Ask Us Anything About… Addiction

A woman sits on a couch, her head resting on her outstretched left hand.

Substance use disorder (SUD) is uncontrolled use of a substance despite harmful consequence. Many people with an SUD have an extreme focus on using certain substances, to the level where the person’s ability to function in daily life, jobs or family settings becomes impaired. In this interview, addiction medicine specialist Dr. Sarah Kawasaki provides some valuable insights.

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Barbara Schindo – Good afternoon, and thank you for joining us. You’re watching Ask Us Anything About Addiction. I’m Barbara Schindo. According to the American Addiction Center, almost 21 million Americans have at least one addiction. But only about 10 percent of them seek or receive treatment. And also, according to the CDC, drug overdose stats have more than tripled since 1990. Joining us today to talk about addiction and answer your questions is Dr. Sarah Kawasaki. Dr. Kawasaki is an Addiction Medicine Expert at Penn State Health. If you have any questions on addiction or treatments for Dr. Kawasaki, please put them in the comment field below this post, and we will get an answer for you. Dr. Kawasaki, thank you very much for joining us this afternoon.

Dr. Sarah Kawasaki – Thank you for having me.

Barbara Schindo – Let’s start with the basics. Can you talk about what is addiction and what makes a person addicted to something?

Dr. Sarah Kawasaki – Thank you for asking. So addiction is a brain disease. It is a behavioral disorder that is actually able — you can actually see it on imaging now. So it is an actual verifiable brain disease that really centers around cravings. And it is all of the damage that happens when your life is solely focused on craving. So it is craving and using and seeking out whatever fix you’re looking for in spite of different obligations that get you through the day and make you a productive citizen. So craving and using in spite of legal problems, using in spite of work obligations, family obligations. You know, going to different emergency rooms trying to get a fix, you know, health risks, you’re life risking. You know, maybe you’re selling your body for drugs or a fix. And so, these kinds of maladaptive behaviors is really the definition of addiction. And the primary symptom is craving.

Barbara Schindo – And so addiction can be more than just to substances from what I understand, right?

Dr. Sarah Kawasaki – That’s correct, yes, yes. So there’s multiple kinds of addictions. There’s gambling. There’s other kinds of behavioral addictions and in addition to substances.

Barbara Schindo – So, what is it that can make an addiction be considered unhealthy. Is you know, any kind of base-level addiction considered unhealthy, or is there a certain criteria for determining that?

Dr. Sarah Kawasaki – Well, so I want to be clear that there’s a difference between addiction and dependence. So a lot of people confuse the two. And dependence is a term that’s used to describe any kind of medication or substance that you’re taking without which you would get sick. So it’s typically seen with controlled substances. But it can also be used to describe any medication you need for a chronic illness like for diabetes or for high blood pressure. Your body depends on those medicines. And if you stop them, you would get sick, and you would be seen in an emergency room. So when you’re talking about addiction, people can sometimes misconstrue that with, you know, I was addicted to heroin, now I’m addicted to methadone kind of thing. But methadone is actually a treatment for heroin addiction. And people can be dependent on methadone without being addicted to methadone. So there — so when you’re talking about addiction, you really are talking about this maladaptive brain disorder. And there’s no sort of safe, harmless addiction. So, people that are nicotine-dependent smokers, for example, they’re actually dependent on nicotine. They’re not addicted to nicotine. You could make the argument, yes, they smoke in spite of any health consequences that they have. But they’re not risking their freedom or their immediate life in order to smoke it. And so it is considered tobacco dependence and not tobacco addiction, for example, as a difference.

Barbara Schindo – Now, that’s a really interesting distinction. I did not realize there was that difference there, but that makes a lot of sense. And I’m glad that you brought up methadone as a treatment and treatment for addiction because this question kind of follows that. Once a person is, you know, considered addicted to something, are they always addicted to it? Or does treatment become about managing that addiction?

Dr. Sarah Kawasaki – So addiction is a chronic illness. It is something that stays with you for a really long time. There is no endpoint to it. It can go into remission, just like sort of cancer diagnosis can go into remission. And you can have recurrences of it. Just like, you know, asthma never goes away, blood pressure never goes away really. But you can have remission and recurrences of these conditions. And so, treatment for addiction can be temporary or life-long. But either way, the diagnosis stays with you.

