of things that we've already pointed out, what's happening in the political climate and everything else, then you need to minimize the news feeds. You need to figure out a healthier way to consume what you're being exposed to. That goes a long way, as well. And it impacts insomnia. It impacts somebody's mood. All of these things actually become quite important, even though, again, they're not prescriptions on a prescription pad, but they're just as important.
Kate Gosney Hoffman:
And it becomes such automatic habits, right just checking the news, the news feed. This constant stream of information into our brains and our nervous system. We're just not even ... It's so easy to lose track of that and to not even be aware that we're doing it to the nth degree, to the point where it may become detrimental.
Dr. Mario Bartoleme:
Absolutely. Yeah. Look, we're getting to a point now where a lot of these things are being worked out and things like the restrictions in terms of access that we experienced in the beginning of this process around residential treatments, for example, or withdrawal management detox centers. Because they didn't know exactly how to handle this. Do they restrict their beds? How do they handle a communicable disease that was happening in a pandemic? And so those are being resolved quickly, still, and I think that, everyday things are a little bit better from the standpoint of access.
Dr. Mario Bartoleme:
But you have to stay informed. There are some resources, both from the World Health Organization, all the way down to the CDC. And SAMHSA, it's another good resource online that you can get information specifically about accessing care. And also even in terms of strategies to cope with stress. All these things can be found free online with some of these locations that it's good to keep on top of.
Kate Gosney Hoffman:
Right. And for people who are struggling or may not know where to start, I mean, that's a good place to start. I'm thinking about the patients that you've been working with. I mean, what, what would you recommend to somebody who is maybe struggling? You mentioned at the beginning of our conversation about the increase in anxiety and depression and the decrease in socialization. And so maybe some people might be just sitting at home trying to do all the things that they're being told to do, but they're really not okay. What would you recommend to them, just based on what you've seen and what you're working with on your patients and your expertise? What would you recommend?
Dr. Mario Bartoleme:
Well, part of it is to really empower the individual and that by itself decreases anxiety. So having a plan around local resources and being able to consume that information, that's the part that they should be really looking at, staying on top of, to know where their support system is. You really do have to be proactive and engaging both with your providers, whether they're the therapist or your doctor. Then also, what's available in your community. And in knowing those things takes a bit of the edge off, from one standpoint and then, you know where to search. Each community is a little bit different in terms of what they might offer. Some of it's county-based.
Dr. Mario Bartoleme:
Some of it can even be accessed through your own insurance, that the health plan might have a managed care plan, for example. They might have services that they specifically offer you to be able to have access to help even with some of the social issues.
Dr. Mario Bartoleme:
So those things, they need to be done ahead of time. If you know you're on a medication, keeping up with the refills, that's another issue from the doctor's side. One of the things that we changed right away, almost, is we gave longer refills because we knew that it may be difficult for people to access us for whatever the reasons. We weren't sure in the very beginning, for sure, how impactful it would be that instead of giving short courses of the medication, if we knew it was a chronic medication, we might give 90 days worth. And then that way, no matter what, they have access to the medication, and we work out the other ways that they might have that. And then we also diminished the number of times you have to go to a pharmacy. Because remember, every time you have to go to a pharmacy, you're potentially being exposed and so we did that, as well.
Dr. Mario Bartoleme:
So working those things out go a long way to help diminish some of the stress and be able to have a faster way of acting if something does come up.
Kate Gosney Hoffman:
That's super good to know. Those strategies that are being put into place to just help with being smarter, working smarter about all these and navigating these obstacles. One of the things that you mentioned is empowerment. In talking to a range of professionals in this field of late through this podcast, that seems to come up almost every time, the word empowerment. And when working with just mental illness in general, struggles with any kind of mental health, substance abuse and whatnot, is empowerment. I just think that is such an important message, to stand in your power, where you can. Even if it's making the phone call to your insurance company even though you dread it. Whatever it is. Reaching out to the therapist, even though you just don't want to talk about anything. Telling your family, you need some support, whatever that looks like. I just appreciate that you said that because I do, I agree that, that's so important, especially with the uncertainty all around. I mean, fear, the fear that a lot of people are experiencing around all this, certainly doesn't do anybody any favors when it comes to mental well being.
