For our next speakers, Rodrigo and Claudia Garcia have been direct healthcare providers for a combined 38 years. Their experience spans the field of emergency room nursing, trauma education, surgery, anesthesia, and most recently, addiction. They are the co-founders of Parkdale Center for Professionals, an addiction treatment center specializing in the management of the impaired healthcare professional. They currently reside in Valparaiso, Indiana, where they raise their family of four children. Please join me in welcoming Rodrigo and Claudia. So good morning. Claudia and I hail from Chicago, Illinois, thereabouts that area, and we've spent our whole life battling the Chicago traffic and becoming experts. But this is a whole new level in Boston. We were completely out of our element yesterday driving around. So let's start off with this here. So the workshop and the following speakers have been partially funded through a grant provided by the AANA, the American Association of Nurse Anesthetists. We have no relationship with any commercial interests, and anything we talk about will not be any off-label uses during the presentation. So catch me if you can. Started about seven years ago or six years ago, I was very freshly off of my treatment stint in an addiction treatment center. And I had this wonderful story, at least I thought it was a wonderful story that I wanted to share with as many people as I could because we had come to realize something, that people were dying pretty quickly at an alarming rate. So we begged and we asked and we said, put us in, we'll tell our story and it's an important story. And everyone said, no, no, no, we don't want an opioid addicted anesthesia provider, we're going to pass on that. And it happened dozens and dozens of times. Just by chance, we ran into a police officer who was actually one of the investigators on my case, and he said, I hear you're looking to tell your story, I'd like you to tell your story to this group that I'm part of. The name of the group was NADDI, N-A-D-D-I, I had no idea what that meant, but I said I'll take it. Turns out it was the National Association of Drug Diversion Investigators, and it was all the police officers who are tasked with impaired providers and investigation at the hospital and whatnot. So we get to this place and we're about to tell our story and we find out that it's very ironic, talking about addiction inside a casino inside a bar, at the casino, and we were here to talk about addiction to police officers. So Claudia and I got, it's the first time we're doing it, and we still get nervous even now many years later, and it was the first time, and Officer Jay Fredericks is at the mic and he's introducing us, and he says, boys, this is the live specimen I was telling you about. And my heart sank. And I realized a couple things. Number one, I need to know where the exit sign is at, first of all, so I can get out if I need to. And number two, this is the stigma that we face every day when we're talking about addiction. And when you talk about addiction in healthcare professionals that are tasked with protecting the public, it's elevated even more than that. So we popped this up on the screen, it says Catch Me If You Can, and if you can imagine a room of 150 police officers in southern Indiana with Stetsons on and belt buckles, they said, oh, we're going to catch you, boy, we're going to catch all of you, and it sent a shiver down my spine. What we have realized, and since we've been in this field in the past five or seven years, is that that stigma still exists. We're going to round them up, we're going to catch them, we're going to make an example out of them, we're going to make sure that this doesn't happen again. So Catch Me If You Can, the impaired provider, we'll spend the next few minutes here talking to you about our program. If you have any questions along the way, please raise your hand, we'll try to save some time at the end. But as you can see, Claudia likes to talk a lot, and sometimes she gets a little long-winded. So we're going to go through the left side here real quickly, because my biggest claim to fame is that I was able to retain my wife in my life. And after you hear my story, you're probably going to ask the same question. So I'm a nurse by trade since 1996. And ironically enough, I should have known when I was getting out of high school, there was this TV program called ER. And I saw this attractive man on ER, George Clooney, and he was getting all the girls. And I said, that's what I want to do for a living. And that's how I picked my career path. So I went into nursing, first of all, off of this show that I saw on TV, and then followed my path through the trauma and flight nursing and anesthesia. That has taken me to this place here where we're standing here talking about addiction. We currently both run a treatment center for health care professionals, which if you think about that, our demographic and our clientele is so specific, and we can open up a facility and be full for the last four years. That should send something to your guys' thought patterns on how prevalent this problem is, how long-standing this problem has been. The compliance director for the Indiana Professional Recovery Program is a monitoring program that monitors health care professionals before they go back into work. So Claudia has secured that contract with the state of Indiana, and we're both involved in running that program. So after they get into treatment and they go back to work, there's a last line of defense that protects these individuals from going back to work so that you guys, when you go there with your family and with yourself to seek care, you know that the providers are safe to practice. So we run that program. 