Dr. Jennifer Purdy: Naltrexone and TSM: Prescribing Tips

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Transcript - Naltrexone and TSM: Prescribing Tips Dr. Jennifer Purdy Day 1 Panel 2

Jenny: Welcome back everybody. How is the sound? Dr. Purdy say Hi.

Dr. Purdy: Hello

Jenny: Hi. How is our sound? Are we sounding good right now? Ready to head into our second panel of the day? All right, everybody says the sound is great.

Jenny: How’s our sound everybody. All right, looks like our sound is good. So once again, I am Jenny Williamson, Executive Director of the C Three Foundation. On behalf of myself and our founder and CEO, Claudia Christian, we are glad you're watching our second annual virtual conference, Stronger Than Your Drink. Please feel free to use the chat function if you are watching live on Twitch to ask questions all throughout the panel. I will be collecting them and asking our presenter your questions during the Q&A following the presentation. Also if you are on Twitter, please feel free to live tweet our conference. Add the hashtags, #strongerthanyourdrink, and #optionssavelives. It’s a great way to amplify the impact of our conference and bring in new viewers. This conference is available to view and to participate in for free thanks to our two co-headline sponsors Ria Health and Workit Health. If you'd like to support the work of the C Three Foundation, there is a donation link in our profile, and we have a timer that will also drop a donation link into the chat during the broadcast.

Next up we have Dr. Jennifer Purdy presenting about Naltrexone and TSM: Prescribing Tips. The panel is sponsored by Deerhaven Gardens. Dr. Jennifer Purdy is a family medicine physician practicing lifestyle medicine in Ottawa, Canada. She attended the Royal Military College of Canada, and graduated with a Bachelor of Arts in 1998. She obtained her medical degree from the University of Ottawa in 2008 and completed her residency in family medicine at University of Ottawa in 2010. In February 2018, she retired from the Canadian Armed Forces, having served over 23 years. Her clinic, Ottawa Lifestyle Medicine, is the only clinic in Ottawa which offers evidence-based Lifestyle Medicine, and it is covered by the Ontario Health Insurance Plan. Dr. Purdy is board certified in Lifestyle Medicine and is a member of the American College of Lifestyle Medicine. Whenever you are ready, go ahead and begin, I'm going to go ahead and get rid of my video here, so take it away when you're ready.

Dr. Purdy: Great, thank you very much, Jenny. Good morning and first off I just want to thank the C Three Foundation because I'm grateful to have learned about The Sinclair Method. When I first started my practice, Ottawa Lifestyle Medicine in 2018, I'd heard about naltrexone when I was reading my board exam and so I was prescribing it, but the first couple of times I prescribed it, I was prescribing it once a day, take it no matter what. And I've definitely seen a significant difference in success using The Sinclair Method. I just want to be grateful for all the work the C Three Foundation does. So, first off, no commercial interest and no conflicts of interest.

This is the outline that we will be covering today. And just to start off with, here’s one person, PJ, who I saw in March 2019. He was a seventy-two-year-old male, retired military, and he had hypertension, which incidentally is an early sign or a sign of heart disease. It's just undeclared heart disease. He also had heartburn, hypercholesterolemia, he was an infrequent drinker, but when he was drinking, he was drinking 13 or more drinks of alcohol, and it was causing problems for him and his family. In the past, he had tried AA, ARC. So ARC is, I believe, alcohol rehabilitation centers. These are centers that used to be run by the Canadian military, up until about the mid-90s or so, I believe. He had also tried outpatient hospital program, The LESA program and that's a program offered at least in Ottawa, which targets, old, you know, people who are a bit more senior, who have issues with gambling or substance use, including alcohol use, and of course he'd also tried to cut down.

