SIMPLIFYING PERSONALIZED ADDICTION CARE: WITH ADVANCED TECHNOLOGIES AND STRATEGIES

Transcript  

[Nicole] 

John, welcome to the Digital Health Transformers podcast where we delve into the heart of healthcare innovation one conversation at a time. I’m your host, Nicole, and today we’re going to be joined by a visionary who’s transforming the approach to addiction treatment through technology. Dr. John Mendelson, founder and chief medical officer of Ria Health brings over three decades of research and clinical practice to the forefront of addiction medicine. Dr. Mendelson is also the founder and medical director of DXRX, Inc. and owner of the John Mendelson MD Internal Medicine Practice. He has an extensive background as a board certified internist with a significant focus on addiction treatment. 

Beyond his role at Ria Health, he’s also the clinical professor of medicine at University of California, San Francisco and has several pioneering research efforts in addiction pharmacology. His dedication to evidence-based treatment and accessibility in healthcare is reshaping how we approach addiction recovery today. Dr. Mendelson, thank you so much for joining us today. 

[Dr. Mendelson]  

It’s a real pleasure to be here. 

[Nicole] 

Wonderful, so let’s get started with your interview. Your career has always been both broad and deeply specialized in addiction. What drove your initial interest in this field? 

[Dr. Mendelson]  

Well, that’s a great question. I was fortunate enough as both an undergraduate and an early medical school education to do some… I went to a college that had co-op work experience. 

And one of the people I worked with early on was a guy named Reese Jones at UCSF. And Reese was interested in psychiatry, interested in cannabinoids and stimulants. And I got to work with him and another great guy named Neil Benowitz who was interested in tobacco pharmacology of nicotine. 

And I asked Neil at one point, I said, how come you’re so focused on nicotine as the drug of interest? He said, because it kills the most people. Cigarette smoking is one of the big killers. 

And that for someone who wanted to go into medicine and become a physician, that was kind of a motivator. C. Everett Koop famously said that 3000 people quit smoking every day in United States. 

The only problem is their funerals are two days later. So it’s a large, interesting problem. It’s also probably one of the most interesting zones in medicine. 

It’s a combination of voluntary behavior, medical genetic and societal risk, and medical consequences. And there really is not an area of medicine that’s not impacted by addictive disorders. It’s not just people who need to go to residential care, but of course it’s infectious disease, it’s overdoses, it’s falls and fractures. 

So it really, it’s across all of medicine. And up until recently, we’ve had like a very, like it’s mainly a spiritual problem, has been the prevailing societal view. And so transforming that view into something that’s more, less judgmental, more accessible and more actionable has been a great journey. 

So I don’t know if it’s a rambling answer, but I hope it gets to some of the points I think you were trying to get to. 

[Nicole] 

You did, you did. And you’re so right. Never thought of it that way. 

The addiction medicine does touch all types of medication, medical specialties, specialties. 

[Dr. Mendelson]  

So- If we had a ward in the hospital, I mean, if we had a ward, I mean, so how’s medicine organized? Well, it’s organized basically by organs, by organs and by what you need in the hospital. Actually, like the ortho ward, the surgery ward, the neurosurgery unit, right? 

If addiction had a unit, we would be one of the largest ones in the institution. You know, I mean, if we had a floor for addiction care, right, that would be, it would be, it’d be huge. It’d be like 10% of the hospital. 

But unfortunately we don’t even have, we don’t even have a department. There’s not even a department of addiction medicine, you know, that exists in any institution that has real estate, that owns real estate inside a hospital. 

[Nicole] 

That is so interesting. You’re right. Never really thought about it that way as well. 

There is no specific department in a hospital that is just for addiction medicine. Most of the time they would do mental health or any of those psychiatric-based treatments or behavioral cognitive treatments, but not necessarily a different department just to address all- No, we’re often subsetted with psychiatry. 

[Dr. Mendelson]  

I’m an internist, but we’re all subsetted with psychiatry. But in fact, much of the consequence, the medical consequence of addiction is felt on the medical and surgical floors. And, you know, so, you know, that that’s the, you know, the hierarchy of medicine has always been about, you know, like the real estate inside hospitals, you know? 

And that’s how, you know, you’re going up or going down. You have real estate. When there is addiction in a hospital, it’s often like the furniture is often second rate. 

A guy years ago took a camera around and photographed the radiology waiting room and the methadone clinic waiting room in the same institution. You know, one of them was full of broken down, used furniture. The other was full of very nice modern furniture. 

You know, people sit pretty much the same. I mean, it’s sort of, you know, so like this, there’s also a stigmatization around, you know, we expect the addict population to be, you know, more, you know, more accepting of, you know, really crummy physical locations and marginal creature comforts. I mean, you know, the same payment sources go in radiology as addiction and it can be the same patient coming, you know, coming for their chest x-ray or coming for their methadone maintenance visit, you know, but the furniture will look totally different and so will everything else, you know? 