700 practitioners are in that program in the state of Indiana alone. That's how prevalent this problem is. So a quick story on that. We had gone through all of the investigative process throughout the state. When I say we, I mean me. And one of them was the attorney general who knew me by first name through the investigation process. And I came home one day and I said, oh, you'd be so excited. I'm so excited. The attorney general asked me to sit on his prescription drug task force, and there's only like 20 people in the whole state, and he picked me. I was so proud of myself. And she said, settle down there, firecracker. He just wants to keep an eye on you. He wants you right next to him so he can keep an eye on you. It's not a big deal. So we both sat on that task force for four years, and what we were privy to was the changing of the trends when they're talking about prescription medications and how practitioners write prescriptions and how impaired providers are becoming addicted and how are they getting the access to the medications, and we're going to talk about all of that. What I didn't have in my life was this order. Husband and father and all the things that really mattered were buried down deep down. How many alphabets, letters can I get behind my name? How many accomplishments can I get so that I can brag about it to everybody? That was my focus in my whole professional career until it came crashing down. Now anything from the yellow line down, you can take that away and I'm still going to be a whole person. It took me a long time to figure out that very basic premise. I remember when I was in anesthesia school at Evanston Northwestern in Chicago, my program director who literally wrote the book on substance abuse policy and anesthesia, she said, whatever you guys do, make sure that this becomes part of your life, not your entire life. Make sure you keep your balance in life. Make sure you're with your kids enough and with your family enough and you're with alone time enough, which was a very scary thought for me to be alone by myself. I don't even like myself. Why would I want to do that? Give me a drink. That's what I would do all the time. For all of you who are just starting your career, keep that in mind. Keep the balance. Let this be part of what you do and not let it define who you are because once that gets taken away, part of your soul will be taken away. We see this every day with every single admission we take into the treatment center. I don't even know who I am anymore. I've been doing pharmacy for such a long time and now I can't do it. Who am I? Who am I anymore? It's this void that we have to fill back up for them or help them come to fill that back up. Claudia has figured this out since the beginning. She's a wife and she's a mother. Anything other than that is gravy on top, is extra icing. She's been able to maintain that since. I just try to hang on to the coattails and let her dictate how far we're going to take this and we just keep on going. That's us in a nutshell. We have four children, two in high school and two in college. I know your immediate thought is, not her. She doesn't have a college kid, but I could see it over here with you. It's because of this here, because of the two girls we have that are transcending through the college. We have, like I said, two in high school, two in college. Next year we'll have four kids in college, so wish us luck. Our eldest, who is now in graduate school for psychology with a focus on addiction, I wonder where she got that idea from. She was just about to venture off into college and she had to have her wisdom teeth taken out. We took her to the doctor and they said, yeah, these got to come out. She met the doctor, the surgeon, for that very first time that day. She also met the nurse. She met the receptionist at the desk. She gave her the insurance card. She met about five or six people. The next day she went to the laboratory and she had her blood drawn. She met the phlebotomist, she met the intake coordinator, got her insurance card again, the greeter at the door, someone helped get her supplies in and out of the facility. The next day was the surgical day. Claudia and I took her in for surgery. We remember walking through the lobby and there were dozens of other family members with their kids in the same phase of this presurgical procedure that we were about to embark on. She met the nurse, the anesthesia provider came out to say hi to her, the surgical tech, probably about seven or eight people, the pharmacist who was going to fill her prescriptions came in to say hi, the candy striper. So totally, in the totality of it, she had about 15 or 20 people that she had met while she was going through this. We walked hands and saw her walking away and it was so vivid. She was going away down the hallway and Claudia and I were nervous. We walked back to the lobby and that's what our first thought was. So while we were in the waiting room, we were both anxious and nervous. We were probably more anxious and nervous than most people would be in our situation given that we're both in healthcare and we knew what she was in store for and we knew she had a great team, a surgical team, but we knew that statistically speaking, one to two of the people that she came in contact with was struggling with substance use disorder. They were either coming in hungover, actively using, or they were looking for their next fix. If we're lucky, it was the lady who took her insurance card, but if we're not so lucky, it's the surgeon who's operating on our daughter. Maybe it's the anesthesia provider, the nurse. It's really all a game of chance. We don't know who it is. So think about that. Every time you go into one of the healthcare facilities, one in 15 are currently suffering. They're currently struggling and it really became a game of chance. Like Claudia said, we walked back to the lobby and we were beside ourselves. No one had no idea why we were nervous, but we were nervous because we were hoping that it was that person that wasn't like me. An impaired anesthesia provider who was so sick at the time, especially during the end, that I would do anything just to make that illness go away, just to make that depression and that anxiety and that shame that we talked about just go away. And at the same time, it would put everybody that I would come in contact with at a significant risk. So in 2016, which is our latest real accurate numbers that we have on this, we have a pretty good idea of how much this is going to be affecting everybody. So we know that one in three people personally know someone. So these are our friends, our coworkers, our neighbors. One in 10 people live with someone suffering with a substance use disorder. These are the spouses, the children, the parents. My heart always goes out to this population because that was me not too long ago. I remember how I used to envy my coworkers when they used to tell me how excited they were to end their days and go home and