So why did I ask if I could give this talk? I decided, I asked to see if I could give this talk at this conference, because many MDs have not heard of naltrexone, and in my case, I got my medical degree in 2008, and I did not hear about naltrexone at that time. I heard about AA and Antabuse, and basically that was it. And the other thing too, like the first time I heard about naltrexone was 2017. The Atlantic had an online newspaper article, and it was basically about this medication that nobody knew about including many doctors, if not most doctors. And then of course, thankfully, when I was studying for my board exam, naltrexone was mentioned in the study material and it may or may not have been an exam question. So, naltrexone sounds like naloxone, and full disclosure, my first patient who I was going to prescribe naltrexone for, I was really nervous because I didn't know anybody else was prescribing naltrexone, and so we had the encounter, the patient encounter, she has, she had alcohol use disorder. And I was, but I thought I knew what I was doing but wasn't sure, so I said to her, Okay, I'm just going to go over things one more time, in terms of look at the medication and that sort of thing, but I think we'll be good to prescribe naloxone. So they sound a little bit similar, and many doctors haven't heard about it, so I'm sure, I may be alone in that regard, but I, that's one of the other reasons to give this talk. One big piece is, there's a known lag in research translating to clinical practice. So yes, naltrexone has been approved since the mid-90s But it's only now I think, at least in Canada, starting to become better known. I've heard there's been several radio shows now, actually, on our national radio broadcast called CBC, where they actually have discussed naltrexone, but this has only been in the last couple years.

"When somebody is able to consume alcohol, their motivation or the cravings will be relatively contained. But if all of a sudden they go into a period of abstinence, the motivation for alcohol, aka craving, is going to start to increase, and it's going to increase, it's going to increase, until they're able to drink again, and then that will cause it to decrease."

Medicine, we are appropriately a conservative and cautious profession, and so it can take a while for new medications, especially something for alcohol use disorder and that sort of thing to get into the public realm where it's better known. One thing I've noticed is that, in the alcohol use disorder world, there's a prevailing philosophy, and it's the abstinence is required. And so, and that's also in society, so the irony is that society seems to encourage us all to drink. But then if it becomes an issue – Well then, gosh darn it, you'd better go to zero, right? And I would suggest, and I know I'm not alone in this, that there should be probably three philosophies. For people who can to abstinence, if you want to go to abstinence, that's wonderful, because as we heard from the previous speaker, there is now just another study came out that demonstrates that there is no safe level of alcohol, and it does increase the risk of several different cancers including breast and colon cancer. But anyways, the second philosophy should be that no, abstinence should be not only tolerated but should be encouraged, because for some people, some people don't want to be abstinent. And then I'd argue this should be a third philosophy, where the philosophy of harm reduction as well. And so my goal today is to increase clinician confidence in prescribing naltrexone using The Sinclair Method.

So this slide is, I think this is really interesting, and this is a study that involves Dr. Sinclair back in the in the 60s. And this kind of points to why abstinence is so hard, and so this is important to keep in mind when we're thinking about this, this philosophy that's prevalent in the AUD world about how a person should be able to become abstinent – Gosh darn it, you just have to stop drinking. And yes it works for some people, but this is why it can be incredibly difficult for most people who will try it. So in this study, they had two different groups of rats, and the group of rats in the bottom, these rats were allowed to have some, they could just drink alcohol whenever they wanted. And the top group, this represents alcohol consumption for rats who had previously just prior to the start of these days at the bottom – they had endured, I guess I could say that, they've spent a week where they were not able to access alcohol at all. So, when they, and they actually ran the study a few different times, so this is a composite of the results, but what you can see is the rats that were able to drink when they wanted to, and to consume alcohol when they wanted to, they did not demonstrate a significant increase in their alcohol consumption, but the ones that had been forced to abstain from alcohol for a week, their alcohol consumption jumped high, as soon as they were able to access it, and then it took basically, takes seven days to drop close to the level of the consumption of the rats that were not forced to abstain.

And then just another picture here, y'all call it the deprivation effect. Again, when somebody is able to consume alcohol, their motivation or the cravings will be relatively contained. But if all of a sudden they go into a period of abstinence, the motivation for alcohol, aka craving, is going to start to increase, and it's going to increase, it's going to increase, until they're able to drink again, and then that will cause it to decrease. So again that points to why this could be so incredibly difficult to go to abstinence for many people, and why you have to be honest with someone, it often times will not be successful. And it's not about the person, this is a, you know, a disease, it's an issue right. It's a health issue.

Anyways, so let's talk a bit about naltrexone. So first off, as we've heard in the last talk, it's an opioid antagonist, and so examples of opioids, otherwise known as narcotics, are codeine, morphine, Demerol, Percocet, oxycontin, dilaudid. There's a few out there. The washout period of narcotics and this is important, the person, if they've been taking narcotics, seven days’ washout is strongly recommended. So, for example, one of the patients I saw had had a hip replacement, so he was appropriately on Dilaudid to control his pain post operatively. But he was getting to the tail of his Dilaudid use and his pain was getting better and he anticipated in a couple of days that he would be switching to plain Tylenol. So, what I did was, I explained verbally. I sent him an e-mail explaining to him in writing about the need to have a 7-day washout period, and then I sent the prescription to his pharmacist explaining do not fill this, and I put 7 days, or it might have been more than that, 10 days or so in the future, and explained that the person was on Dilaudid and they required a 7 day wash out period.