[Nicole] 

Do you think it’s just that addiction has those medicine, like longstanding treatment centers, like medicine clinics and rehab centers that they don’t have a department in the hospital or what are your thoughts on that? 

[Dr. Mendelson]  

Well, it’s partly that. It’s partly that we haven’t also had the same level of intellectual advancement. I mean, you really think about, you know, again, you know, like the moving from the AA model to a medical model, you know, from the mutual support, you know, like a model to something more medical is only 50 years old at this point, right? 

Whereas we’ve been doing surgery since before the Civil War, you know, we’ve been doing cardiology since before the Civil War, you know, so I think it’s partly due to time. It’s partly due to time. It’s partly due to, you know, the fact that many, you know, many people with addictive disorders, their behavior is complicated. 

They’re often self-destructive. They can be hard, they can be, you know, I mean, there is a legitimate set of concerns around the behavior of the patients. You know, your 80-year-old lady waiting for her chest X-ray is unlikely to be screaming, you know, and, you know, having behavioral crises, you know, so it’s, you know, there are real reasons for this, but I think part of what we’ve been about at REIA and part of what I’ve been fortunate enough to be part of in my career is transforming, you know, what has been thought of as a set of intractable social problems, you know, social defects into more of a medically approached universe. 

And at least that provides dignity for everybody and, you know, at least treating people in a respectful, kind manner, right, to address their problems. And I think that’s, you know, that’s been, and that transformation is ongoing and continuing to improve with every year. So that’s a great journey, which a lot of people contributed to. 

And it’s been my pleasure to be on that ride, you know. 

[Nicole] 

That’s so great. Great. I read about your professional background in LinkedIn. 

It’s very quite, very impressive. My next question for you is, addiction is a complex field with evolving challenges. What are the current trends in addiction treatment and how is Ria Health addressing these through a technology? 

[Dr. Mendelson]  

Well, so yeah, so Ria is focused on alcohol addiction. So not all addictions are the same, right? And I think anyone can understand that if they just think for two seconds, the person who smokes cigarettes, you know, the cigarette smoker, which is the most prevalent addiction on the planet, right? 

Cigarette smokers, they don’t engage in too many antisocial behaviors. They don’t generally lose their jobs. They don’t crash their cars. 

They don’t abandon their children, right? You know, and they, you know, other than an unpleasant odor and, you know, maybe occasional house fires. I mean, they really don’t present a risk to anybody else, you know, but yet it’s a highly lethal condition. 

It would continue for many years. You know, people will die from it. On the other side of the other extreme might be stimulant dependence, right? 

Stimulant abuse and dependence where people can have psychotic episodes. They’re running down the street naked. They can harm and hurt other people. 

You know, they can be killed by the police and, you know, get someone cited delirium. I mean, you know, so you have massive social disruption on one side, no social disruption on the other side. Both of them are addictions, right? 

So alcohol sort of sits in the center of this, at least to me. You know, it’s something that’s been with humanity since the dawn of time. Since the dawn of time, people have had alcohol addiction and abuse problems and consequences and consequences. 

And the consequences have been not just, you know, to themselves, but to their families, their communities. In fact, I would challenge anyone listening to this podcast that everyone listening to the podcast has a family member, a friend, someone named a colleague, a neighbor who’s had an alcohol problem. It’s that prevalent. 

And that’s around the world. That’s in every part of the world. There are no parts of the world that don’t have alcohol problems, period, right? 

There are some cultures that don’t permit drinking and they do have a lower rate of alcohol problems. They still have them. People ferment, they make, they make, they make, you can ferment any kind of thing that’s got sugar in it into alcohol, right? 

So what’s the big trend? What’s happening? 

Well, first off, we’re, we’re, we’re, we’re now treating it more like, like a complicated problem that can be solved rather than, rather than just a spiritual journey, right? And, and, and so the, the big, biggest trends coming along are that, that, and this really came up with opiate use disorder is that we’ve, we have developed medications to attack the problem, right? And within Western medicine, medications, pharmacology has been the, the, sort of the vehicle to address, you know, to address complicated problems, you know, whether it be infectious disease or, or cardiology or GI, whatever, whatever area you’re interested in, medications have been a big player in that. 

So we’ve developed medications to treat a number of addictive disorders most, most successfully in, in opiate use disorder, opiate dependence. And, and, but alcohol is coming along fast now. We actually have a number of tools that, that, that with number of medications that work really well in alcohol dependence. 

Do they work in every patient? No. Do they work rapidly for every patient? 

No, right? But then again, you know, across all of medicine, we’ve had, you know, like we, we don’t expect people’s cholesterol to drop in an hour, you know, right? And, and, and more importantly, the plaque that the cholesterol built to, to resolve in a week, you know, so, so, so I think we’re, we’re, we’re, we’re at a point now where we have, we’re, we’re, we’re, we’re developing tools and, and, and learning how to deploy those tools. 

