Dr. Joe Tatta: Dr. Reef Karim is an expert in human behavior, has dedicated his life to healing, educating and helping people understand themselves better. He is a double board-certified psychiatrist, addiction medicine physician and relationship expert as well as a writer, community coast and media personality. He is an assistant clinical professor at the UCLA Institute for neuroscience and the founder of the control center, which is a personal transformation center in Beverly Hills for self-expression, mental health relationships, personal growth, and chemical and behavior addictions. He’s appeared on Oprah, Dr. Oz, CNN live, Dr. Phil, Anderson Cooper, and Nightline the today show, Chelsea Lately and many others. Dr. Reef Karim, welcome to the Healing Pain Summit 2.0 it’s great to have you on this year. So I think it was really important to have an addiction specialist, a psychiatrist on to talk about some of the issues around the chronic pain epidemic. Um, I noticed it’s something you see every day in your practice. So just tell us, you know, where we are. I think first where we are as a country, as a whole, as far as prescription drugs go. And then we can maybe kind of talk about the pain medications.
Dr. Karim: Yeah, I think, you know, prescription pills have been a problem in our country for a long time. I mean, people act like it’s a new thing, but yeah, you know, I’ve seen it in our field since the late nineties even it’s, it’s been progressing for multiple reasons. One of the reasons is the availability of the medications and a big piece of it has been direct to consumer marketing. So think about it. It used to be in the old school days, uh, patients or clients or people would say, Oh, well maybe I need a medication. Something’s going on in my life. I’m not sure I’m going to go see the doctor. And a doctor would be the gatekeeper. They would say, okay, maybe you do need this medication or maybe you don’t. So the pharmaceutical companies were like, Oh, well we need to, to get to know the doctors a little bit and you know, see how we can either give them information or possibly do something else to coerce them to start prescribing medications.
Dr. Karim: Well then in probably the mid two thousands or even earlier, they, the pharmaceutical companies went direct to consumer marketing whereby, you know, we see it all the time. We see ads on television all the time. Uh, do you think you have this, we’ll try this medication. So all of a sudden clients and individuals were like, Oh, I need that medication, I need that medication. And so what I’m finding as a physician is this huge shift from a doc. I was wondering, uh, I, I have these symptoms, what do you recommend I should do about it with a huge shift to doc, I need the medication, Zoloft and per panel and whatever else because I saw commercials on them on TV and this is the dose that I need and I’m waiting for you to prescribe it to me.
Dr. Joe Tatta: So, so in your practice, what are the most common medications that you see people are addicted to? And um, I guess we could start talking about the pain medications. And obviously this is a pain summit, so we know that people that are try them and there may be a place for pain medication.
Dr. Karim: Well, let’s just talk about natural a little bit. Yeah. The, the most common, uh, medications that are abused. Currently, there’s three categories. There’s benzodiazepines, sedative, hypnotics, those are medications for anxiety and for sleep, like Klonopin and Adavan and volume and Xanax. Of course, we all know Xanax. Uh, there are stimulants. There’s Adderall and Dexedrine and Ritalin and, and medications in that category. And then there’s narcotic analgesics, which we’ve all heard about. That’s the Oxycontin’s, the Vicodins, the Lortabs, the Norcos, the Percosets, you know, that whole world. Now. It used to be that muscle relaxers were also a big problem, especially with the medication Soma. Uh, we don’t see that quite as much now, but those first three categories we see all the time.
Dr. Joe Tatta: And it’s interesting this year the opioid epidemic seems to have exploded, but has it existed before this year? And is it really kind of still, you know, more to talk about it
Dr. Karim: are, you know, use of opioids. You know, what’s really hard as treatment practitioners, providers, uh, informational, you know, disseminators like you and I is, we have to catch up to technology. And one of the big things about drug addiction and mental health and where they kind of fit together, uh, especially when this epidemic, uh, situation is our technology is far advanced in comparison to our ability to catch up to these drugs. So what I mean by that is first off you’re talking about a delivery system, the delivery system. Let’s take weed for instance, weed in the 1960s had a certain THC content that was pretty low but a very low level of THC and, and in a joint or you know, how on a bond or whatever you’re smoking now because of our technology, because of the way we can make the drug more potent, we can, you know, you’ve got, you’ve got every type of edible possible that you can, you can put a combination of THC and CBD and mix it and, and uh, you can package it any way you want.
