Groups Recover Together
This week I am talking to Gus Crothers, MD, Chief Medical Officer, Groups Recover Together (find out more here) who have focused on solving the Opiod Use Disorder (OUD). Gus’ journey to this role is interesting as he described his ‘beginner’s mindset’ that allowed him to see the opioid epidemic with fresh eyes and question the underlying trajectory and what was happening to our patients, as he describes it
I didn’t watch the guidelines kind of get published incrementally…creeping the dosage up, I just landed right there where it was causing so many problems that it was impossible to ignore
Looking back the turning point in the perception of a problem took place when the opiate or drug overdose deaths surpassed car accidents as a cause of death in the US.
Addiction is a Solution to a Problem
We discuss some of the underlying causes to the opioid epidemic – there is no smoking gun but rather plenty of problems and faults throughout the system and as Gus highlights – to get to the root cause you have to start with the understanding that
Addiction is a Solution to a Problem
It may not be the right problem being solved but it was the attempt to solve problems that got us into this mess.
We discuss the impact of COVID19 has had on the epidemic – probably not a surprise but things have gotten worse with more people dying from overdoses, but the good news is they have solutions that work that importantly involves much more than law enforcement because as Gus points out you “cannot arrest your way out of this epidemic”.
Listen in to hear about their successful group therapy path that is filled with hope and potential that builds on solutions that we know are highly effective
- Medications
- Counseling and
- Peer support
You will hear how their success has been built in a virtual world, one that was initially cobbled together but is now based on a new platform they built specifically for the purpose. Oftentimes we find digital solutions amplify the disparities of access and inequities but they have found their community has been part of the solution with individuals helping others to navigate these challenges.
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Dr. Gus Crothers. He is a board certified physician specializing in addiction medicine. And he’s the Chief Medical Officer at groups recover together. Gus, thanks for joining me today.
Gus Crothers
Thank you so much for having me, Dr. Nick.
Nick van Terheyden
So always helpful to understand people’s background. You’ve obviously come at this as a clinician, but through a specific era. Tell us a little bit about your journey to this point and how you ended up
Gus Crothers
here. Yeah, people are always interested to know how I found the field of addiction medicine. Because I’m a bit of a rare breed. There aren’t very many of us who are addiction medicine specialists. So I originally trained in family medicine, I was setting out to be a primary care physician. And just by, you know, by circumstance and dumb luck, I happened to train during the peak of the overprescribing epidemic of opioids. So this was kind of in the mid 2000s, where if you look at the graphs, you can see the number of prescribed opioids per capita in the US was really peaking. And so, you know, I didn’t know this background, I was just put in it. And so I had a bit of a beginner’s mindset, and looked around and said, Guys, this just seems crazy, you know, what we’re doing to our patients? I know what’s what the guidelines say, I know what the evidence, quote unquote, says, but it just doesn’t seem right, it seems to making things worse, not better. And that experience kind of turned me off to traditional primary care. And I was lucky enough to stumble across a mentor who was actually treating addiction in his primary care practice, which back then was extremely rare. And today, sadly, is still all too rare. And he really turned me on to the the impact you can have on patients by by treating addiction. And it caused me to do a pivot in my career. And the first job I took out of residency was actually in an opiate treatment program, which is a more traditionally called the methadone clinic. And, you know, I really just jumped in with two feet. And I learned so much about addiction medicine from that. And the rest is history. I really, you know, I’m a little sad that I never really focused on primary care. But at the end of the day, I think if you just look at the, the epidemiology of what’s going on in us right now, what the what the US really needs is more people who are paying attention to addiction. So that’s, that’s where I focus my career.
Nick van Terheyden
Yeah, I’m just going to say that you have focused on primary care, because that’s an awful lot of the contributory elements. So I would put that to one side and say, fantastic that you’re in this space. We don’t have a lot in the way of resources or activities to date. But obviously, that’s changing. If anybody was to state, you know, opioid use disorder as a term. I think most people would say, yes, we’ve got a problem at this point. Yeah, the time that you entered in, that wasn’t the case. Tell us a little bit about your journey. And your discovery through that was, was there something that really stood out to you? What were the elements that really made you think differently? Because ultimately, you’re seeing it different? Was it because you are new, I’m curious to know how you spotted it and others weren’t. And
Gus Crothers
I really do think the beginner’s mindset helped the fact that I was new. You know, I wasn’t wined and dined by the pharmaceutical representatives, I didn’t watch the guidelines kind of get published, you know, incrementally in your career kind of creeping the dosage up, I just landed right there where it was kind of causing so many problems that it was impossible to ignore. And you’re absolutely right, that when I got started, in this work I used when I had speaking opportunities like this, or conversations like this, I used to spend more of my time kind of raising awareness that, hey, we have a problem. It’s nice that I don’t have to do that anymore. You know, sadly, all you have to do is read the newspaper at any given day in any city in America. And you’ll know that there’s a drug abuse and an opiate epidemic going on. And so today, it’s more questions about hey, what are the possible solutions that we have? And so I spent more of my time talking about, you know, the educating folks on the treatment options and what what works, what doesn’t work, what’s innovative, what’s coming down the pipeline, etc.