And I think that, that, that we still have a long way to go there as, as, you know, which is, you know, like there was just a meeting on people. So now Trexone for, for alcohol use disorder has first, was first, you know, it was approved in 96 or something about that 90, you know, like, so now Trexone was, was developed well before 1996, maybe in the early 90s, late 80s, late 80s. And, and it, and in animal studies, it rapidly showed an ability to decrease alcohol use in animal models of, of, of, of, of alcohol dependence. 

And it was an uphill struggle to get the company that was manufacturing it to, to, to, to agree, to allow now Trexone to be, you know, to be used, you know, to, to, to market it, to affect the nationals of alcoholism and alcohol abuse. And NIDA had to really twist their arms, right? To get them to be interested in, in, in, in alcohol. 

They were hoping it’d be a diet drug, right? They were hoping it would be good for weight loss. And, and even after that, the FDA put a black box warning on the drug, which was not appropriate, which was actually, you know, only been recently removed, that really inhibited prescribing. 

And insurance companies don’t pay for the full dose, right? People, people, people, people, they pay for one 50 milligram tablet a day, many of them. But lots of studies show that 100 milligrams a day is better, right? 

So, so, you know, we’re still in this, you know, 35 years later, we’re still in this struggle, you know, to get the better furniture for the waiting room, you know? Right? You know, to get, to get, to get, to get, you know, to get, to get taken seriously. 

And that’s on a background of, you know, like just last, the, you know, so between 2016 and 2020, there was a 30% increase in alcohol-related mortality in the United States. So I said it again, 30% increase, more in women than men, 35% in women, 25% in men, up to 178,000 deaths. That’s now more deaths than stroke, Alzheimer’s, or diabetes, okay? 

And we’re still, we’re still struggling to get the appropriate dose of naltrexone, which has been available for 40 years paid for, right? But we have a whole bunch of other meds coming along too. And, and, and, and so the challenge now is that most docs haven’t been trained how to use them and, and don’t, and don’t have an, and they don’t have the, they don’t have the, they not only haven’t been trained, they haven’t been trained to diagnose it either.  

And they have a fairly negative view of alcohol use disorder from their period of time as residents when the same patient comes cycles in and out of the hospital all the time with drinking consequences. You know, so, so, so I think that the thing, the really positive things are happening are first, we have new tools, okay? And those are coming along nicely in the pharmacotherapy side. 

Second, second telemedicine, which is what is so exciting about Ria, telemedicine lets us bring the expert. We don’t have to train every doctor, nor should we train every doctor, right? Telemedicine lets us bring actual experts in this care to, to, to where they need to go, which is to the patient, right? 

So, so that’s been another sort of just a slight digression. That’s been another, another challenge in the addiction field is that, is that people think anyone should, any doctor should be able to treat addiction, right? And I think that’s a huge mistake. 

This is a big complicated set of illnesses. They’re not even the same across the types of addictions, right? And, and so the first question I always ask those people, and if any are listening, the first question, you want every doctor to be able to, you know, so why can’t every doctor treat opiate addiction or, or, or alcohol addiction? 

And, and the first question you got to ask them, what do you want them to stop doing? I know very few physicians who have any free time with their patients. You know, they’re on, they’re on the clock. 

You know, the minute, you know, the, the, the doors, the doors, the exam room shuts, it’s a 15 minute cage match, you know, between the doctor and whatever disease the patient has, right? You know, and the bell’s going to ring at the end of 15 minutes. And if you can’t figure it out in 15 minutes, you, you, you know, you got to, you got to go for another round. 

And that, and nobody likes that. The patient doesn’t like it, the doctor doesn’t like it. So, so, so, and there’s a big list of things the doc has to solve in 15 minutes, you know? 

So, so, you know, like, so if you say, if you say all physicians ought to treat addiction, the first question you got to ask is what do you want them to stop doing, okay? And the second question you got to ask is how are you going to train them, right? You know, like, like, like, like, you know, and are you going to, what, so what, so the nested question within that is what do you want to stop training them on? 

I mean, you know, maybe a little less time in the ICU, maybe a little less time, you know, in the, in some specialty, you know, rotation, you know, less time doing family therapy or group therapy if you’re a psychiatrist, you know? I mean, so, so, so, so, so telemedicine lets us get people who are well-trained and we, you know, we were able to train our clinical staff really well and have seen a lot of cases, a lot of experience, get those people in front of the patients as real experts. And I think that, that, that’s, that’s a huge deal that’s, that, that, that’s not talked about much. 

And I think it’s going to be one of the big revolutions across all of medicine is that we can expect, we can expect, you should expect in the future that the person you’re seeing is an expert in what you have, right? So, so where does that leave primary care? Well, primary care is going to still be expert in quite a few things, right? 