spend time with their children and cook and do all the fun stuff you do at home. Sometimes it was the worst part of my day because I didn't know what I was walking into. Was I walking into sobriety or was I walking into death or an overdose? And one in 15 people meet the DSM-5 criteria for substance use disorder. These are our doctors, our nurses, our pharmacists, our pilots, our lawyers. These are all the people that suffer with this disease. As you can see just by looking at these numbers, it doesn't just affect the person that's using it, it affects everybody else as well. So I remember what Claudia used to say to me and it used to break my heart. She said it's the worst part of my day when I go home. When I'm going home, I don't know what I'm going to go home to. Are you going to be alive? Are you going to be driving around impaired with our kids? Everyone else at 3 o'clock in the afternoon was excited to go home. On a Friday, a beautiful day like it was yesterday or today, excited to go home and that was the actual worst part of her day. So like I said, 2016 is when we had these last numbers. So let's just look at the sample size, pretend this is the United States here. Going off of these numbers, these tables on this way would be affected by drugs or alcohol. About 50% in one way or another. So that would mean maybe the two tables in the back had the family members, a table and a half or so. In this room here, there's a table full at least that are going to go home to somebody today, son, brother, husband, cousin, daughter, child, parent, that's suffering with drugs or alcohol just here in this room. And that is really what brings it home. And those of you that are feeling and thinking about that person, you're not alone. This is, we're all in this together and we're all here to help together. So if you look at about three of the tables here in the room, the other three that are not the family members, those are the ones that can name somebody. My neighbor's daughter, yeah, she's overdosed, I remember that. Or my classmate from one of my kids, one of their classmates got into some trouble. You can name them in one about degree of separation. Then we have one table. I'm just picking on this table because they're in the front. I didn't see anybody out last night, but this is just, I'm picking this one randomly. This is about the sample size here in this room of people that are suffering with drugs or alcohol. One table in this room that would meet the DSM-5 criteria to be admitted into a treatment program for substance use disorder. That was 2016. So by a show of hands, I'd like to ask you, how many of you know an addict or an alcoholic, have one in your family, maybe it's you, have suffered with it in all seriousness? You can, one degree of separation, so maybe you worked with them, maybe you hired them, maybe they're the neighbor, maybe they're in your family, or maybe it's you. How many by a show of hands can name an addict? So we can see in three years, we've gone from 50% to above 95%. The harrowing thing is that this is going to get worse before it gets better. This is going to get much worse, and we're going to talk a little bit of reasons why this is going to get worse before it gets better. And this is one of the reasons. This was done by the National Safety Council. Did you know that 80% of the world's opioids are prescribed here in the United States? 90% of the world's hydrocodone is prescribed here in the United States. How scary is that, though? Claudia and I were in Ghana, Africa in 2013, we were on a medical mission. And when we went out there, it was a beautiful experience. The Ghanaian people are some of the most beautiful, respectful, thankful, grateful people in the world. They would line up two days before we arrived, because it was free surgery by the Americans. It was a very indigent population. The accommodations at the hospital, some of the lobbies had dirt floors. This is the picture I'm trying to paint for you. So when we get there, we see this line of people about a mile long outside the hospital. Claudia and I spent, with the team, we had about 20 people with us. The first two days, just triaging. Who can we do? Who can we not do? We can't do any ICU-type cases. We didn't have the capability to do that. They had to go to the government clinic. So the first two days, we had the schedule lined up. The third day, we had about a 20-hour surgical day, lipomas, hernias, relatively outpatient procedures where we can get them in and out. At the end of that first day, finally getting to the end, Mr. Martin comes up to us. He was one of the locals. Mr. Martin had a dental abscess that was so large that it was closing his eye. And it was red, and it was painful. And he walked past, and he said, can you take care of this? I said, I can't. I can't take it. I apologize. He said, we have to go to the government center, because if we do this, there's about 300 people outside with similar ailments that we'll have to take care of as well. And he said, is there anything you can do? And kind of tongue-in-cheek, I said, well, we can do it right here on the dirt floor. We can do it right here. And he said, yeah, do it right here. I said, well, there's no anesthesia, and there's no surgical, and we don't have any medications. He said, do it right here. So a resident was passing by, and I love the residents, because they still kind of listen to you at that time. So I pulled the resident over, and I said, can you help me out here? I gave him a scalpel, retracted, made the incision, drained it, packed it with Iodoform gauze. The whole thing took about a minute. Mr. Martin is tearing up. I'm tearing up, because it looked painful. And he has this most beautiful smile on his face. He hugs us, and he says, thank you. Not one complaint of pain, not one request for pain medication. And I said, Mr. Martin, doesn't that hurt? And the following words from Mr. Martin have really kind of set us on a course to where we're doing today. So completely simple. He said, hell, yeah, it hurts. Of course it hurts. The pain is the same in Africa as it is in the United States, if you didn't know. You put a knife in my jawline, it hurt. But you learn to live with pain. And that was so fascinating to me that that was the mentality, and we saw how that happened for him. So part of the reason why we're here today, and we're on this