Dr. Karim: With high potency, it’s absolutely going to have a different effect. What was maybe 10% THC at one point is now 60, 70% THC in, in some of the edibles. So, similarly with opiates, we now are able through you know, mechanisms of technology, we’re able to grab highly potent molecules and put them in a very small pill and then make, you know, the Mexican cartel is involved and now opiate medications that you think are coming from your doctor’s office, but they’re actually packaged as pills, much stronger potency than you would get from a pharmaceutical grade drug on the streets that are brought into our country in different sources. So our technology is one of the biggest problems.
Dr. Joe Tatta: Hmm. That’s so interesting. I’m glad you brought up other countries cause we were looking at pain rates around the world, the industrialized nations, the United States, Canada, Britain, Britain, Australia, and they’ll have similar pain rates about one third of the population. So when we look at the rates of opioid use, they’re much, much higher in America, probably, you know, twice or three times as high. Why is that? Why is that the case in America? But it hasn’t been that way in the other industrialized countries.
Dr. Karim: So if you look at some of the data, which you know, I’m sure you know 80% of the world’s supply of narcotic analgesics are abused in our country, in America. So think about that. Eight out of every 10 pills that’s manufactured for prescription narcotic pain problems is abused here. What is, what is going on that’s very specific about our country. That’s not the same in other countries. And I think it’s a multiple, it’s multiple things. First off we are, we are prescription pill problem society. We’ve now become accustomed and our condition to popping a pill to solve all of our problems. If you’re an emotional pain, pop this pill. If somebody broke up with you, pop this pill. If you want to feel better and celebrate pop this pill, it’s become a pill popping society. Our doctors are not helping our medical prescribers because you could give somebody, I mean w from a dentist to an orthopod to a psychiatrist or whoever else.
Dr. Karim: Somebody might need a week supply of something cause they’re in pain cause they just had a dental procedure or they just had, you know, an orthopedic procedure. They probably need a week. What does the doctor do? The doctor gives him a month and gives them two refills. So when you have access to something, you’re more inclined to potentially utilize it. Especially when the doctor says, Hey, I’m going to give you 90 days of this medication. Well, if the doctor in the white coat is saying, I’m going to give you 90 days, the patient’s going to be like, I must need 90 days. Whereas if the doctor said, I’m going to give you a week and then I’m going to give you only a one or two week refill, that’s a better way to prescribe that medication. But it’s more of a pain for the doctor because the doctor might be called by the pharmacy. The patient might need to come in more often. Doctors don’t want to deal with that, so they’re like, Hey, let me just give you a bunch of these pills and just take it. And most doctors I know, I mean, I ended up counseling some of them, but most doctors I know don’t talk about the abuse liability or the abuse potential of these medications. That’s a huge crime. That should be part of your bedside manner for any physician.
Dr. Joe Tatta: Yeah. I mean it’s, it’s you and obviously probably talking to these physicians cause you’re probably sharing patients and you know, sharing a patient chart, things like that. Are they getting the, the training like, you know, is it, is it education, does it continue education, you know, they are medical societies, you know, say, okay we have a problem. Let’s start to slowly change the way we’re prescribing.
Dr. Karim: Yeah. I would love to say that all these doctors are getting trained, but they’re not, I mean there’s some that are, that will call me. I get calls quite a bit from different physicians with big practices that are like, listen, I got this guy and I know he’s abusing my pills and I don’t know what to do about it. But here’s, and I hate to be the cynic, but here’s for the most part, what many doctors are doing, they’re calling me because they’re worried about overdose potential for their own liability. You know, I, I’d like to think that yes, they care about their patients, but I think they’re just as concerned about, wait, what happens if this guy prescribes him? I prescribed a bunch of things. This guy, Odis, he gets respiratory depression, gets him into cardiac arrest and what happens to me then? So there’s defensive practicing medicine and you know, if you look at what our government’s been doing, um, and the CDC has, you know, specific opiate prescribing regulations that came through this year where they’re trying to really narrow the focus of what, what standard procedures, standard care standard practice is in regards to prescribing.