Barbara Schindo – Thank you, Dr. Kawasaki. You are watching Ask Us Anything About Addiction with Dr. Sarah Kawasaki, an Addiction Medicine Expert at Penn State Health. We welcome your questions for Dr. Kawasaki. If you have any questions about addiction or treatment, please put them in the comment field below this post, and we will get an answer for you. So Dr. Kawasaki, talk a little bit more in detail about the treatments for addictions. What are some ways addictions are treated?

Dr. Sarah Kawasaki – So, not all addictions are treated the same. And not all individuals need the same treatment. So there are multiple different kinds of addiction because there are multiple different kinds of substances. We could start with alcohol. Alcohol is the most common substance of abuse. And it is a medication — or sorry — it is a substance that can — that can respond as well to intensive behavioral management and intensive peer support as it can to medication. There’s lots of great medications that can help with alcohol use disorder. But if you go to an inpatient program, if you attend a lot of peer support services like Smart Recovery or Alcoholics Anonymous, you can gain a significant amount of sobriety for a very long time, and that can be lifelong. So it is — that is one set of treatments for one particular substance use disorder or addiction. For opioid use disorder, which has been getting so much press, the reason why it’s been getting so much press is because people really can die very quickly and easily with it without appropriate treatment. And so for what is appropriate treatment for opioid use disorder, it looks very different than for alcoholism in that medication is really the mainstay. There are three medicines that are used to treat opioid use disorder, methadone, buprenorphine, and extended-release naltrexone. These three medications work in different degrees and are differently efficacious, but medication is a must. There are very few people that will do well without medication, but you know, it’s sort of like cancer treatment. Do you want to, you know, treat it with vitamins and, you know, sort of herbs? Or do you want to treat it with chemotherapy, the thing that we know we have evidence for?

Barbara Schindo – And you brought opioid use disorder. Can you talk a little bit more about that? You know, that stuff that you mentioned we see, you know, we see a lot about that in, you know, news headlines. Is it a public health crisis? What makes it so unique?

Dr. Sarah Kawasaki – Definitely, so whenever we see a cluster of folks that are dying from a single reason. No matter what the reason, that is a public health crisis. I think before COVID came about, not many people really understood what a public health crisis meant. You know, it means that it can hit anybody at any time. And addiction and death from an opioid can happen at lightning speed before you realize it. So what’s good about declaring opioid use disorder as a public health crisis is that it generates a lot of attention, a lot of money, a lot of media to make public awareness be heightened. And also divert resources to the problem to try to fix it either through policy or treatment or both.

Barbara Schindo – Okay, thank you, Dr. Kawasaki. And we do have — we have a viewer question. We have our first question, which is a good one. This question is from Barb. She says, “I have a friend on Suboxone therapy, but she still has cravings for heroin. Are heroin addicts on therapy able to still do heroin? And what are the effects if they use while they’re also using a different type of drug therapy?”

Dr. Sarah Kawasaki – So great question. Such an important question. People with addiction have addiction. And so, some medicines are more effective than others in certain individuals. For your friend on Suboxone, it’s important to find out if they’re on the right dose of Suboxone that they need to control their cravings. Sometimes they need to be on a higher dose to make sure that their cravings are controlled. And if they’re not doing well with it, in other words, they get their prescription, and they just sell it for heroin, or you know, they do something else with it, that may be a sign that they need a more controlled setting where they’re observed taking their medicine every day or they’re switched to methadone, or they need to go inpatient. So it’s a sign that they need more treatment, not less treatment, if they’re still experiencing cravings. With Suboxone, if you have it on board, you know, if it’s in your system, it’s really hard to get high when you’re taking other opioids. And so it protects somebody from using again even if they want to use. And even if they do use, the likelihood of overdose is much, much smaller if they Suboxone on board. However, many people will not take Suboxone in order to use heroin because the cravings are so high. And so when that happens, it’s really an indication that they need to be in a more controlled treatment setting, either with methadone or with inpatient treatment.

Barbara Schindo – Okay, thank you for that. And Barb, thank you very much for that question. You know, we talked a little bit earlier about the opioid use disorder being a public health crisis. And you know, over the last year and a half, we’ve been facing another public health crisis with the COVID-19 pandemic. Can you talk a little bit about, you know, how has that COVID-19 pandemic affected people that are living with addiction?

Dr. Sarah Kawasaki – Terribly. I think that isolation is really a horrible thing that has happened in the pandemic. And especially for people with substance use disorders, when they isolate, bad thoughts happen, and they end up self-medicating. So we’ve had a 30 percent increase in opioid-related overdose deaths during this pandemic. It’s been astonishing. And in addition, I think people without any alcohol use disorders before have certainly been drinking more. So it’s been stressful for many individuals for many different reasons.