Nick van Terheyden
So, if you cast your mind back, could you see an inflection point at the point that you had to you were no longer having to explain that. Was there a time when it changed? Or did it just sort of it just slowly moved to this point of awareness? And I don’t want to say acceptance. We don’t accept opioid use disorder. But was there an inflection point for you?
Gus Crothers
You know, I can’t think of an exact inflection point. It certainly seems like it’s been gradual. I think a soundbite that I hear a lot is you know, there was a year A couple years ago where opiate or drug overdose deaths surpassed car accidents as a cause of death in the US, and I feel like to me at least that was a, that’s a talking point I’ve used that really seems to turn a light bulb on for people. Because, gosh, if you just think about how often you see a car crash on a highway, etc, you know, every time you see one of those, there is the equivalent of someone losing their life, you know, prematurely to a drug overdose. And, to me, that was a point when it became easier to explain the gravity of this to folks I was talking to.
Nick van Terheyden
Yeah, I think that’s really key is that, you know, it’s funny how specific visualizations or data can really sort of change the conversation. So, you know, as you said, earlier on, your sort of focus is on how to fix it. We’ll talk about that in a second. But as you look back, obviously, with the benefit of you know, hindsight, what are your thoughts about how we got here? I mean, there was clearly No, I, at least in my mind, there was no mal intent. With the distribution of these drugs, we had pain, we had a solution to pain, it was a medication, you could take orally, all of those things contributed. And I think everybody, for the most part was excited, but we sort of missed something through that. What what what do you think we could learn that could help us prevent a similar occurrence with other medications?
Gus Crothers
It’s a great question. Yeah, there’s, there’s certainly plenty of blame to go around in terms of the underlying drivers of the opioid epidemic, it’s easy to cast around for kind of the simple one cause but like, like any big complex phenomenon, it’s always multifactorial. If I had to pick one, one, cause I would say it’s the it’s the system of for profit medicine that we have in America. I mean, and I think this is just I’m not saying it doesn’t do good, it doesn’t lead to innovation that leads to discovery, it you know, etc, etc. But I think the opioid epidemic is an example of what can go wrong, when there are appropriate checks and appropriate regulatory oversight. And, and if you think about it, there were there were failures at every layer of the system. I mean, everyone knows it’s very well publicized kind of the, the problems that at Purdue pharma, and kind of how they somewhat manufactured and perhaps, you know, marketed their products in ways that they shouldn’t have, obviously, there was over prescribing done by providers who should have known better and, you know, shouldn’t kind of double check their evidence to double check their sources. But then you go, you know, you go up the line, there were, there were unrealistic expectations from patients, there were pharmacists who totally turned a blind eye to their regulatory role. There were distributors who failed in their supervisory, the DEA wasn’t doing enough. And then, of course, there’s, you know, the underlying factors of society, I think all of this is driven by kind of rising inequality, lack of, you know, erosion of the social safety, net lack of resources. I mean, I think one of my mentors taught me the code, I don’t know who it’s attributed to originally. But it he says, you know, if you, if you want to understand addiction as a problem, you have to first understand it as a solution. Because, you know, everyone who starts using a substance and especially uses it to the point of becoming addicted, is doing it as a solution to something, they’re usually trying to solve something going wrong in their life. And so for a lot of people, that’s poverty, that’s relationship problems, it’s lack of economic access. So anyway, all these things together, coupled with an incredible opportunity for profit that the manufacturers of these medications saw really created the perfect storm that that landed us where we are today.
Nick van Terheyden
Yeah, it’s interesting. You bring that up, I think, you know, that’s a great anchor point for me is it sort of says it more elegantly that, you know, people don’t go in with Mal intent through was there to solve a problem, albeit, maybe solving the wrong problem, but I think that’s a great way to sort of frame this. So here we are, you have, you know, just extraor I can only think it’s gotten a whole lot worse. How much worse did it get with the pandemic? Did that really do a number on us? Or was it just it was on a trajectory anyway?