Dr. Karim: And I can tell you after that happened, there were a lot of upset doctors. I was at a couple of dinners where the doctors were really upset that they’re going to be regulated in the way that they prescribed their medications.
Dr. Joe Tatta: Yeah. You know, for, for the patients on the summit or people you know, struggling with pain, can you explain to them what happens in the brain with chronic opioid use? Obviously, you know, I think a lot of people have been upset by some of the CDC. Um, announcements cause they feel like their, their drugs are being taken away, right? We’re going to take something away. You got to be responsible as clinicians and you know, give them other alternatives. But what happens with longterm opioid use in the brain and why is it a problem?
Dr. Karim: So if we look at, if we look at our brain, of course our brain is very complicated as many different parts to it. One of the parts is the reward circuitry and the reward circuitry is comprised of the ventral tegmental, nucleus accumbens and prefrontal cortex. That’s the primary circuit, the primary drug from a neurochemical perspective, the neurochemical that shifts in the brain is dopamine. You have a certain level of dopaminergic tone. Now what some people will say, what a lot of researchers will say is maybe the addict has some genetic predisposition, is hardwired differently so that maybe they have under-stimulated dopaminergic tone. Maybe there’s less dopamine receptors, maybe there’s something wrong with their dopamine circuit. Something’s going on where they’re more vulnerable to drugs hijacking this part of the board’s circuitry and amplifying the effect whereby initially take the drug recreationally. Cause lots of people will take drugs recreationally.
Dr. Karim: But then a shift happens in the brain. And that shift involves learning memory, reward, reinforcement, uh, the emotional content that you get from that drug. And what that does to all of it changes in the brain, in an addict after the drug use. For some it’s one use for some it’s twenties is for some it’s 200 uses, whatever it is, uh, whereby you start prioritizing that drug and that feeling that you get in your body, uh, with higher levels of reinforcement and reward to the point where eventually you need the drug more than you need air more than you need food more than you need anything else. Now, in an opiate addict, uh, that opiate addict may take an aspirin and pop an aspirin. The aspirin floats around from a, from a pharmacol kinetic perspective and a bioavailability perspective, it goes through your body. It goes to where it needs to go.
Dr. Karim: It never touches that reward circuitry in the brain. Cause aspirins not addictive to the addict or to the Nannette. You pop an opiate, you pop a Vicodin or Norco or an Oxy or you snored Oxy and and and get it into the bloodstream quicker, it’s going to go in the addict to that reward circuit area. It’s going to affect the opiate receptors in that area. It’s going to have an initial opiate response effect, which kind of is more of a warm connecting, relaxing cause it’s got a great axial lytic effect. The opiates do and and inevitably it’s going to make you shift the way that you feel, whether you’re escaping your problems or you’re just chilling out or whatever it is that you’re doing. But over time your opiate receptors are like, Oh we liked that, we liked that. That was a good feeling. That was a good feeling.
Dr. Karim: Let’s do that some more. Let’s do that some more. And most of these opiate drugs have a shorter half life. Heroin has got to like a two to four hours half-life and unless you’re doing Oxycontin, which is a longer half life, the drug is going to get out of your system. So imagine a gas tank, you do the drug, the gas tank is full. Then slowly over time you’re losing gas cause you’re living your life and you’re losing gas every hour you’re losing more gas. Eventually you get to about 30% full. At that point is when your opiate receptors start going, Whoa, there is a problem right now. We don’t have enough of that opiate gas in our system. We’re freaking out. We need that to keep functioning and keep escaping and keep doing what we’ve been doing. We now have to act out in order to get more of this opiod in our system.