"Naltrexone was approved by the FDA and by Health Canada here in Canada in the mid-1990s, and so the nice thing about that is there’s been a long period of time when we can observe for side effects, long term effects and that sort of thing, and nothing has been observed."

So as mentioned, naltrexone was approved by the FDA and by Health Canada here in Canada in the mid-1990s, and so the nice thing about that is there’s been a long period of time when we can observe for side effects, long term effects and that sort of thing, and nothing has been observed. Okay, so this is a very safe medication. It’s now considered front-line treatment in Canada and the United States, so even though it’s not well known, it doesn’t mean that a doctor’s who’s prescribing this is doing something that may not be recommended or whatever, this is in the treatment guidelines for AUD, first line treatment. So we should all be appropriately prescribing it when the patient fits the bill and there’s a diagnosis of AUD, moderate to severe. And sometimes, even if a person is like mild to moderate, I’ve definitely prescribed it for people who are trying to cut down if they are having difficulty doing so.

One reassuring thing as well for doctors and health care providers is that naltrexone cannot be abused. So it’s easier for doctors. It’s also easier for patients that it cannot be abused. So the effects on the liver. It’s always important to do a risk/benefit analysis, and the other thing to is that you can always monitor LFTs a little more frequently in patients if they have elevated LFTs to begin with. It is important to note that elevated LFTs have only been seen from my understanding, in patients where they were being given 300mg of naltrexone a day, and that’s significantly more than the normal standard amount. But again, if somebody has some mildly elevated LFTs, or moderately elevated LFTs, one might just decide to monitor LFTs a little bit more frequently, and those are liver enzymes, simply because what’s causing the LFTs to be increased in the first place is going to be the alcohol, right? So doing a risk/benefit analysis is so important, as opposed to perhaps just making a gut call that ‘Oh the LFTs are elevated. I’m not going to prescribe this.’ Think beyond that. Think about why the LFT’s are elevated and what is the greater harm. For a person to have AUD and continue with significant alcohol consumption or to be offered the naltrexone, monitor the LFTs, and help them to decrease their alcohol intake safely.

So, how does naltrexone work? You take the naltrexone one hour before the first drink, and when you do that it blocks the opiate receptors in our brain. And so, and this is a key part, when we consume alcohol then, alcohol always lead to an endorphin release. But, what will cause us, you know, this feedback that we develop is, the endorphins will normally fill the opiate receptors in the brain, and that will cause us to feel some pleasure and that sort of thing, although in some ways, obviously, drinking is causing a lot of problems, but we get that positive feedback by the endorphins filling those opiate receptors in the brain. But if the opiate receptors are blocked with the naltrexone, then there's no positive feedback that is occurring. So what we're doing there is a psychological concept called extinction, where we develop this behavior where drinking normally causes a certain reaction in positive feedback, but it no longer is causing that, so we're going to get this process of extinction where we are extinguishing this behavior, and extinction takes a long time, whether we're talking, alcohol or any kind of behavior. It usually takes quite a while to get, you know, permanent extinction. So in this case, it usually takes about six to nine months. But the good thing is, people usually see a significant amount of improvement over the first four months. One important piece is, if the drinking time span last four to eight hours or more, they may need to take a second dose. So what that means is, that can be a person who wakes up, and who is drinking all day, but it can also be the person who wants to have a glass of wine at lunch and then, but the normal drinking pattern maybe starts at five or so. If they don't take that second dose, and I'll talk to patients of course about this, what they may find is at five or 6pm or whatever, they maybe start to notice that the alcohol is starting to feel a little bit better. And that means that those receptors are not fully blocked. And if, if we don't take that second dose, then extinction can take a lot longer, and people may not notice that their drinking is reducing as much.

"If you just take the naltrexone without drinking, then this is not gonna be successful, and apparently oftentimes then, people will eventually give up because their cravings are still there."