trajectory, and when we talk about it's going to get worse before it gets better, it's because of this. The medications are so much in surplus. We have yet to have a patient come in that says something along the lines of, God, I was driving down the street, and I went underneath the toll bridge, and I saw this guy up there with a brown paper bag and a tourniquet and a dirty, rusty needle. And I thought, that looks good. Let me try that. It never starts like that. That's not how the heroin story starts. That's not how the diversion from the fentanyl story starts. It starts with, I had a prescription. I had an injury. I had a surgery. I had a chronic pain. I've been dealing with depression and anxiety and shame and guilt and trauma for my entire life, and now I have found something that fixes it. I've been unbalanced in one way or another my entire life, and that's what fixes it. So if you take the United States and all the industrialized countries and you put them in order, who diagnoses ADD and ADHD the most? We're about number eight on that list for all industrialized countries. But we prescribe 80% of the world's amphetamines here in the United States. This is the sleeping dragon, the amphetamines. This is the one that's going to creep up on all of us and make the heroin epidemic look very minimal, at the least. We have one of our kids, our son who was in college, he called us up about the end of the school year last year. It was his first year in college, and he said, it's three o'clock in the morning. Anybody have kids? You have kids? Older kids? Teenage kids? I'm sorry to hear that. It's a struggle. It's a rough struggle. Is there anything that you can think of that's worse than getting a phone call at three o'clock in the night when your teenage kids aren't with you when they're not in the house Right, they're supposed to be in the house They're supposed to be at their friends and you get that phone call Well, we got that phone call the phone call comes through and I said, what's Carter? What is he calling for and she's nervous and I'm nervous and instantly our heart rate is three o'clock in the morning We jump up and he gets on the phone. He goes Dad, I love you. And I'm like, oh he's doing drugs for sure. Something's not right here. So something is off here I love and thank you guys so much and you guys helped me so much and thank you for college Thank you for school and everything that you've done for me and he's just gushing we're like, okay So the next morning we call him and he had settled back down to his normal teenage self and we said What was going on last night? And he goes well, I don't want to tell you guys cuz you'll be mad and I go Well, just tell us anyway So what we were all studying and we wanted to get good grades and we're all just jamming and we're doing good So we all took Adderall so that we can stay up and we can study and I said, oh my god Why would you do that? I could see the headlines now son of owner of drug treatment center busted Amphetamine ringing campus, right? So he said, you know, I'm gonna be honest with you And what he said really really shook me to my core he said I can get an Adderall pill for cheaper than I can a Starbucks cup of coffee and it works better and That's the mentality of this generation that's coming through. So think about that anyone you guys are just newly out of your undergraduate studies How difficult would it be to get an Adderall pill? It's right there It's as easy as you can get a cup of Starbucks coffee. So this is what we're facing here And this is what we're coming up to There's a reason why we're here as a society and there's a reason why and Claudia and I are here So let's talk about that first one There's one thing that set this whole thing down the trajectory that we're on now What do you think it was it started in health care? It started this whole mentality and this whole idea of give it a pill. Give it a pill. Give it a pill. Yes, ma'am Pain is amen pain is the fifth vital sign So you have four beautiful objective vital signs and they said well tell me what you think and tell me how you feel Pain is the fifth and now so they took this objective very subjective Question and then they tied everything reinsurance reimbursable and satisfaction scores to it So now the motivation is make your patients happy so that they can give you a good review ask them how they're feeling I started in the inner city in Gary, Indiana, and we had a young lady in there. Her name was Diana She was affectionately coined Demerol Diana She was a sickle cell patient that would come in every week and Demerol Diana would say hey Regal How are you? Hey last time when you gave me the IV It didn't like that I got the port-a-cath use the port-a-cath and this time flush it flush it faster because you didn't really do it last time So I'd like my Fenergan and my Demerol so I same routine every week I'd go up to the doc and say, you know She's here again. What do you want to do? Give her her protocol share own protocol named after give her her protocol So we did gave her Demerol and the Fenergan 10 cc's of fluid and flush it through the port-a-cath Ah, you could just see it on her face. That's what she was looking for. And every time before she left she said Where's your evaluation? I'd like to fill out your evaluation your customer survey because she knew raving reviews five stars all the time as long as we Gave her what we wanted to that's what started us and there's a lot of steps in between and there's a lot of steps That's been happening after that and we're trying to undo 30 or 40 years of this now We're all working very hard But the fact is this is how it started with the mentality and the frame of mind that if there's a problem Take a pill for it. How did we get here? So Regal and I met working in surgery I was a charge nurse and Regal was the chief nurse anesthetist and What I noticed about Regal early on when it was that he was well-liked while respected he was everyone's go-to person He was the one that would receive the awards every month For his performance after a few years of dating Regal decided to join a baseball league Because he thought he was still young and in shape. So he decided to join this baseball league And little did I know that joining this baseball league was going to forever change our lives He joined this league and I remember sitting in the bleachers