But, but, but, but hopefully they’ll have the ability to more rapidly, more rapidly find the expert for the patient that, you know, like, and, and hook them up with them, even, even in an exam, even if it’s an in-person visit, even, even, even, you know, virtually through an in-person visit. So I think it’s, it’s all an exciting territory, new tools, new recognition of ways to bring, bring the delivered care to people and, and, and, and increasing acceptance that, that, that, that a medical model, you know, meeting less stigma, evidence-based outcomes, and, you know, it, it, it is worth doing, is worth doing. 

[Nicole] 

Thank you for that very comprehensive answer. Thank you for walking us through the medication histories and the pharmacological prospects and utilization of different medications throughout the history of addiction, especially alcohol. And I appreciate you bringing up the idea that, telemedicine, you should be facing the experts. 

And every time you are with someone, not just a primary health, not just a primary doctor, but also health experts in the field, because it provides a robust engine to talk about different ideas and treatment with that. 

[Dr. Mendelson]  

Yeah, I mean, I think in the broader spectrum too, you know, like we’re, we’re having, we have many more nurse practitioners now, advanced practice nurses coming along. Well, the APRNs are great. They, they, they, they can be really good, but, but again, they haven’t had this broad, they haven’t had the same training I’ve had, you know? 

So, so, so, so the way to make an APRN work is to train them narrowly, make, make sure they become total experts in one area. When they do, they’re just as good as any physician at, at that particular problem. They, they, and they spend a lot of time in their training on knowing their limits, the APRNs, you know, like when do I need to call for help and when do I need to send out? 

But, but telemedicine makes that perfect because then you can have, you can have, you know, like, like I’m pretty sure that in other areas, cholesterol management, because you now have injectables and statins, cholesterol management, diabetes management, you know, which, which we have like over 25 meds to choose from these days, you know, those are all going to devolve into, into, into specialized, you know, APRNs who manage those problems. And, and they’re going to, they’re going to do a great job with them. 

And the patient, you know, like, you know, if you needed something managed today, you know, your mom needs her cholesterol meds managed, you know, you, you have to, you have to take off work. You know, you can’t interview cranky guys like me, you know, and you got to take off work and go, go, go, go, go sit in the park, go to the parking lot and then sit in the office. And the doctor’s a half hour late and you’ve already read that issue of National Geographic. 

The doc spent seven minutes and your mom forgets to ask the two most important questions. You know, I mean, like, like, like, like a half, it’s a half day out of your life to get your mom to her, to her, to her doctor’s appointment to have her cholesterol meds adjusted, right? Again, telemedicine makes it all much better. 

You can finish up with me, join with the telemedicine doc or APRN, get your mom squared away and then go back to, go back to, you know, whatever else you want to do in life, right? You know, so it’s, it’s like, it’s like a much, it’s a much more attractive universe for everybody, right? Much more attractive universe for everybody. 

And that, I think that, that, that’s, that’s a really, and so for addiction where we have a smaller workforce, we don’t own real estate in the hospital anyway, right? You know, right? It’s a real, it’s a real, it’s a real advantage and gonna be transformative. 

[Nicole] 

Absolutely, and telemedicine, especially since COVID have ballooned so much and it gives us that engagement with a specialist, especially if you have a smaller group of specialists to a greater, bigger population. So thank you for sharing that. How do you ensure that treatments provided through REIA Care or through REIA Health are accessible and effective for diverse patient groups? 

[Dr. Mendelson]  

Yeah, so, so we, we have, we’ve been, you know, we’ve been just trying to gain altitude. We certainly have, we certainly have, you know. So we have 52% of our patients are women. 

Traditionally in alcohol addiction treatment, only 35 to 40% have been women, okay? And, and women have all, women have often expressed difficulty with AA and that the joke is the 13th step is getting hit on, you know, after like, right after, after the meeting, right? You know, the, the, so, so, so we’ve been able to reach women when other people have not been able to reach women. 

And, and we think that’s for a couple of reasons. First, many women have both jobs and childcare responsibilities. They can’t go to one week or one month of residential care, right? 

You know, and worse, their deadbeat boyfriends and husbands can’t, you know, but the, the, the, that’s, so, so, so we, we, we’ve done well with, with women. We’re mostly insured, our population. I mean, how do people pay for us? 

Well, 70% of our patients are in network with an insurance plan. And, and so, so we have not been great on, on, on being able to reach really poor people. We’re not, Medicaid is very, very hard to get contracts with, right? 

And, and it’s really the last, the last mile of the health insurance contracting world is Medicaid. You know, in addition, you don’t get national contracts, you get at best, a state contract, at worst, a city or locality contract. So it, that, that, that, that’s, that’s going to be, that’s structurally built into the, into the care of the, of people at the economic, at the lower, lower, lower economic ladder zones. 

The, we are reaching, you know, we are reaching, you know, we are reaching a fairly diverse population by race and ethnicity. Though, honestly, we don’t really find that useful to track, right? I mean, cause it doesn’t, it doesn’t make any, it’s really quite interesting. 