One big piece, and this is hammered, hammered, hammered again and again, with very good reason in the book The Cure for Alcoholism, is one must drink for it to work. So there have been issues and I've heard this sometimes, sometimes from patients who've talked to doctors about taking naltrexone, is that sometimes in some of the studies, especially the studies for naltrexone demonstrated to quote unquote not work, naltrexone is being prescribed and the patient's being told not to drink. You have to drink for it to work. We need the endorphins that will only occur for drinking alcohol, we need those endorphins to come out and to, you know, come out in the brain. And then, for them not to be able to fill those opiate receptors because the receptors are blocked by naltrexone. If you just take the naltrexone without drinking, then this is not gonna be successful, and apparently oftentimes then, people will eventually give up because their cravings are still there. And so they'll start taking the naltrexone and they'll start drinking again because abstinence is very hard and because the treatment doesn't work because it wasn't being done properly.

One thing that can be important to mention to the patient and possibly to their family, is that this is not Antabuse, otherwise known as disulfiram. Antabuse is the medication where if you take it and then you drink alcohol, it makes you violently ill. So the good thing about naltrexone is, it doesn't make people feel badly. It doesn't make people feel good. It just basically blocks those opiate receptors so that, that feedback loop that normally occurs for people with alcohol is broken, thereby allowing extinction to occur over time.

Now, do I need to take it forever? I've heard this a lot from patients, and for some people, especially with severe AUD, they will have to take it forever. And for many people who have moderate AUD, they may very well have to take it forever, and I know that what I'm going to say here maybe a slightly unpopular opinion, but I do believe in patient autonomy. So what I'll say to people if, let's say, they have mild to moderate AUD, but cutting down has not worked. What I will say to them is, I don't know. I do think you should be taking this, for probably at least two to three years. But it's possible, possible that if somebody is in a good place internally, so have no depression or anxiety, they feel relatively good. Externally, you know their work, their work life or if they're retired, in their social life, they feel that they're doing well and they've got no significant concerns, there may be the odd person where AUD may not have a long term role, and they may be able to, at some time in the future if they really feel that they're in a good space, that they may be able to trial not taking naltrexone, but then they'd better, you know – number one, they better pay attention to how does it go when they drink the first time, but then also monitor how they're doing after that, because maybe the first time you might have a couple of drinks, but maybe by the end of the week, you're up to 10 or 12 a day or whatever the case might be, or they're just noticing it might be a problem.

Now the worst case scenario of course to keep in mind is if somebody stops taking naltrexone, and they find that, oh they still need it, the worst case scenario of course is that they just say well, forget this, I'm going to just enjoy alcohol and then it becomes full blown AUD, and they're having an issue. So it's quite possible that many clinicians may just decide to say, you must take it forever and that is definitely the easier answer, but I just throw that out for consideration.

So barriers. I’d just like to mention barriers, and some of these barriers may be important to maintain and they're very much clinician dependent. So an easy example of that is testing for liver enzymes and blood tests, right. At least in Canada, it's important. We have a bit of a different healthcare system so labs are free, seeing a doctors free, you have to pay for your medication, unless you're unemployed, on disability or have a very good insurance plan. But, so testing for labs, there can be barriers like for example if the person has a phobia for needles or if, in times of COVID, obviously, that can be a barrier where the person does not want to go to a lab, even though they're perfectly safe. But depending on the clinician and depending on the patient as well, somebody has said, I've had increased liver enzymes in the past. Then he may very well want to test the liver enzymes, just to give you a picture of where that person is at, and where their liver is at.

Stigma and self-stigma is a huge thing. I've seen a lot of people with self-stigma, and so I just talk very gently about that, because people are very hard on themselves. Again, money can be an issue for inpatient treatment, obviously, but we're not talking about inpatient treatment today. Psychotherapy is actually not covered, for the most part, under the Canadian healthcare system. And then naltrexone, to me it's fairly expensive on a monthly basis. Let's see, and then social barriers. Important social barriers to keep in mind is that their supporters maybe abstinence only, like, and I'm sure many of the doctors, you know here, who have been prescribing this have met some family members who are just like, “No, this is got to be, you know, this is highly convenient that my loved one who has a drinking problem gets to drink with this treatment.” So, there may be supporters that might present a barrier. And to me what I do is I say, if you want me to talk to your family, or if you want to have them in, you know, for the patient encounter, you are more than welcome to and that's what I say to the patient. But also keep in mind, there may very well also be enablers, where there's people who they drink with maybe loved ones that they drink with, and if they decided that they want to get treatment, that may not be seen as a positive.