and I saw him jump up to catch a ball We came back down. He had inverted his ankle and from a distance. I knew he was in trouble I knew he probably broke it Of course He was not the compliant patient that he should be but he refused to go to the ER that night We get we get home the morning. He wakes up in excruciating pain He's like I can't breathe and my leg hurts and he's of course in pain. We get to the ER They did an x-ray and sure enough. His ankle was broken They gave him a prescription for opiates. It was the first time Regal had ever taken an opiate They told him he needed to wait a few days for the swelling to go down for the surgery He was still on opiates had a surgery still on opiates went through physical rehab stayed on opiates He was back at home going through physical rehab for about six weeks. And while he was at home, I noticed he was different He was disconnected Irritable moody, but of course, I thought well he just had surgery He's probably not feeling well, and maybe he's missing work and needs to get back to work after about six weeks He returns to work. I'm super excited because I wanted the old Regal to come back the happy cheerful engaged Regal Well when he came back That old Regal never came back. He was still the same guy. I saw the past six weeks. He was isolating He was taking multiple breaks We were always looking for Regal in the department couldn't find him half the time He was just acting odd, but I didn't know what it was This went on for about six to eight months And one day we're in our kitchen and we're cooking and from across the room I thought I saw track marks on his arm. Of course as a nurse. I've seen them before I know what they look like I thought could he be using drugs? So I questioned him I asked him what those marks were and he's like, oh, no, I fell or he gave me some excuses But I knew that he was lying at that moment. I knew he was in trouble and I knew he was using drugs What do I do as a loved one as a colleague as a friend? So I get back to work and I start talking to his employer his boss the director I said, you know what doc I think Regal something's wrong with Regal, but I didn't want him to go to jail I just wanted him to get help Said can you guys look or review his charts or maybe keep an eye on him at work because something's just off Well, this went on for another two months investigation at work and they couldn't find anything. They kept telling me No, maybe he's just stressed out. Maybe it's your relationship. Maybe something with you guys Like I know it's not cuz I'm finding syringes and needles and tourniquets at home, so I knew he was in trouble So, of course about eight months at this point. It's still going on. He's escorted. He's caught and he's gone just like that Now, I remember when he left to treatment There was a big sense of relief for me and I was at peace knowing that he was no longer at work But I remember while I was reflecting at home couldn't help but ask myself How did we get here and what are the chances that I would be in love with the drug addict That still doesn't get easier to hear It was it was a very dark sad time for us I remember I was I was I was in the treatment center for the first week and It's horrible it really was and the first week I said, hey, I want to come back home I want to be around my family and you know, I miss my family and I called Claudia and I said Can I come home? I want to see you guys and they gave weekend passes and she said no just stay where you're at You know things are good. I don't know how she held it together and didn't you know, throw me out But she said just stay there stay where you're at. Things are good here and but I got mad And so the next week I went to my counselor and I said can I go home for the weekend? You're letting everybody else go home. They said no, you're still not ready yet. So I would call her up and she would say Telling these guys won't let me go and I really want to go and she's like stay where you're at They know what they're doing. So the third week same thing happens again, and I'm Very very upset with them because they won't let me go home. I can't believe this I'm calling Claudia and I said I gotta get home I got to take care of the kids and I got to cut the grass and she's like You never did that when you were here Why are you all of a sudden want to do that now and I said, that's not the point. I need to get home She said all right. I'm gonna tell you something. I'm gonna Conscientious of how sensitive you are with all this so I'm gonna be gentle but the world doesn't revolve around your ego and I was like Doesn't And she goes as a matter of fact some parts of it get better if you're not in it And I was like, oh, that's hard One of the hardest most real things anyone had ever told me even to this day It still kind of gives me that stomach punch But my patients were safer My kids didn't want to have to wonder why dad was on the couch and didn't want to play with him because I was going through withdrawal She was happier didn't have to worry about if she was gonna come home to somebody who was overdosed The whole thing made it better as difficult as it was and made it better So the question that I had to start on peeling back was how did I get here? How did this happen? How did this happen a year ago? I'm at the top of the the top the pinnacle in every aspect of my life my health my profession my family life I was at the absolute top and here we are less than a year later, and I'm in a treatment center Unemployable being investigated may never work again probably gonna end up divorced. My kids are ashamed of me and worst of all I'm ashamed of myself That was the worst thing out of all of it How did that happen? So we really started diving into it and trying to figure it out And this is the whole Basis of the presentation for you today is we want to show you a little bit of the inside pull the curtain back and show You how this happens and then you take that information back and look at things with a new perspective Maybe or start to understand a little bit of maybe what your role can be and how to do this So if you look at Claudia's has described chance is a chance meeting in the in the lobby We're just going off of chance every time we go in the hospital. It's a chance What are the chances of her marrying an addict? These are the five reasons and we're going to