It makes very little difference in our treatment plans. You know, what, what there, there, for us, there aren’t any, any racial or ethnic differences in response to treatment, right? So, you know, so, so that the, the, so our staff is incredibly inclusive and diverse, have a, have a huge number of, of, of African-American physicians and, and, and coaches, have a really high number of, we’re really diverse on, on our employment side. 

Lots of veterans, lots of people who’ve lived experience with addiction, with alcohol dependence. So, so, so, so we, we, we’re good on that end, reaching the next set out, you know, we’re, you know, like, of like, of like availability to people, you know, we, we, we’re very interested in working with people who’ve been prior, had prior incarcerations, but you know, the, that, that, that’s a, people are unaware of this, 30% of people in, in prison and jail today committed their crime while intoxicated on alcohol, okay? So I want you to grok that number for just a minute and then think about any treatment, there’s no treatment, there’s nothing, nothing that’s done for people coming out of, out of an incarceration, a carceral setting that, that would help them avoid going back to drinking. What’s the first thing that’s gonna happen when they get out of, when they get out of jail after, their friends are gonna take them out for a drink, right? 

You know, right, let’s celebrate, you know, right? And you know, well, not to have a plan here is just, is just guarantees recidivism, right? Just guarantees it. 

And, you know, we’re, so, so we’re not in that universe yet. There are, Native Americans have a higher rate of alcohol use disorder than other population, and alcohol-related mortality. They actually, the same rate of alcohol use disorder, higher rates of mortality than other populations, a very complicated population to get into as well, due to the fact that, I mean, you know, like if, if you’re, if you were the, if your population was something of genocide, you might not be so trusting, might not be so trusting of the group that genocided you, offering you some kind of new treatment, right? So, you know, that, I mean, there’s really good reasons why it’s been hard to get in and, you know, but it’s something that needs to be addressed. 

And so that Native American and Alaskan Natives and American Indian populations, you know, are an area that definitely needs addressing, but, you know, it has to be done with a lot of cultural sensitivity and a lot of being able to integrate other, the other culture into your treatment, you know, the primary cultures into the secondary culture of treatments. So anyway, you know, it’s like, but, so we’re aware of it, but as I said, right now we’re, our focus is, you know, just becoming, getting more available across the board. And the assumption is that as we gain acceptance and availability, others will, you know, other communities will want to join and want that addressed. 

We, you know, we do have some Spanish speaking providers and, you know, but we haven’t made that, you know, Hispanics, we have not made a focus and that will eventually have to happen, but it hasn’t happened yet. 

[Nicole] 

That’s great to hear that you’re expanding and your services to a very diverse population. I would love to hear a comment about mental health and addiction. Working for a methadone clinic in the past, they mentioned that most, about 50% of the people who have mental health have some sort of addiction and vice versa, 50% of individuals with an addiction have mental health. 

Can you comment on that? 

[Dr. Mendelson]  

Well, I think something like 20% of Americans have depression or anxiety. So that means when you go see your asthma doctor, you know, 20% of those patients have mental health issues as well, right? And I think, so the apple and cart here has been, you know, which goes first, you know, like there are some who say that all addictive disorders are a subset of mental health. 

At first you have depression, anxiety, or some other mental, you know, psychiatric diagnosis, then you develop addiction, right? I think that’s not a true statement. There are others, and we see a lot of, honestly, we see a lot of misdiagnosis of anxiety disorders and to some degree depression and people having alcohol withdrawal or alcohol-induced health problems. They often present with what on a first glance appears anxiety or insomnia. 

For example, person is drinking a pint of distilled spirits a day, seven standard drinks a day. They try to stop, they’re going to have insomnia. They’re going to be anxious. 

They’re going to present with what could look like panic symptoms, racing heartbeat, like sweating. If you don’t take the alcohol history, and you’d be surprised how many people don’t. You’d be surprised how many people don’t because it’s an uncomfortable history to take. 

You end up with people being treated for anxiety disorder when in fact they just had alcohol withdrawal disorder. Our formulation is that there are people who have both sets of, they have primary psychiatric diagnosis and primary addictive disorder diagnosis. Just as they also have primary cardiovascular or gastrointestinal diagnoses. 

I think one of the more gratifying things we found is if you do address the alcohol and you reduce alcohol consumption, many of the other problems get better. They don’t necessarily completely resolve, but they’re not as severe. I think that’s really exciting. 

I think if we address, just as again, it’s just as addressing your diabetes. We’d have less fatigue, less urinary frequency, like you’d have more energy, and you might sleep better. If you do all those things, if you make the right diagnosis, and then institute what should be effective therapeutics, you can actually decrease those other problems. 

I don’t think they’re all subsets. Many of our patients, trauma is an interesting area. Childhood abuse, neglect, and trauma. 

This factors into so many, it’s a risk factor for so many severe psychiatric and addictive disorders. I think it definitely makes it worse. It definitely, oftentimes in those families, there’s a strong family history of alcohol abuse and dependence. 