"Many of the people I see, or at least some of the patients I see, they'd be very compassionate towards somebody else, if they had a problem, including AUD, but they lack compassion sometimes towards themselves."

Okay, compassion. I mention this more for patients. It's just good to keep in mind for doctors of course and health care providers, but I do mention this because patients, because compassion. Many of the people I see, or at least some of the patients I see, they'd be very compassionate towards somebody else, if they had a problem, including AUD, but they lack compassion sometimes towards themselves. So it's important to keep in mind, AUD is an illness, and I will emphasize – this is no different than high blood pressure, cholesterol, depression, heart disease, etc. And like I said there, usually many people will be harder on themselves than they would be if there was a loved one or a friend who had AUD. So, switch to Socratic questioning, i.e. distancing. and what that means is basically I'll say, “Listen, if you had a friend or family member who had AUD, would you be this hard on them?” And hopefully, and usually, though, to be honest, the answer of course is no. So I really usually encourage people to be compassionate towards themselves.

I also like to remember the first appointment is probably very stressful for this person, especially, in my case, I don't do primary care, so people just see me for lifestyle medicine issues. And then, in the case of the AUD, they'll see me a few times right for follow up and that sort of thing. But, they're meeting me for the first time and then they're basically baring their soul. This is a very personal issue for most people. Yeah, and sometimes their doctor knows, sometimes their doctor doesn't even know and it's a sort of thing where they've had this relationship with their doctor for so long that they don't want to talk about it. And so they'll see me instead.

So typical first visit. I will usually ask about medical history, including prescribed medications, family history, I ask specifically about narcotics, and I will explain why I'm asking. And then if they say, usually they say no, then I'll explain, you know, for example, when they get a prescription filled, they will get a little piece of paper from the pharmacist with their name and naltrexone, which they’ll just slide into their wallet. And I'll also explain what to do that if you're having any major dental surgery or any major elective surgeries to make sure their doctor or dentist knows that they're taking naltrexone. So, and I also ask of course about liver disease. I like to know their history of alcohol consumption, drink of choice, are they drinking most days or rarely, etc. And then I would do an alcohol use disorder identification test. It’s 10 questions and allows me to establish the diagnosis. And usually after I've asked those 10 questions, I ask people how they're doing. This goes back to compassion, and the fact that they're meeting me for the first time, I ask them how they're doing, and then I say okay, you know, just asking because we were just meeting for the first time, and here I go asking you a bunch of questions, and that usually gets a laugh and then we can go on. So, and then I'll say I've been able to establish diagnosis, so, let's talk about naltrexone.

So just a word about templates. Many of us are already now using healthcare systems. And the good thing about a healthcare record system is that we can use templates. So this helps me to remember what I need to talk about. And I always ask for example, or find out what they've tried to manage AUD, because in theory if somebody hasn't tried even cutting down, then, at least in Canada, our family medicine guidelines are that a person should at least try cutting down, but if that's not successful that we should be trying something else including naltrexone. And of course, by the time people find me, they've usually tried at least cutting down, and things are not working, right. The audit score because like I said, I ask, I conduct the audit test with them. And then let's see a couple of other things, key chain. I always mentioned the key chain which is really brilliant idea from the C Three Foundation. It attaches to your key chain, it's a little fob but carries a couple of naltrexone tablets, and I just mention, it's not a requirement, but I like patients to have all the resources they need to succeed. I also mention that TSM is off label prescribing because naltrexone was approved by Health Canada and the FDA to be taken once a day, whether the person's drinking or not. So I'll explain that it's off label prescribing, explain why, and the why is because it's more successful than taking it in the traditional fashion.

So I always like to just ask about anxiety and depression if it hasn't come up when I was taking their medical history, because I want to know what there’s anxiety or depression. Those health issues can be co-morbid with AUD. And if they say yes, I'll ask if they've done a psychotherapy or counseling, but then I also like to talk about free resources they can access, including online cognitive behavioral therapy, sometimes there can be a cost. And also there’s a great workbook called Mind Over Mood, and that will come up in the resources at the end of this talk. I will talk about the handouts I'm going to send them.