say chance in quotes here characteristics accessibility and necessity accessibility enabling misdiagnosing Inadequate intervention and expert knowledge. This is why the addictions happen This is why impairment with healthcare professionals happens because of these five reasons. So the top two characteristics in accessibility and necessity Everyone is in this room gets a free pass for this because all you have to do is understand it. That's it There's absolutely nothing that you can do to change this the reason why I was able to practice as an impaired professional was because those two parts were Part of the equation and there's nothing that anybody can do to change that However, three four and five the reason why the disease was able to progress for as long as it did was because of three four And five three four and five felt directly on the responsibility of co-workers employers family members friends policy holders aana professional organizations society everybody everybody else has a direct impact on three four and five So step number one is to be aware of what this is and then you do your own self inventory and figure out where You stand on these positions. We asked the question today in 2019 how many of you think that addiction is a disease not disease? Thank you. And how many of you think that this is a choice and it's it's a choice You don't want to get sick. You don't do it. You don't want to get addicted. You don't pick up the pill you don't do it and Anybody bring one up to say that because I know it's a it's a contentious topic. So there's a physician in Vancouver, Washington I'm sorry, Canada Vancouver, Canada, dr Gabor Mate and he coined the term perfectly at least for me Although the initial actor ingestion is voluntary cessation of the disease process is not that's something we can agree upon so when I was out back to work on my very first day and The withdrawal system systems were almost completely debilitating by the third case I was kind of got the flu and why do I have the flu and I can't ask for any more days off? Because people need me and if I ask for help, then I'm gonna show people that I'm not As perfect as I think I am. So let me take you back to that story that point in the story I'm literally in my car and I had a decision to make I Ready sigh of self-diagnosed that I was going through withdrawal symptoms Because when I went out to my car for the body aches that I thought was the flu and I took one more pill Everything went away. So now I'm standing right here at this crossroads in my life. These are my options Think about what you would have done All right, we go. Listen, you got a choice to make here. You're addicted to these pain pills Option one you can march back in there. You could raise your hand You say I need more time off work. You guys have been very gracious and giving me six months off But guess what? I just found out I'm an addict. I'm an addict. I need to get some help I need to take time off of work I need to see a doctor and I know everyone's gonna know about it and my wife is gonna be embarrassed and people may Kind of jeer at me and maybe hold their medications to the side when I walk through but I'm an addict and I need some help option number one Option number two. I have the medications here. I went to school. I know how to I don't want to give these better than anybody Else it's a prescription. It's legal. You have about another week supply here. Just wean yourself down. You know how to do this What you do for a living and if you can't get it in a week get one more prescription and wean yourself down That's how you do it. Nobody will know get back to work chin up shoulders back get to work. They're looking for you They need you the world can't survive unless you get back in there Those are my two options and I took that option and then the prescription ran out I got another one and then that one ran out and I got another one and they said no more no more So now I'm six weeks more addicted to these medications and the withdrawals are Exponentially worse now and that's how it starts That's how it starts 25 mikes of fentanyl under your tongue during a case where you think you're gonna be at home to take that one more pill but it goes later and it goes later and God, man, this works. This works faster. This works better and guess what? It would have just gone down the sink. Anyway, nobody's gonna know it. No one's gonna miss it So it goes from that level to a full-blown daily IV use dependency on these medications Escorted off of the facility and losing everything. How long do you think that took? that precipitous fall when a switch from IV to out in How long you think that's Six months. It's like you were there figure there. Okay, but yeah six months. It doesn't take very very long After about one month people around me started rallying the troops trying to help me trying to help me out. So Let's talk about what do you think this looks like? Let's look at characteristics first Scenario for you guys. Let's say we have a doctor or nurse who's taking 60 to 80 Vicodin pills a day for six months or 300 milligrams of morphine IV every day for six months What do you think this person might look like? at work It's your actual case studies on some of the patients that we see we've had patients Admit to taking 80 Vicodin pills a day 2,500 mikes of fentanyl a day IV while they're working whether practicing while they're working So, what do you guys think? Shoot out some stuff. What do you think this person may look like at work? Like everybody else Normal Lots of breaks lots of breaks why lots of breaks Lynn How do you get to their medications Oh That's a good one Did you hear that with the brakes why else well So you guys are the pharmacist or the chief anesthetist or you're the program directors and they tell you hey We got this person down there. We just have their employee number you go out there and find them Right 300 milligrams of morphine a day 2,500 mikes of fentanyl a day. What do these people look like? They're giving lots of breaks. We got one clue working overtime Lots of call working overtime Anything else physically, how about physically? What do they look like physical? Weight loss as you can see I'm all I'm good right now, right? Nobody said anything. That's the craziest thing. You look good. It looks like you're losing weight. I'm like I am yeah Yeah Exactly