Gus Crothers
Well, no, I think it really changed the change the course of the underlying substance abuse and opioid epidemic. I mean, we’re in the story is still unfolding in front of us. I mean, what’s in the news right now is just a few weeks ago, some new numbers were released, looking at the 12 month period, from ending in April 2021. And going 12 months back to eight to the April in 2020. And essentially, the number of overdose deaths in that period, were the highest ever over 100,000 in a 12 month period, which was almost a 30% increase from the 12 months prior. So you know, sadly, things are going in the wrong direction. And the challenge here is, as your listeners might know, is the nature of the epidemic that has changed It really started. As you know, prescription opiate epidemic. We’ve talked a lot about that previously with prescription opioid over prescribing. As the prescribing rates reduced, things shifted more towards heroin or more traditional street opioids, and now it’s flooding the market is fentanyl. And there’s a lot of reasons to that that I can go into. But but the end result is that fentanyl is just significantly more potent, and definitely more dangerous. So so even if the underlying usage patterns and epidemiology of the epidemic weren’t actually changing, just the fact that the dominant substances changing would lead to more deaths. But then you also have all of these, you know, increases in social isolation, increases in depression increases loneliness, decrease in economic access, again, getting back to the fact that addiction is a solution to a problem for most people’s lives. And I think all of us know how much COVID has impacted our lives and cause problems. And so those those two forces, more more potent synthetic opioids like fentanyl, and all of the challenges we face from COVID have really been a train wreck.
Nick van Terheyden
It’s worth just unfolding a little bit underneath the covers of fentanyl, because it’s not quite as simple as people understand it, you know, without going too deep. How people understand why that has sort of overtaken and what that constitutes because I don’t think that particular story is over by any stretch.
Gus Crothers
No, it’s not that happy to and I think the if your listeners take one thing away, it’s that the rise of fentanyl is kind of a direct response to our emphasis on trying to solve this problem with law enforcement. And I’m not trying to blame our proud, you know, members of the law enforcement community out there, I just want to point out the fact that, you know, we cannot arrest our way out of this problem. And the reason for that is really simple economics and frankly, physics. Fentanyl is potent. You know, a roughly a marble sized quantity of fentanyl is roughly equivalent potency wise to, you know, like a small suitcase of heroin. Which of those two items is easier to smuggle across the border or to hide from a police officer, you know, a briefcase or a marble, obviously, the marble so as as the you know, as the science and technology, the ability to synthesize fentanyl has kind of spread throughout the illicit world. It’s become the dominant substance of choice. And the more we continue to apply pressure, interdiction pressure at the border, you know, basically just any sort of criminal justice pressure, it’s only going to be an arms race. And there’s already new, more potent synthetic opioids that are beginning to emerge. Now that makes sense. It all looked like a walk in the park. So I think all of us in the trucking community are scared that if we don’t balance out, both law enforcement with treatment, that we’re actually going to push the potency of these drugs beyond what our our momentum of medications is able to handle. That’s kind of my biggest fear right now.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today, I’m talking to Dr. Gus Crothers. He’s a board certified physician who specializes in addiction medicine, and also the chief medical officer at groups recover together, we were just talking about the history and how we got here. You know, I think history is always informative in understanding how to sort of resolve it, I think, some great points around, you know, addiction being a solution to a problem, which, you know, for me anchors much of our discussion. The good news is, you’re in this, you, you have an approach. Tell us a little bit about how you’re going about this and how we see a pathway out because it’s clearly gotten worse. How do we fix this?