I think you can just wonder whether you’re just seeing the same. It’s all just alcohol that led to the trauma that’s leading to the new trauma or there’s something special that happened with trauma. But clearly, preventing childhood trauma, abuse, neglect is really an important factor, at least in the severity of the addictive disorders. 

[Nicole] 

Wonderful. Thank you for giving us your two cents on that. How about socioeconomic status? 

In your experience, what do you see? Are the socioeconomic status of your patients or of that in general that are into this addiction? 

[Dr.Mendelson] 

Well, I think first thing to say is that all addictive disorders are downwardly mobile socially. Nobody does better in their future by having a drug problem. Even the smokers, it’s relatively downwardly mobile. 

You can say that for all diseases, like having a disease definitely decreases your income and your prospects for future employment. These are downwardly mobile diseases. You get them, you go down. 

That is something which we don’t talk about enough for why people ought to go into treatment. I mean, you’re going to cut your own foot off for having a future economic success. Most of the surveys show that alcohol use disorder doesn’t care what your SES is. 

It could care less of what that is. Again, if you get severe alcohol use disorder and you lose your house, you get homeless, you lose your job, you lose your kids, you lose your family, your SES is going to get a lot worse. But you go to jail for drunken driving. 

Those are all downwardly mobile events. But it doesn’t care what your SES is to start. We have plenty of people who are very highly successful, like super high achievers in many domains. 

They still can’t stop it. They still drink one to two bottles of wine a night, and feel crummy the next morning, and get memory loss and blackout. Remember their kids told them, and end up missing work meetings in the morning because they’re too hungover. 

We’ve got plenty of those. That’s one of the tropes of the past, of course, is that it’s just the poor people who get this. If we just lifted their socioeconomic status, they wouldn’t have an addictive disorder anymore. 

That’s wrong. That’s simply not true. That’s simply not true. 

And the people, again, so America, in the United States right now, we estimate there are 20 million people with alcohol use disorder, right? 20 million people with alcohol use disorder. That’s two-thirds of California, okay? 

All right, it’s an immense number. It’s an immense number. It’s like one in five. 

And again, all of us know someone who has alcohol use disorder. Every last one of us knows someone. So this idea that an economic model would explain why that exists, it’s just not true. 

Just not true, right? I’m gonna go back a little further. I mean, one of my favorite stories for like, to sort of show people how deep addiction goes, it comes from the Bible. 

So if you go to the Sistine Chapel and look on the roof of the Sistine Chapel where Michelangelo has painted pictures in the 1570s, one of the paintings, the one that’s furthest from the altar is the drunkenness of Noah, right? And do you know this story at all? No, you don’t know this story at all because nobody knows. 

It’s on the roof of the Sistine Chapel. What kind of school did you go to? Right, did they educate you? 

No, but seriously, no one gets educated on this, right? You know, no one gets educated on this. So in the Old Testament, after the flood, the flood’s resolved, right? 

The ark lands. What’s the first thing Noah does? He plants grapes, okay? 

What’s he plant the grapes for? To make wine, right? He makes wine and he starts drinking a lot of wine, right? 

And one day he’s drunk, he’s drunk so much wine that he passes out drunk, passes out drunk. This is the old, I want to tell you, this is the foundations for, there are no other people on this planet except Noah. And the first thing he’s doing is getting drunk, okay? 

He’s getting drunk, you know? So he passes out naked and drunk and his kids see him. They see him naked and they don’t want to humiliate him so they back in so they do not gaze on his nakedness and try to cover him with a cloth so that he’s no longer naked. 

He comes to, sees them, and he throws one of the kids out of the family, right? Throws one of the, he exiles one of his own children who saw him, right, while drunk, right? So what, and so what’s going on with, and why is this, so what a weird story, right? 

I mean, is this story weird or not, right? So how would we tell that story today, right? And so this is like, you know, so there’s, so Noah, after retiring from a successful career in logistics, right, working for a really difficult boss, right, he retires and he does his job, he completes his work, but all of his friends and everyone he knows is dead, okay? 

So he becomes a gentleman farmer in Napa, right? He gets a nice vineyard in Napa, retires to his farm in Napa, but, you know, for the trauma, for the trauma of his career, right, from the trauma for his career, right, he becomes a heavy drinker, right? And that leads to a family fracture when the family tries to intervene and address his drinking, okay? 

It’s a story we all know, right? So the SES here, that Noah had a quite a successful career. In fact, he was the only survivor in his industry, you know, right, you know, right? 

And then destroys his family from drinking, okay? So it goes a long way story-wise. 

[Nicole] 

Absolutely, it goes back in history, especially when alcohol is so prevalent in our culture is to celebrate to wins or losses or whatnot, so. 

[Dr.Mendelson] 

And every culture, every culture has an alcohol-focused origin story, okay? Every culture has one. You can go, you can find, just go to the origin story that the Navajos are drinking, that every culture’s origin story involves something around alcohol, okay? 

[Nicole] 

Absolutely, very true. Looking ahead, what future development, whether it’s digital health or medication, do you envision for addiction treatment? 