Barbara Schindo – You are watching Ask Us Anything About Addiction with Dr. Sarah Kawasaki, an Addiction Medicine Expert at Penn State Health. If you have any questions for Dr. Kawasaki, whether you’re watching this now live or you’re watching this on playback, feel free to put your question in the comment field below this post, and we will get an answer for you. Let’s shift gears just a little bit to talk about something that I know is associated with addiction. There’s kind of stigma, you know, with addiction where people, you know, a public perception that it’s not necessarily a legitimate disease but more so about the choices people make. What do you wish that people knew or understood about addiction?

Dr. Sarah Kawasaki – That addiction is a disease. It is not a sin. And what’s really important is that there’s — to just realize that there’s really no other disease process where the treatment gets as stigmatized as the illness itself. So you know, we don’t shame people for needing blood pressure medicine or for needing medication for diabetes. But people get shamed all the time for being on medication for opioid use disorders, so much so that I’ll even advise some patients of mine going to Narcotics Anonymous meetings not to disclose if they’re on any medicines for their opioid use disorder. And the reason is because everybody’s got an opinion. And it’s not just the people in treatment, and it’s not just the family members. Even physicians, it’s even people in the healthcare world that people will stigmatize those treatments and say, no, that’s not good for you. Or, you know, you shouldn’t be on that. You’re just trading in one addiction for another. And we know, we already talked about how addiction is different from dependence. You’re not trading one addiction for another. You’re trading an addiction for dependence when you trade in heroin use for a medication for opioid use disorder under a supervising medical practitioner. So really important to understand the difference.

Barbara Schindo – You talked a little bit about, you know, a certain stigma or opinions about the way, you know, addiction is treated. And that makes me think a little bit about Narcan. There sometimes is a public backlash for, you know, people that have access to Narcan for overdoses and, you know, a negative connotation for people that are using Narcan or the fact that Narcan is widely available. You know, what — can you talk a little bit about like the importance of Narcan and, you know, maybe why it should not have the kind of bad reputation that it does?

Dr. Sarah Kawasaki – So I think a lot of politicians are afraid that people will have so-called Narcan parties where they’ll be more likely to try to overdose so that they can get a better high kind of thing. We haven’t seen that really come to fruition with the widespread availability of Narcan, just like the availability of condoms never led to an uptick in teen sex or teen pregnancy. You know, having these measures of safety be put in place is specifically meant for the people that are using heavily and are at high risk for overdose. So you know, what it has done, I think in a positive way, is that it’s given people who have chronic opioid prescriptions for conditions like musculoskeletal pain or even cancer-related pain, that the medications they’re on you can cause then a overdose or accidental poisoning at any time. And so recommending that these folks also get Narcan has been extremely helpful not only for patient education but for prescribers to know that, you know, what they’re writing for is a loaded gun.

Barbara Schindo – Mm-hmm. Thank you very much for that context and information. And I want to move into kind of talking a little bit more about addiction treatments and what’s available. And that actually brings us to our next question from another viewer named Gary. And maybe we can talk a little bit more broadly about this too. So Gary is asking, “Does Hershey Medical Center have a detox unit?” I guess we can also kind of expand that to say, what kind of treatment is available at Hershey Medical Center for addiction?

Dr. Sarah Kawasaki – Sure. So not specifically, Gary. There is no specific detox unit at Hershey Med Center. However, if you do come in with withdrawal, active withdrawal, you will get treated at Hershey Med Center unofficially or officially actually. It actually is medicine. So anybody coming in with signs and symptoms of alcohol withdrawal or opioid withdrawal will get treatment while they’re at Hershey Med Center, either directly in the emergency department or once admitted to the floor. Also same at, the same thing at the Pennsylvania Psychiatric Institute, which is the inpatient psychiatric facility affiliated with Penn State Health. Anybody coming in with alcohol or opioid withdrawal will get treatment while they’re there. So, in addition to these two inpatient places and emergency department, we have a full-service opioid treatment program which is outpatient attached at the Pennsylvania Psychiatric Institute that offers methadone, buprenorphine treatment, and extended-release naltrexone alongside several levels of counseling that are individualized to group sessions, individual sessions, and all kinds of different therapies are available.