Dr. Karim: And the way they act out is all of the withdrawal symptoms that you get. You get the body aches, you get the goosebumps, you get the runny nose, you get, you know the feeling of restlessness, the feeling like you want to jump out of your skin. All of that stuff is part of that withdrawal. So then you pop another opiate to make yourself feel good again. Right? So again, the question is you just get off all these drugs. You know, can someone wean themselves off this drug or is it essential that they get help and once they seek help, what’s the process of Rubio made from using these drugs? Yeah, that’s a great question. They, they, there’s, there’s a couple of ways you can get off the drugs, but the opiates are a little scarier than the other drugs. We’ve heard about prints, we’ve heard about many, many other, you know, I, I’m in LA, in Hollywood and I’ve ended up either potentially treating or consulting or whatever with a number of celebrities.
Dr. Karim: And it’s, it’s scary and, and not just for the celebrity brain for any brain because there’s the same, but it’s scary because higher dose opiates can cause respiratory depression. And as we know, the respiratory depression is where you literally stop breathing and you can die. So it’s very fatal. Also, if you’ve been on opiates for a certain time period and then you get off, there’s a recalibration of your system. Your system used to be able to take this much opiates and now it can only take this much opiates. What that means is if you’re conditioned or habituated to remember how much you took last time that you were on it when your body was used to it and was tolerant of that dose and you go back to that same dose when your system has now changed, you could Odie on the exact same dose that you had previously.
Dr. Karim: And I see that happen a lot. That’s usually when I see ODS. So the way that you get off the drugs, there’s the old school way, which is you take a bunch of supplemental medications to treat the symptoms that occur when you go through the withdrawal period. So I would give you something to stop the restlessness. I would give you something to stop feeling like you want to jump out of your skin, something for nausea, something for sleep, you know, and, and we give you supplemental meds for a week, two weeks, three weeks until you’re off the drug. And then when you’re off the drug, the hope is that you’ll stay off by getting help for whatever the symptoms were, the put you on a drug in the first place, you know, alternative pain management, anxiety. Those are usually the two biggest ones. Another way of doing it is to utilize the drug Suboxone.
Dr. Karim: So we all know about methadone. The reason methadone was such a big deal is heroin’s got, like I said, a short half life and methadone is got a much, much longer half life, potentially 36 hour, half life. So instead of having a full time job of using heroin or using opiates, oxycodone, whatever it is, popping the pill, feeling good withdrawing, I need another pill and you spend your whole day in this kind of cycle. The thought was, why don’t you ingest methadone early in the morning, it’ll last you all day, it’ll last you all night, and then you just go back the next day in the morning and you get your next dose and you feel decent throughout the whole day and you feel stable. Well then Suboxone came along in this country around 2003 and, and I’ve been a teacher of how to use the drug for awhile. And the drug is, is it’s a, it’s a pill or a strip and the strip is like a Listerine thing that you put under your tongue.
Dr. Karim: And what it does is it, it activates that gas tank, not at 100%, so you don’t get high, but it’s 60%. So it’s 60% bonded to the opiate receptor, which means that you’re going to feel stable and you’re going to feel stable for an extended period of time and it can knock off any other drug that’s on there. So let’s say somebody took Oxycontin or, or took heroin or took whatever, the minute that Suboxone drug gets in the system, it’s going to kick off the drug that’s on the opiate receptor and it’s going to sit here and it’s going to stabilize your opiate receptors from crying out or acting all crazy.
Dr. Joe Tatta: That’s fascinating. And you know, some people have been asking you about LDN, so I’m wondering if you can explain what that is and if that, um, you know, has a place in, in pain care,
Dr. Karim: w w where do you see it going? Like, uh, what of, what have people said to you?
Dr. Joe Tatta: Well, I think a number of physician was saying I’m going to, you know, put patients on LDN versus putting them on Oxycontin and the more, you know, another type of drug basically.
Dr. Karim: Well, you know, the concept really is what is the binding affinity of the drug? Uh, what is the ability to be tolerant on the drug? What is the, uh, abuse liability of the drug? Oxycontin has a very high abuse viability and the company tried so hard, am I going to talk about a specific company? But they tried so hard to convince us that the drug was fine and it wasn’t. And eventually there are enough suits out there and enough problems for that pharmaceutical company that show that this was a problematic drug. And I’ve, LDN has a better, uh, abuse liability response where it’s not as abusable it may be. It’s got a more stable half-life, maybe it has secondary and tertiary metabolites, whatever the, the composition is of the drug that makes it a better drug for people to use. That’s a good thing because you know, what we need to be doing now in regards to drug manufacturing is finding something that perhaps activates and binds to the opiate receptor, but with the least amount of, of, of morbidity or mortality to the individual when they’re taking it.