[Dr.Mendelson] 

I think, again, we have a great number of medications coming along. We’re finally getting, you know, getting good signals on treatment meds. We’re understanding better how to assess them and what they can and can’t do. 

I think there are some, you know, like transcranial magnetic stimuli. There are some other procedures that might actually also be useful in altering some of the circuits, the neural circuits that seem to propel going from the first drink to the second, the second to the fourth, the fourth to the eighth. You know, I think we have a whole set of interesting tools coming along, some from pharmacology, some from other ways to manipulate the brain around. 

We have a digital health coming, you know, and we sort of talked about, I really think, you know, like for most disorders in medicine, you know, you’re gonna see your digital, your expert, you know, you’re gonna have a primary plus you’re gonna have, you know, digital experts for most everything. And I think we’ll all like that. That’ll be really good. 

Get university level care every place. I think the other thing that’s coming that’s very exciting is this acceptance. It’s acceptance that, you know, you can have a, you know, that you can have a period of time when you have some drug misuse and that, you know, that starts out as something you enjoy, but something later on, something that dominate you, you know, and inhibit you. 

And that can be discussed and be tackled, you know, in a nonjudgmental, you know, way. So I think those are all the good things happening. You know, I think for, you know, for, we still have a long way to go. 

There’s still, you know, still, I mean, because alcohol use disorder does, you know, in Noah’s situation and the story of Noah there, it would not be unreasonable for the family to say that God, he needed to get better with God. I mean, he actually worked for God, you know? Right, it wouldn’t be unreasonable to say he needs to go to 10 to 12 step program, right? 

You know, and that he needs to, you know, address his trauma and his spirituality as well as get a little naltrexone or whatever else we’re developing, you know, right? Along the way. I guess the final thing that’s really interesting, exciting, that the no alcohol, the no alcohol, the alcohol-free beverages, these have a really interesting potential coming. 

And so, you know, so, you know, I think one of the really potentially exciting things, so, you know, right now the alcohol content of beverages is pretty fixed. You know, I mean, the beer people have been experimenting with much higher levels of alcohol in, you know, the IPAs that have 10% alcohol, basically a wine, right? And wines have also sort of drifted up from 12% to 16%, though there are some low alcohol wines. 

I think there’s going to be a big space for innovators to present with low or reduced alcohol content beverages, right? And particularly for young people, for young people, low alcohol beers and wines may be a much safer way to introduce them to alcohol, you know, as they’re between high school and college and, you know, between 18 and 24. You know, so I think there are some other things that are coming that can be very exciting in terms of making it less risky for you and I and for our kids to develop an alcohol problem. 

[Nicole] 

Those are great thoughts about the future development in not only alcohol beverage industry, but also in medication and pharmacological industry. With such a robust involvement in research, how have you seen your work influence current treatment modalities? 

[Dr.Mendelson] 

Well, I was fortunate enough that, you know, I was fortunate enough that early in the research career, Reese had grants and contracts from NIDA to develop buprenorphine naloxone combinations. And so I was fortunate enough to be along in that ride and did a lot with, you know, fortunate enough to be able to do a lot of the foundational studies, you know, for buprenorphine naloxone. That has been transformative, has been transformative. 

The, you know, the stimulants, you know, I had many grants looking at stimulant dependence and we were unable to find anything that budged stimulants use in people. You know, a lot of early work, I was also fortunate to have collaborators who were, you know, and I kind of led the team, but the other guys were the real brains in it. You know, the, in hallucinogens and tactogens, you know, and that area is evolving. 

It is, you know, as a, you know, as a, you know, as a really interesting area, though I’m not sure, I’m not sure that the promise is ever going to be as good as the hype for the hallucinogen community, you know, because I’m basically, they’re claiming that it helps everything, right? You know, like with just a single dose. The, I don’t think that’s going to work, you know? 

So I think it’s going to be useful, but not like they’re thinking. The, but I think this, the alcohol field again, you know, following Benowitz’s, you know, point, I mean, this is where the people are dying and for doctors, that’s where we want to be, you know? And, you know, we want to be in front of that freight train and try to push it off the tracks, you know? 

So, you know, that’s, and that’s been a blast and, you know, it’s been a good, that’s been a good, a good life, you know? So it’s been, it’s been, that’s been really good, you know, and I have to, I do have to say that not a day goes by when we don’t hear an alcohol-related horror story, you know, of like, you know, like, you know, this man isn’t covered, this isn’t being done, you know, these people, you know, insisted on something crazy, you know, right? You know, like, there’s a lot of, every day there’s a surprise that you wouldn’t guess would be a surprise, you know? 

Right, you know, right, this is, this can’t, they really can’t be that naive and they are, you know? So, so that, that, that’s, that, we still have a, we still have a really long, long way to go, you know, before we get, before we get this, you know, get, get this to a point where the, where the average person has access to really good evidence-based care that’s safe, effective, affordable, and not intrusive, right? So- Very true. 