that's how it was. We're glad that you're an addict. We thought you had cancer you're losing weight so fast you look horrible So So this is what people aren't usually looking for and this is why it was really difficult for me to figure out that regal Was battling an addiction problem because regal didn't fit this description here. He wasn't disheveled at work He had a job. I considered him responsible Responsible he wasn't dirty. He got up every morning and he was well groomed This went on for six months or more possibly and It wasn't obvious where nobody at work knew nobody saw because we're looking for that So the Talbot Recovery Center, which is the first and the oldest professionals health professionals program treatment center in the country It's in Atlanta, Georgia. They did a study in 2011 in 2017 we emulated the exact same study in Parkdale and all we wanted to know is one thing. We asked the family members We didn't ask the addict. We asked the family members and the co-workers Describe to us your loved one. Just describe to him the one that's in the treatment center now doing 2,500 mikes a front I'll describe to him characteristics and this is what we found. They're intelligent. They graduate in the top 25% of their class They're well liked and respected. They are supervisors and managers. They have advanced degrees. They're the top performers. They're charming They're likable. They're charismatic. They win awards. They're the leaders of the group. They're the smartest of the smart This is what the profile looks like of the impaired professional. This is why it was so hard for them to find me Would it surprise you to know that I won an employee of the month award in the morning and got escorted off the premises in the afternoon They don't see it They don't see it and that was the second month in a row that I had won the employee of the month award For the reasons that you mentioned I came in early I stayed late I gave all the breaks when I left to work and I was whisked away and like Claudia said nobody even mentioned that Who do you think was most upset about that? Besides this angry Latina that was standing next to me besides her who was the most upset that I was gone. Oh My god right there, right My co-workers who's gonna work the weekends now and who's gonna do the Thor Academy that comes in at 3 o'clock p.m On a Friday cuz I was like, I'll do it right here And they would all I'll look at me Claudia was I don't know I don't know if you've ever mentioned this to you But Claudia was the charge nurse in the surgery department that I was diverting medication from. So if you married men out there want to win husband of the year, do not do that. Because that didn't help. But she saw it. She saw it all from the employer point of view, the co-worker point of view, the patient advocacy point of view, the father of her kids point of view. And it was a horrible, horrible position that I painted her in. This is the position that if you're not that 10 to 15 percent that's suffering from it, the rest of you are likely at some point in your career is going to be in that position. And that's why it's so important. I would have never, ever, ever, ever asked for help on my own. It's too shameful. It's too shaming. I needed people like Claudia, who turned me in, by the way, to get the help that I need. So the drug screen came back that last day, and it was negative. And I'll let Claudia tell you the rest. So Riggle was very good friends with the CEO of the facility. And when he got caught, he came home and said, you know, they're suspecting that I'm using. But I knew he was using. So I said, so are you worried about anything? He said, no, not at all. I didn't do anything. I said, well, then don't worry about it. If you didn't do anything, then you're good. So he gets home, and they told him, you know, we're going to keep you off for a few days until your drug test comes back. So he gets a phone call, and I can hear him in the other room. And he's like, uh-huh, yes. Okay, good. I'll be there Monday. Hangs up the phone. And I, of course, I go, what happened at work? He said, oh, they said my drug test was negative. Everything's fine. I can go back to work on Monday. And I remember thinking, there's no way it could be negative. I know he's using. I'm seeing needle marks. I'm finding stuff. I'm actually finding vials, empty vials. I know what he's using. So I called the CEO, and I said, look, Joanne, I know you love him, and I know you believe him, but I'm telling you there's more here. Are you sure you drug tested him for everything because something's not adding up? She said, well, let me find out. So she calls the lab. She calls Regal back 10 minutes later and says, hey, you know, Regal, hold off on coming back on Monday. We have to do some more further testing before you can come back. What we found out was that Fentanyl was a separate drug panel, and they had not initially tested him for that, and that's why his drug screen was negative. But a few days later, they said, you know what, go ahead and come back in on Monday. He came back. He went in. He was with the administrative team, and they gave him his results. And they told him, you're positive for Fentanyl. But had I not called and done that, I don't know what would have happened. So what we learned here today is that Claudia's a snitch. You see that, right? She's brilliant, brilliant. So, you know, the truth of the matter is an honest truth. She saved my life, and she saved my career. When we know that 96% of the people will end up in a treatment center because they get caught, they overdose, they get divorced, they get arrested, they get forced into a treatment center. 