I always recommend that people track their drinks, and just to quickly give a couple of stories. I've had, you know, a couple of patients where they didn't, they said, “this isn't working.” And so thankfully, I decided to ask them, “Okay, well, walk me through what's going on.” And by the way because the Canadians are very polite, they say like, “it's okay, but I don't think it's working.” So the first person was a woman who drank wine. She said that “I get home from work, I take my naltrexone, wait an hour, and then I start drinking, and then at the end the night I pour some wine down the sink and then they go to bed.” I said, wait, wait, wait, did you pour wine down the sink before you started naltrexone, and she's like, “Oh God, never!” and then she realized what she said. So, the second person, a gentleman, drank beer, And, yeah, I get home from work, I take naltrexone, wait an hour because that's key, right, but they're both following the rules, they’re taking the naltrexone and waiting an hour. Then I drink my beer. At the end of the night I’m usually putting a can of beer back in the fridge, and then I go to bed. I said, did you ever put a can of beer back in the fridge because it wasn't fully drunk before naltrexone? He's like, "Oh God no!" and then he realized what he was saying.

So, tracking the alcohol. What I found is if patients with their alcohol consumption goes like this, and drops like a stone, then they are my happiest patients, but sometimes if they feel like it's not dropping enough, Number one, they're not tracking the alcohol. Right. And number two, because your alcohol is not dropping significantly, like they're not saving a bottle a day or whatever, they may not notice it. And so that's why tracking alcohol, I don't make it a requirement because I don't like to have barriers, I want to encourage people to be doing this, but I do recommend that people track their alcohol. And I talked with the C Three app, the spreadsheet and that sort of thing.

And of course, doing something pleasurable if there are days without alcohol. Again we're just re-framing what brings us pleasure and enjoyment, and that sort of thing, and also people will often find that they have more energy to do things that bring the pleasure on the days when they're not drinking, which is fantastic. Let's see. And then finally I got permission from the author, we squeezed out permission from the author via the C Three Foundation to share a PDF copy of The Cure for Alcoholism book and the tip sheet that comes from C Three Foundation. And so I'll share those with patient consent. Yeah, so that's my template.

So prescribing naltrexone. What I'll usually write. This will come out on a prescription and should be on the bottle, is starting doses 25 milligrams, that's half a tablet for two to four days. In Canada it's recommended for three, but I don't like to waste half a tablet, so I just write two to four days as needed and I'll say to the patients, you can play with this. If after two days you're like, I just want to start the full dose, they can do that when they want. Again this is a very low risk medication and I want people to do what works for them. But of course, the side effect that can occur is nausea, and so that's why I encourage the half tab as a starting dose. And then after that, you're going to graduate to taking 50 milligrams, one tablet, and there'll be one hour and I write down one hour before event. That's code for one hour before your first drink, as needed. So on days when they're not drinking, they're not gonna be taking the naltrexone. And then I write, may take a second tab after 4-8 hours as needed. And just a worthy note for myself, I did not used to write that, that they could take a second tab. I would tell them that, but I started to do that because a pharmacist was concerned about the quantity, and the patient said that she was actually getting coaching from the C Three Foundation, and the patient was like, “Yeah, I heard that might be a good idea if that was actually on the prescription.” I was like, Yeah, you're right. So I started to put it down on a prescription.

Note that some patients may need more, and they may need less, so I had a patient who seen him by zoom and basically we had a follow up appointment, and thankfully he was engaged to a pharmacy technician or pharmacy assistant. And he said, my fiancé told me I should tell you I'm like six foot four, six foot five and 300 pounds. I was like, Okay, thank you and he said, I don't think the medication is working as well and my fiancé told me to tell you that. So it's like, well done your fiancé, because he, clearly 50 milligrams was an insufficient dose for him. At 75 milligrams, he found it was much more successful for him. I've had, only had one or two women were, and possibly even one, and the first thing I heard was, medications affect me differently. I usually don't need much. And sure enough, her full dose, her starting dose was 12.5 milligrams, so a quarter of a tablet, and her full dose for her was 25 milligrams. So just keep that in mind that that can occur. Just sometimes pharmacies don't want to refill early, in spite of the prescription, in spite of this being a very safe medication, so conversations can help. I've spoken to a few pharmacists, and I also, of course, spell it out on the prescription: see above. And the quantity of the prescription should of course be what the doctor, sorry, I should say doctor or healthcare provider are comfortable with. And I also try to work with patients regarding affordability, public or private insurance claims etc. like 90 tabs with three refills or 30 tabs with 10 refills, it's the same difference to me, but I don't want to be causing the patient any financial concerns or worries.

"It's important to keep in mind this is a lonely journey for some people, for many people it's a very personal journey."