[Nicole] 

My last question, it’s more of a statement. I would like to give you a chance to tell us more about REA Health, whatever you want to tell the audience about the current projects that you’re working on, anything they want to give a shout out to, the floor is yours. 

[Dr.Mendelson] 

Okay. Well, you know, REA Health is a nationally scaled telehealth solution for, for alcohol use disorder. Our technology component is breathalyzers. 

We, everyone is, gets a breathalyzer. We actually measure the thing of most relevance with alcohol use, their alcohol use, right? We actually quantify it. 

And, you know, so, so, so I think, you know, when we’re the first to really incorporate this combination of objective measures of, of, of behavior and, and treatment. And, you know, so far we’ve collected over one, in our 10,000 patients, we’ve collected about 1.3 million breathalyzer readings. And, you know, so we have an incredibly good, good uptake of the device and of, and of the, and, and its utility and treatment. 

The, the, you know, the, the research, the medical staff we have is, again, distributed across the country. And it’s, it’s, it’s better than most academic medical centers in terms of, in terms of both diversity, inclusiveness, and training. We have, we have, we have active research projects going on with Stanford University and looking at using. 

So in, in everyone’s electronic health records there are patients who have elevated liver function tests. And those liver function tests are often ignored by doctors because they’re not very, very high. And it turns out a lot of those people have alcohol problems. 

And if you actually approach them to, to, to, to, to, to see if they’re interested in alcohol treatment, they are. And so we’re demonstrating that through a project in Stanford. We have a collaboration with Mayo Clinic. 

Mayo Clinic sought us out for this collaboration to, to, to, to use in the, in the, in the liver clinics for people who are either pre or post liver transplant to see if we can treat their alcohol use disorder, make this, maybe decreasing their, their risk of needing another transplant or decreasing the, increasing the time before they need their first transplant. The, we have a, a really exciting project that’s being funded through the Department of Defense looking at inhaled xenon gas to suppress alcohol withdrawal symptoms and treat comorbid PTSD. This is a planning grant. 

This is, we’re a ways from actually doing this but it turns out xenon gas is a medical gas. Turns out xenon, an element, right? Fits into a binding site of a protein called GSKB3 beta. 

And does things, who knew? Who knew, right? It was really interesting. 

You know, so those are some of the projects we’re doing. We’re also, you know, we are, we’re certainly trying, we’re still continuing our expansion into multiple states. What are our roadblocks? 

What’s the difficult parts? Well, we, we’ve, we’ve, we’ve gone, we’ve tried to do value-based pricing with our insurance partners. That makes a very long, a very long, a very long contracting cycle, like a couple of years per carrier. 

So in this model though, this is better for the patients. They pay a fee once a month, have one copayment a month. And it’s better for us. 

We, our agreement is we provide all the care the patient needs during that month for that fee, right? So our providers aren’t, don’t, don’t have to care about, you know, like, like, like extra, doing extra visits or not. We encourage them to do as many as needed and no one’s being rewarded for extra, for extra charges or fees, right? 

So, so, so we have an economic model for the, for the, for the payers that, that, that, that, that’s, that’s pretty nice. We give the same model to patients, but have a, you know, most of the service provided the first three months of the most intensity occurs there, but we have a schedule of payments for patients that, that, that, that, that’s, that’s much less money than the alternative. We’re about 4,000 a year, the alternative about 40,000 a year, right? 

So, so, so those are all the real exciting things. You know, we got going, we got to, you know, we have, we have, we have investors who, who, you know, made the commitment to go on the ride with us and to, and to, and to get us to the point where we’re, where, you know, our, our goal is to be treating, to be having an active treatment at any one time, 10,000 people. We have 2000 now. 

So it’s, it’s a, it’s an attainable goal. And, you know, and, and again, continue to drive these great outcomes and to be partnered with, you know, to have clinical research as a, as, as a key part of that, you know, as, as, as part of the drive, the value driver for both the patients and, and the providers and the pay, and the payers. 

[Nicole] 

That’s great to hear and wonderful to hear about the great practices and innovations and projects that you’re currently working on your team and you are currently working on. And it’s amazing through your leadership, how further it’s gonna go for, for helping people. Dr. Mendelson, thank you so much for such an enlightening discussion, these transformative approaches to addiction care with you. Thank you for sharing your insights and experiences. We appreciate your thoughts and just your, your foresight and your insight. Thank you so much for being our guest today. 

[Dr.Mendelson] 

It’s a real pleasure. I really enjoyed it. And I hope, I hope the audience likes it too, you know. 

[Nicole] 

Wonderful. To our listeners, we hope this conversation has provided you with deeper insights into how technology is revolutionizing addiction treatment. Remember, change begins with understanding and innovation is the key to better health outcomes. 

Join us next time at Digital Health Transformers. Thank you again, Dr. Mendelson. 

[Dr.Mendelson] 

It’s been a pleasure, been a pleasure.