Gus Crothers
Yeah, thank you for asking that. You know, the good news, I’ve been all doom and gloom so far. But the good news, especially in opioid use disorder is that we actually have effective treatments. And in the grand scheme of things, if you look at other chronic disease treatment, or in other chronic diseases, which we have treatments, the the treatments for opioid use disorder are pretty darn effective. You know, we can cut mortality roughly in half, we can cause tremendous improvements in quality of life, we can help drive all sorts of recovery, we can do this with a combination of medications, with counseling, with peer support, etc. The challenge is in delivering that there’s a huge gap between what we know in the research phase and what actually happens out there to the average person who needs treatment. So that’s kind of where I’ve focused my career. In my role at groups are coming together, I lead our practice model. And what we are is a, you know, an addiction medicine practice. We operate across 15 states and our goal is really to raise the bar for quality for everyone from all walks of life who needs access to addiction treatment, and we do that by combining a really innovative treatment model that brings together all those kinds of evidence based best practices and started to rattle off, we bring together the medication prescribing, the counseling, the peer support, the social services, the community, the technology, all of that under one roof. So whereas traditionally it’s been siloed, or fragmented and thus doesn’t happen to the average patient who needs treatment, we bring it all together under one roof, we make it seamless, all you have to do a show up and say, hey, you know, I want help, and we’re gonna make sure that you get the latest cutting edge treatment wherever you are. We also I think, what makes me really proud of what we do is we focus on the underserved. So over 65% of the folks we treat are on Medicaid, which I think is really unique in the world have kind of venture backed tech enabled. healthcare service delivery companies like like the one that I work for, most are kind of chasing after the employer lives with the commercial lives. And we’re really focusing on where the help is needed, which is Medicaid, for the most part, if you if you look at just the prevalence rates of addiction. And we’re tech enabled, which I think also makes us unique, and I’m happy to speak more with that as it relates to COVID. You know, we can, we have over 100 Physical offices across 15 states, but you can get the same high quality treatment from us by using your smartphone or your computer or your tablet, everything we do is available via telemedicine. And obviously, the pandemic really pushed us in that direction. But since since we’ve done that we’ve spent a long time and worked really hard to study our outcomes. And essentially, they’re equivalent. We’re seeing the same grade high quality results for our members. And I apologize, I call it we call our patients members, you might hear me use those interchangeably. We’re seeing the same great quality results over telemedicine as we used to get and continue to get in our in person treatment as well.
Nick van Terheyden
So I mean, that’s laudable, and I think you’re exactly right, you’re servicing the community that is most affected. I mean, maybe I’m wrong, but certainly intellectually, it feels that way. You’re using technology. Tell us a little bit about how you’re doing that, because I think that’s, you know, it’s an enabler. What’s going on? What are you doing?
Gus Crothers
Well, when the pandemic first hit, we had to scramble like a lot of treatment providers, we always use telemedicine a little bit, it was kind of a, you know, a little augmentation to our traditional which was model which was mostly in person. So then when you know, when tell when COVID happened, we had to turn that up from like a five on the dial to 100%. And we basically over the course of two weeks switched at the time, we were treating roughly 6000 folks every week across the country, we had to switch all them over to a pretty, pretty budget telemedicine platform. I’m going to speak frankly, I mean, we it was a pretty lousy patient experience. We were asking them to log into zoom for their counseling sessions, go to their email to, to get information, go to HelloSign design treatment forms that they needed, receive text messages for minors mean we were asking them to go to so many different places, it’s amazing that they put up with us it was a terrible kind of consumer patient experience, not consumer grade, not modern. We we got things stabilized, we quickly studied our outcomes, and we’re pleased to see that it was working. We surveyed our members and we’ve done so numerous times now since and we learned that members like telemedicine, not everybody, but roughly 75 to 80% Depending on how you ask the question, say they either prefer or find telemedicine, you know, kind of equally preferable to traditional in person care. And if you ask them how supported they feel, the majority over 80% say they feel as supported or more over telemedicine. And then we looked around the ecosystem or you know, the ecosystem of technology to see hey, what tools are out there to help us make this experience better for our members? Heck, we unify things. And the sad truth is we didn’t like what we saw there. You know, you might have heard this from other guests on your show, the EMRs were no help. There were kind of a big surprise, right? There were a lot of point solutions out there that cert looked, you know, tried to engage the member, but they didn’t do all the things we needed. So we basically made a big investment. And, you know, a few months ago, we were proud to announce that we rolled out our own proprietary digital platform, which really takes all those disparate things that we asked our members to do and brings them all together under one app. So just as in our traditional political model, we’ve worked hard to bring all the evidence based pieces of the multidisciplinary care team under one roof so that the patient didn’t have to go anywhere. We’ve now done the same thing in the digital world. So all you need is a smartphone or a computer. And you can get the great treatment, really from anywhere where we operate.
Nick van Terheyden
So I think that’s great. And you know, bringing it all together. The one thing that jumps immediately to my mind is that community that you specifically referenced that you’re targeting is also the community that tends to lack those resources quite often lack internet connection, lack of devices, and all of that tied together to a community that is essentially underfunded because of the way that the funding mechanisms work. Yeah Are you doing this to make this profitable with an approach that is designed for the group that most needs it?