Dr. Mario Bartoleme:
Absolutely. Absolutely. Yeah.
Kate Gosney Hoffman:
Yeah, so I appreciate that. And the resources you gave, SAMHSA is a really good, is it just samhsa.org, S-A-M-S-H-A, .org. Is that what that is? I want to make sure.
Dr. Mario Bartoleme:
I believe, yeah, S-A-M-H-S-A, it might be .gov, actually.
Kate Gosney Hoffman:
Dot gov, yeah.
Dr. Mario Bartoleme:
Because that's a governmental ... The Substance Abuse and Mental Health Services Administration. They have lots of publications and information. The other one NIDA, as well. They have interesting publications on there, too. That's National Institute of Drug Abuse. Dr. Nora Volkow, she writes some very helpful booklets and things like that as well as post there for parents, for example.
Kate Gosney Hoffman:
She's great.
Dr. Mario Bartoleme:
Teens that are struggling with substance use, there's a little bit more on the science of addiction, as well. So yeah, if they're going to spend any time on being on the internet, those could be some good sites to be on.
Kate Gosney Hoffman:
Great to know. Thank you. And the work that you're doing is so important and just thinking about what you have had to adjust to, as well, this year in your personal practice and professional world, just that kind of-
Dr. Mario Bartoleme:
Well, luckily, the government gave us the option to do it.
Kate Gosney Hoffman:
Totally.
Dr. Mario Bartoleme:
Before this was a significant barrier. And particularly because some of the medicines, controlled substances that we use, they're controlled by the DEA. There was a law that said that we could not prescribe those without having to see somebody face to face, in person. And so that was limited, going back to that person in the rural community, well they were just out of luck.
Kate Gosney Hoffman:
Yeah, exactly.
Dr. Mario Bartoleme:
I mean, if you didn't have somebody close by. And so this just really brought down the barriers and it needed to happen. It had been already happening in other areas. If we can do a surgery by use of a robot by somebody in another state that's controlling the, we could help people with substance use disorders. Remember out of all, the folks that have diagnosed substance use disorders, our country still does not fare well in terms of how much access we give.
Dr. Mario Bartoleme:
Only about 11% of those people receive professional care from from someone like you and someone like me. This is what we dedicate some of our time in and enjoy doing. So, that's not great, the more we can increase access and decrease barriers, particularly for the vulnerable populations. What we saw with COVID was that a disproportionately affected folks that were African-American or Latinx, and then also folks with chronic issues, even substance use disorders. So, it's important to do whatever we can to increase access to treatment.
Kate Gosney Hoffman:
Well, it seems to me that, that's a silver lining in all of this, is like you said, that the increased access and it needed to happen because we do it in so many other parts of the medical world and healthcare world, that why not apply that to mental health. There's other ways of doing things. Thinking outside the box is not a bad thing.
Dr. Mario Bartoleme:
Absolutely.
Kate Gosney Hoffman:
So, well, I appreciate so much everything you have to offer. Is there anything else that you feel like you need to share with our audience about what somebody might need to know or what you want them to know? You've said a lot already, but just checking in with you before we wrap up,
Dr. Mario Bartoleme:
The main thing to know is that there is support. There is support out there and having the situation that we're in, the vaccines are being rolled out but there is support out there. But you do have to be proactive and reach out and plan ahead so we can start dropping this overdose rate and dropping some of those stressors that are out there that are impacting the quality of life of people there with mental health issues.
Kate Gosney Hoffman:
Awesome.
Dr. Mario Bartoleme:
So don't give up.
Kate Gosney Hoffman:
Yeah. Don't give up, keep up the good fight. Stand in your power, right? Okay. It's been so delightful talking with you. Thank you.
Dr. Mario Bartoleme:
Thank you so much, Kate. You take care. Bye-Bye.
Kate Gosney Hoffman:
Bye-bye.