Barbara Schindo – Okay, thank you, Gary, for that question. Let’s talk a little bit more about treatment. So you know, addiction is very wide-ranging. It can affect a lot of families, a lot of relationships. It can, you know, be very hard for somebody to see a loved one struggle with addiction. What can someone — what can people do if there’s somebody in their life who they think needs help, who is suffering from addiction? What kind of resources are available? What should they do?

Dr. Sarah Kawasaki – Yeah, so first and foremost, there is recovery support for loved ones of folks with substance use disorders through Al-Anon, through Narconon. These groups are fabulous in being able to help individuals find peace or get sort of solidarity, therapy, you know, have a community of folks that they can bounce ideas off of. You know, I think unfortunately, we’re not living in a society where we can help people against their better — against their nature. You know, we can’t stop people from harming themselves or making poor decisions. That said, you know, I think that I’m not an advocate of tough love. But you know, but I do think that saying, you know, there are places you can go where you don’t have to feel sick and you can just get treated and not have to worry about arrest or losing your life or, you know, you can be a more productive member of — You can get your job back, you know, stuff like that. And if you need any help with that, I’m here to help. And sort of having some quick resources at your side, be able to do that. You know, I know that our [phonetic] Clinic will — has a 24/7 phone line at the Pennsylvania Psychiatric Institute and also there are other places like that in Central P.A. and elsewhere.

Barbara Schindo – Okay, I will, I think — I’m sorry, I got distracted by the host [phonetic] chat here. We do have another question. And this question is from Amy. Amy is asking, “Can people become addicted to marijuana? I thought it wasn’t addictive, but I’ve seen someone close to me become an everyday user. Should I be worried, even if it’s medical marijuana?

Dr. Sarah Kawasaki – So marijuana is such — this is such an important question, Amy, especially in Pennsylvania when marijuana has become decriminalized and also developed into a quote-unquote medical treatment. I put quotes around it because it’s not actually medical. I think that what — there are people that will prescribe it as sort of a way to decriminalize it for folks that are using it already. But there is not good evidence to actually make it a full-on medical treatment that’s approved by the Food and Drug Administration. Marijuana is still technically federally illegal. So it’s hard to research it like you would any other medication for a chronic condition. So you know, unfortunately, medical marijuana in the State of Pennsylvania is just marijuana with an asterisk which is that it is a lot more potent than what you see on the street. And so, it’s not that more people are using marijuana because marijuana is decriminalized. But I think that you’ll find that more people are using it more heavily. And that the marijuana is more potent. And we actually don’t know what that does to an individual. And that needs to be studied. So is there a thing as cannabis dependence? Absolutely. And cannabis addiction, really. And the key is to remember the — I guess the key is to think about the definition of addiction. If it’s interfering with their work, with their relationships, you know, if it’s somehow affecting their ability to drive or be productive, then they have an addiction and a dependence. And it can be to anything, you know, especially if it’s legal, right? We’ve seen this with alcoholism. So a cannabis disorder is absolutely possible.

Barbara Schindo – Amy, thank you for your question. And thank you, Dr. Kawasaki, for that information. Before we wrap up, I’ll ask one more question here. I know, so Penn State, The College of Medicine participates in the Penn State Addiction Center for Translation. Can you talk a little bit about, you know, what that is and the work you do there?

Dr. Sarah Kawasaki – Yes. So the Penn State Addiction Center for Translation is a center that combines all the efforts that are research, clinical, and teaching for the immediate University, College of Medicine, and the surrounding community. So we do a lot of advocacy. We do a lot of community work. We think of some innovative ideas in research. And we talk about how we can expand our clinical services all at the same time in this center. And it’s filled, you know, all the fabulous faculty at Penn State and Addiction doing the work that they do.

Barbara Schindo – Okay, Dr. Kawasaki, thank you so much for joining us today for Ask Us Anything About Addiction. For those of you that are watching this, whether you’re watching this live or watching it on playback, if there is something that we have not talked about that Dr. Kawasaki hasn’t addressed and you still have a question, you can still ask that question. You can ask it either in the chat below this, even if you’re watching it on playback, and we’ll get an answer for you. Or you know, if you’d rather ask a question in private because, you know, you want to keep things anonymous or private, you can do so through a direct message or private chat, and we can get an answer for you. And we will put some more information about the Penn State Addiction Center for Translation in the comment field if you’d like to learn anything, you know, any more about the research going on at that organization. So again, Dr. Kawasaki, thank you for joining. And thank you for watching.

Dr. Sarah Kawasaki – Thank you so much.

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