Gus Crothers
It’s a great question. And I’ll try to answer it a couple different ways. So the first is we’ve actually been pleasantly surprised by the ability to access technology within our membership. And remember, this is mostly Medicaid, roughly 65 to 70% of Medicaid, but it does our population skews a little younger than the traditional population, just by the nature of the opioid epidemic. So that helps us but essentially, about 90% of our members log in via smartphone every week on telemedicine, the others, it’s a combination of a computer, or they you know, they don’t have technology access, in the end, they’re dialing in, but frequently, that’s a temporary situation, they ran out of minutes, they dropped their phone, in the toilet, whatever. And they’ll be back on smartphone next week. So there’s not as much of a tech barrier. As we anticipated. We’ve also worked hard to make sure on the back end, our app is compatible with you know, kind of even lower end smartphones, it’s really important this population of what is a barrier is broadband, that that is challenging. And so we’ve gotten really good at getting creative and helping members figure out hey, there’s local public library, you can park your car there, you can park your car in McDonald’s parking lot, community has always been a big part of our treatment. A lot of as our as our name implies, groups recover together, we do most things in the group format, group counseling, Shared medical visits, etc. And that community has really helped us out because members will help each other up they’ll say, Hey, I’ve got internet come over and join group for my place. Or you know, you don’t need you’re out of minutes. Well, I got minutes on my phone. So you know, we can buddy up this used to happen in our in our in person treatment, people would share ride share job postings, etc. And the same thing is translated into the digital world.
Nick van Terheyden
Wow, isn’t that heartening to hear that, you know, that sort of genuine community translates into the digital world? I’ve got to be honest, I wouldn’t have expected that not that people are not but you’re just two dimensions isn’t the same from a community standpoint, but you’re obviously disproving that in the remaining time. What are you excited about what you see happening in the next coming months? Well, you
Gus Crothers
know, I think we’ve proven through our studies and our in our kind of track record that telemedicine works, and that, you know, it can get the same great results we were getting in our physical offices. And what I’m excited about is the next challenge is saying, hey, what can telemedicine give us? And what can digital technologies give us the frankly, we never had in the in person setting. And I think you know, the secret here is just, you know, engagement. You know, in our traditional model, most of us we go to the doctor once a month in our model, we tend to see our patients weekly, but even so that’s an hour or two a week, the rest of your life, all the decisions are going to make happen in between. And so if we can stay relevant via the phone that’s in your pocket, I think we can really move the needle and help improve outcomes. So the sort of things we’re doing now just scratching the surface with is, you know, kind of building social network type communities within our app group chat, one on one chat, message boards, affinity groups, etc. I, you know, I think relationships and social communities are so critical to treating addiction. That’s been our philosophy since the early days when our founder used to always say the only thing harder than being opioids is trying to do it alone. And so that’s why we founded this kind of community group based model. And what we’re most excited about is spreading that community into the digital realm. We’re not the first people to event this, Facebook, Twitter, etc, you name it, we think we can just kind of leverage it for better outcomes against this really tricky disease.
Nick van Terheyden
You know, it’s interesting, you bring up the community, I would say that, you know, I small personal experience, not with opioids, but with weight loss that I struggled with for, you know, period of time. And the inflection point that I can point to every single time where I changed the course, was when I created a commute, there’s only three of us. Yeah, and we shared our weights via email, I entered into a spreadsheet that I then shared back to watch progress. That was the turning point, because now suddenly, I was I was answerable to other people. And I think that community element is essential, the more that we can enable that. I think it’s going to be essential going forward. Everything concern you?
Gus Crothers
Well, I think technology is has the possibility of exacerbating disparities in terms of health outcomes access, you know, I mentioned the broadband challenges. And if they’re, you know, there’s a role for government here, there’s bills coming down the pipeline that can help address that. But essentially, if the technology gets out ahead of the equity, we could, you know, unintentionally drive a wedge between the haves and the have nots, even more so than this country already has, in terms of its its health outcomes.
Nick van Terheyden
Yeah, I think great point to finish with the, you know, that inequity, it’s, you know, I’ve seen on Maslow’s hierarchy where people put essentially broadband as part of that sort of fundamental business, and I think that’s a absolutely an essential component. Unfortunately, as usual, we’ve run out of time for the episode but just remains for me to thank you for joining me Gus has been a great pleasure. Thanks for joining me.
Gus Crothers
Thank you so much.