So follow up. First follow up one to three weeks after medication start, but I tell people I'm here as a resource to help you succeed. If you're having any issues, questions, concerns before your follow up, let me know, we'll get you in early because I want this to work. It's important to keep in mind this is a lonely journey for some people, for many people it's a very personal journey. So, I'm the person who is helping them, but I'm very supportive. I know it because we all mess up sometimes, things can happen we forget to take naltrexone, whatever, that's okay. The important thing is to start taking it again. And then once a patient is on a stable dose and you're doing well, six months to a yearly follow up and again I say to people, I want to see you if you want to see me. But if you're doing well, and you don't have questions or concerns for me, then I don't want to waste your time, and in our case provincial resources.

So PJ in terms of follow up. He followed up May 2019 and at that point, he'd had maximum three alcohol at a time since starting his medication, he started the naltrexone with the TSM method. His wife and his family of course were hesitant at first, because we're saying that drinking is okay with naltrexone on board, but they had seen the difference and they're hopeful. And then fast forward to April, end of April 2021. He had two beers in the month of February because his wife decided to do a no drinking month and he decided to join her and he had two beers total. He drinks rarely, he takes naltrexone every time he drinks one hour beforehand. Very happy patient.

So my resources. The most important resource for any doctors or healthcare providers who are listening in today, I think is the one at the top by Dr. Steven Cox. I've never met him, but this is posted on the C Three Foundation website, and it's very helpful, has a lot of useful information. The CAMH information sheet. This is, CAMH is Center for Addiction and Mental Health. This is a Canadian organization but I would suggest if you can find American, or you know British or whoever, wherever you're listening from around the world, if there's a credible information sheet about naltrexone, that could be helpful to for you to send to your patients. And I send this to my patients because if they have a family doctor or they can find a family doctor, then if they feel comfortable, they can always share this information sheet from a credible source. And it’s very short to read, and that might help their doctor to become more familiar and more, you know, they might, the doctor may actually start prescribing naltrexone, which is great, you know. Perfectly good for me as well, because the more of us who know about it and are comfortable prescribing, the better. C Three Foundation of course for research papers, the apps for tracking their alcohol and other resources. Dr. Roy Eskapa’s story The Cure for Alcoholism is a fantastic book. And then, yeah, CBT. I'd mentioned Mind over Mood by Dr. Greenberger and Dr. Padesky and CBT Insomnia. Sleep normally improves, and I hear this from so many patients when we start using naltrexone because alcohol, of course, it totally interferes with our quality of sleep, or sleep architecture. But every now and then I just have this in my back pocket in case somebody finds that their sleep is is disrupted or they're having a hard time falling asleep, because some patients will use alcohol, thinking it will help them fall asleep, but it doesn’t help them to stay asleep, but Say Good Night to Insomnia is a fantastic book. It’s CBT or cognitive behavioral therapy for insomnia, in book form. And that's it for me.

Jenny: Okay, I am back. This is why I have multiple volunteers that are cuing me on when I forget to un-mute my mic. So as our audience continues to send in questions, I'm going to start with the one I'm asking all of our presenters. In your TSM patients, what would you say the overall success rate has been?

Dr. Purdy: So I don't know unfortunately, and I was able to hear for the first presenter that this question was going to be asked, but I don't have an easy answer because I have not been keeping stats, and of course I do lose patients to follow up, and I don't know what's happened to them, or whether they're still taking it, or family doctors prescribing naltrexone, or whether they weren't, you know, they decide they stopped taking or whatever. But with patients who are not lost to follow up. I'd have to say 70%- 80% at least. It just seems to be incredibly successful and actually I don't, I can't think of anybody other than those two people who I mentioned before, who have said definitely this has not worked. Yeah, no it's just, it's normally working, and if it isn't working, the biggest tip I can suggest to other doctors and healthcare providers is, ask them what they're doing, you know, and actually I did have one patient who is still drinking a lot, like quite a bit and it's been over a year. And when I talked to her last time, and she is a little bit scattered, she has a lot of anxiety. And she, we went over what was going on, she wasn't taking a second dose of naltrexone. That can be very key for somebody who's drinking, many hours, more than four to eight hours, right. So the big thing is to ask what's, to go through their day, and I had sent her that information, but you know sometimes we have to repeat things a few times in any walk of life, including medicine. But yeah, so for most people, this is wonderful medicine because people are just happy. It gives realistic hope, and I'd say the vast majority of people it's working for, and if it doesn't, it may be they're not taking it one hour beforehand or again, not taking a second tab, you know it's not taking that second dose and that sort of thing.