Dr. Karim: So basically there’s options out there for people to explore. Yeah, absolutely. I mean, and, and we know about all sorts of non pharmacotherapy, uh, Punic, uh, options. There’s, there’s, you know, acupuncture, there’s Chinese medicine, there’s STEM STEM machines, there’s, there’s, uh, medications that are not abusable at all that are medications and other disciplines. There’s psychiatric medications that have a pane effect. There’s non-opiate medications that have a pain effect. And as we all know, pain is absolutely exacerbated by stress. So the more you work on your personal development, the more you work on your, your anxiety for yourself. The more you find anxiety relieving techniques, the better you’re going to affect your pain.
Dr. Joe Tatta: Yeah, I mean those are some good tips right
Dr. Karim: there I think. But you know, just kind of looking at this kind of, you know, obviously on a national level, in a global level, how do we start to kind of change the epidemic? And I know it’s a big, big question that was lots of, you know, different parts here, but how do we start to change the epidemic? So this is a great question as well. And you know, I started talking about this when the Oprah show was on and I talked about our prescription drug epidemic. I think it was like 2004 or five I mean a long time ago. And one of the things that I mentioned there is something that I would continue to mention is first off, we need a federal registry to be able to track what patients are on abusable medications. We’re trying to do that only now. I mean, in the state of California we have something called the cures report.
Dr. Karim: And I’m sure there’s other States that have, you know, similar versions of this. But it’s, it’s not all the pharmacies are in it. Not all the med patients are in it. Not all the medications are in it. It helps, but it’s not really universal. When we can get to the point where we have a federal registry to track all these medications where they’re coming from, what pharmacy they’re coming from, you know, are are certain doctors really abusing these medications in regards to their prescribing habits to make it easier for patients to abuse. That’s a big one. The second one is Narcan. You know, Narcan is the antidote. When we heard about Prince, uh, the, the reports were a week before he passed, he needed an immediate Narcan, um, immediate Narcan, which is an antidote to prevent you from overdosing and you know, you can get them in stores now.
Dr. Karim: You can just get them in any store like defibrillators. We need to fibrillate hours around to prevent somebody from having a cardiac arrest or an electrical stimulation problem with their heart. We need the same with NaRCAD because enough people are on opiates that if somebody passes out or goes into respiratory depression or like ODS and you see them stop breathing or potentially get to the point where they’re going to stop breathing, they need that Narcan. So that’s the second thing. The third is how how we, how we teach doctors to prescribe. I mean, I had no addiction training in medical school at all. I’m double boarded now in psychiatry and addiction and I try to teach as many doctors and medical students as I can now, but I had no training and even in residency there wasn’t a ton of training. So we need to be able to train doctors how to prescribe appropriately by mentioning a, why am I prescribing you this drug B, what are the side effects of this drug?
Dr. Karim: C, what are the alternatives of this drug? What else could I be prescribing you? And D, what is the abuse liability of this drug? Now think about it for everybody listening for you, Joe, like when you and I have gone to the doctor’s office, how often does the doctor say all four of those things to you? I mean, they’re busy. They’re, they’re like moving and rarely do I get somebody that tells me all those things, but you know what? It’s a doctors. I think it’s there they should be doing and it’s part of their job to tell us what we’re taking in our body. Then we are the ultimate consumers. Every single person out there that goes to a doctor’s office has to know, yes, your doctor has an expertise, but they are your consigliere. They’re, they’re your advisor. They’re just an advisor. They don’t own you. You are ultimately responsible for what pills you put in your body and your, you should utilize your doctor as your expert advisor.
Dr. Joe Tatta: Perfect. I mean, I think that’s excellent. I mean, I think the framework you said it’d be so intelligent could you to talking about really educating people about what they’re currently taking and what the alternatives are. And you may need an opioids for a little period of time, but she’d also integrate some other non-medication things into your recovery, into your rehab days. Building’s really brilliant. Thank you for sharing it.
Dr. Karim: Yeah, I mean, you need to ask some smart questions. When you go to the doctor’s office, anybody that’s here, take it as an interview. You are interviewing that doctor about your condition and if your condition is you have diabetes or you have high blood sugar or you can’t get an erection or you, whatever it is that you have your, you’re interviewing them about their knowledge base and what are, what are my options here? Lay down my options for me so I can make an informed choice about it. You know, I, I, I have a treatment center that I run. It’s, it’s a, it’s a personal transformation center and uh, it’s, it’s called Lumion and, and it, it combines like light and positivity. And the reason we named it that, and the reason we exist at all is to empower people to take their own life in their hands and make a better life than they currently have.
Dr. Karim: And it could be overcoming limitations. Like I popped too many opiates or I, I act out or I self-destruct or it can be to enhance their life. And I think so many people forget that you have the ability, you can be empowered to enhance your life and make it better than it is now. And I think so many people just accept the cards that they’re dealt instead of anything. You’re not trading a card in and taking a new one. Uh, and so I, I always ask people, especially people in pain, you don’t just need to pop pills to get by. You can actually do something to change your circumstances.
Dr. Joe Tatta: Yeah, that’s a great point. It’s one of the reasons why I’ve done this something now two years in a row. It’s really just to get the information in people’s hands and they’d let them sift through it, let them decide, let them discuss it with their, their family or their medical providers and they can kind of make a decision to help transform the life kind of, you know, going forward. Um, you mentioned your treatment center. Can you tell us about where it is and where people can look and find you?
Dr. Karim: Yeah, so, so my website is dr reef.com it’s doctor spelled out. So dr reef.com and uh, I have a treatment center, the Lumion centers. It was formally called the control center cause we were all about helping people with self control. And I wanted to amplify that to a much bigger place in people’s lives. So it’s called the Lumion center. So it’s Lumi on center.com uh, and then the other thing that I’ve been doing, which I know I’ve talked to you about is I think it’s so important that we disseminate information to people that are younger, not just, you know, people that that are moving on in their age, which is obviously very important. But so a lot of people that get into prescription drug problems, relationship problems, anxiety problems, mood problems, impulsivity, they develop it in their teens or their twenties. So to me it’s been a very important thing to, to convey information to them.
Dr. Karim: And let’s be honest, are they watching the news now? Are they going to lectures? No. Are they mostly listening to podcasts? Maybe, but, but not that often. What they’re doing is they’re watching John Stewart, they’re watching the daily show with Trevor Noah now they’re watching Jimmy Fallon there. So I decided to start a late night talk show on self out on personal transformation, on dating, sex, drugs, relationships, whatever. And it’s called reef madness. And you can go to reef madness show.com or you can just YouTube brief madness and you’ll see all sorts of episodes and hopefully it will help people inform them and make them laugh. And you’ll see some interesting celebrities and guests and all sorts of other people on it. It’s, it’s been a fun experience.
Dr. Joe Tatta: I know your show has, it has kind of a comedy slant too, which I think is so powerful because I think kind of laughter can ease people’s, obviously anxiety and say it’s an approachable way for them to learn. I think.
Dr. Karim: Yeah, it’s…I think, you know, laughter truly is the best medicine and it’s the best way to convey information to people. They have a good time within an S at the same time, they’re like, Oh, I didn’t know that. That’s kinda cool. Uh, so I love educated, entertaining. I feel like that’s what I was made to do. Right.
Dr. Joe Tatta: So I want to thank Dr. Reef Karim for being on the healing pain summit 2.0 please have them out by sharing this video. You can hit, use the button below to share on Facebook as well as Twitter. Make sure you check him out on his website, which is dr reef.com and I want to thank them again and we will see you next time on the Healing Pain Summit 2.0
Dr. Karim: thank you for the opportunity, Joe. Take care.