Jenny: And it's just a rough estimate of how many TSM patients do you think you've treated over the last few years?

Dr. Purdy: Oh boy, I think it must be about two or 300 now, I think, I don't know, because again, I should have looked at that before the talk, but I didn’t.

Jenny: So you mentioned earlier in your presentation that naltrexone is considered a first line treatment in both Canada and the USA, but you also mentioned the lag between research and clinical acceptance. What in your opinion can be done to increase TSM acceptance in family practice settings?

Dr. Purdy: Boy, well I think this having a free conference like this is fantastic, because people including doctors and health care providers can seek this information out themselves. One thing I am going to do is I'm going to see if the Family Medicine forum will take me as a speaker to talk about this for their next conference which will occur this fall. I may miss that deadline but anyways people talking at conferences, doctors who are comfortable talking about this, please, you know, continue to do this, get out to conferences and talk about TSM and naltrexone. Talk with your colleagues and your peer groups. Have the evidence ready just in case. And then the other thing too is for patients. If you've had success with this, and you have a family doctor who may or may not have prescribed this, if they haven't prescribed this to you, maybe perhaps let them know, if you feel comfortable, let them know, because it oftentimes, it will just take one or two patients where, you know, where it's successful, to help get started to get that word out a bit more.

Jenny: And what do you think about prescribing vitamins such as thiamine and folic acid to TSM patients at the initial visit?

Dr. Purdy: Yeah, to be honest I think I've always considered I've went in that, maybe twice, when it was like severe AUD, alcohol use disorder, and dietary intake was decreased because of the alcohol. And I just thought I wanted to protect the brain, but I don't do that on a regular basis, to be honest.

Jenny: Let's talk about support for a moment. You mentioned well-meaning supporters that might actually be a barrier to success. So how do you advise patients on TSM, who may only have support if they are either abstinent or quickly become abstinent in, like in the cases where we'll see people who say, “Well, my husband says they support me as long, and they have to see this work in six weeks or less.”

Jenny: Yeah so, to me, again, for doctors and healthcare providers, it's always up to the patient, but I always tell the patient that if they want to have their family or their partner listen in on my encounter with them, or we can have another appointment, just to discuss this issue, I'm happy to do that because that can help with buy in. The other thing too is, usually with the person, they've already tried that, they've tried cutting down, they've tried going abstinent, they may have tried AA, it is not working so we can also perhaps look at the family or talk to the family and or talk to the partner, and the person might say, Listen, like, I've tried that, we know how this has worked before me going completely absent, it is not working. I don't want to lose this relationship either. And I'm asking you to trust me, but maybe we can watch One Little Pill, maybe, would you be interested in reading Dr. Eskapa’s book with me. Please, maybe you might want to attend the doctor's appointment with me so we can, we could talk about this together because I'm grasping at straws, I don't want to lose you. And, but abstinence is clearly not working for me and it doesn't work for most people and maybe even pull out some of the stats right for inpatient treatments even. AA has varying levels of success, by maybe little as 6%. So that's where I would probably go with that.

Jenny: And then final question, how does TSM make your patients Stronger Than Their Drink?

Dr. Purdy: It totally makes it stronger than their drink. It gives them, honestly I hear, this gives me my life back. As the cravings, one big thing that people will say is that the cravings, they just kind of go away. And so it completely makes it stronger them stronger their drink. And it's really interesting from the first appointment where people are understandably nervous or meeting me for the first time they don't know how terrible I might be or whatever, and they're incredibly anxious, and they're losing hope. But then the second encounter, there's usually small smiles, and there's a lot more relaxed but you're also starting to see that the hope is realistic, they're starting to see improvements, and so it totally makes them stronger than their drink.

Jenny: Well thank you so much to Dr. Purdy for participating in our second annual TSM conference, Stronger Than Your Drink. Show your appreciation in the chat. We'd like to thank our sponsors Workit Health and Ria Health, and thank you to our panel sponsor, Deerhaven Gardens. We’re going to take a short break. We’re going to prepare for our next panel, So, get up, stretch, grab something to drink, and get ready for our next panel with Dr. Roy Eskapa. So thank you everybody, and we’ll see you in about 15 minutes.