4% of those people that come into a treatment center will have the clarity or the wherewithal, or maybe they've been through it before, or maybe they have a good support staff. I'm not sure, but 4% will say, this is not good. I can't stop this. I need to get some help. I don't care if people call me an addict and label me. I don't care. This is going to be bad for me. So I was in that 96% pool, as most people are, and it took somebody like Claudia. It's going to take somebody like you, a family member, a co-worker, a program director, to pull these people out because they will not do it on their own. I can promise you that. And we're going to talk about that. We have over 500 health care professionals at Parkdale to date, and not one of them has ever come in voluntarily. Usually it's the work or the spouse or someone who's pushing them into treatment. So we did this. One of the best things that we do as parents, and you parents, I'm sure, can relate to this, is we love to embarrass our children any opportunity we get the chance to. So when our kids go through their high school years, when they're a senior, we have it worked out with their school that we do a presentation very similar to this to the school. It's a great cause, it's a great service, it creates a lot of chatter, and it embarrasses our kids, so that's all good. So our son, last year, the year before, when he was a little too excited for the presentation, and I didn't understand why, so him and his two knucklehead buddies ran to the front of the row, and they were sitting there, and they were just smiling the entire time. And we get to this point in the study, in the presentation, and we say, what's the message here? What's the take-home message here? You see what it looks like and what addiction is looking like, and his buddy's waving, like he's waving down an airplane. He's just right here in the front row, and I'm looking over him. Anybody, please raise your hand. So I finally pick on him, and he said, Mr. Garcia, I know what it is. I know what it is. Don't be an overachiever, and this won't happen to you. The other take-home message is this has taken our best and our brightest and our smartest. This has taken the cream of the crop, the top. Everyone is surprised when they hit that person, and the family at work, in the schools. So keep your eye out for this, because it's very, very important. I want to talk about accessibility and necessity. Just stop. Just stop. Just stop, right? Claudia, I'm going to divorce you. Just stop doing it, Rigo. They're looking in the windows right now, like literally, making sure you're not nodding off. Just stop. Kids don't want anything to do with you. Just stop. How many times have we said that? Just say no. Just stop. Well, we know that that doesn't work. We're going to take you all the way back to the first H&P and physiology class, because this is really important. We're all going to zone in on one area, and we're not going to spend a whole bunch of time on it, but we're going to talk about this thing called the reward pathway. And this is something that I studied a long time ago to pass the test, and this is something that I live in now, because it helps explain everything else that we're about to talk about and the just stop. So if you look at this, and you look at just two parts of the brain, the frontal cortex, that's your higher learning, that's your decision-making, that's where your morals and your ethics are at, and then you have this middle part of the brain right there, the VTA and the nucleus accumbens, and that is just driven by pure primitive instincts. Your body gets a reward because it wants you to keep doing it. To sustain humanity, it gives you a reward. You do it again, it gives you a reward, you do it again. So we have evolved as a species to have this prefrontal cortex. That's the decision-making. There's an actual connection between the two. So we're the only species on the planet that will get this primitive impulse, and our bodies will know, this feels good. I'm going to reward you if you do that. But what it does before it jumps on it is sends a message to the prefrontal cortex and says, all right, let me go through the checklist. Is it legal? Am I going to get divorced over it? Is it something I shouldn't be doing? Am I going to hurt somebody else's feelings? No? Okay, I'll do it. Sounds good. So there's a lot of things naturally and normally that will give us this dopamine release that will reinforce this behavior over and over again. We can now quantify that. We can have the experience, draw the blood, measure the levels of dopamine, see what it is. So 200 mics of dopamine is the ceiling that we can get naturally and normally. Everything that feels good, that's enjoyable, that's pleasurable, that reinforces humanity can be achieved 200 mics or less. So if you're sitting there and I'm trying to tell a joke once in a while and make eye contact so everyone's not drooling on themselves, nodding off, you may get a little 20, 25 mic bump of dopamine. And if you hug your kids, especially the ones you like, you might get a little higher bump of dopamine than that. So there's a lot of things, and we're going to talk about that. And if you look at this, what happens with addiction, this is the last part we're going to talk about this, visually speaking, this connection right here is going to be completely obliterated. It's gone. So now when they're in the throes of the addiction and the alcohol and the methamphetamine and the fentanyl and the opiates and the pornography and the gambling and the shopping and the sex and the Internet, they don't have the time to process this in the front. They're driven strictly on that primitive response of your body needs it. So it's such a powerful indicator that some of these substances that you take from the outside that stimulate this dopaminergic response, if you don't feed that pathway, your body will shut itself down and kill itself. Alcohol, you drink alcohol, and then you just stop cold turkey, you go to DTs, you have seizures, and you die. Benzodiazepines, long-term use, you stop cold turkey, your body shuts down, and it dies. That's how powerful this response is when these outside variables start interfering with this dopamine pathway. Any questions on this? So God's cruel trick on us is that he doesn't make this path, this frontal cortex, fully developed until you're in your early 20s. And Claudia says, as men, they never get that fully developed, and sometimes I keep proving her right over and over again. But that's what happens. So when our son, when he was 7 years old, the younger of the two sons, he was 7 years old, we live in a cul-de-sac, the top of the hill, my sister lives there, and we lived at the last house on the bottom of the hill. Downhill, no cross traffic, no stop sign. I'm going up the hill to see my sister, and I see this little kid coming down on a skateboard with no shirt and his hair flying through the wind. And as he goes by, I did one of these things to catch him off of the skateboard, and I said, Jay, where'd you get the skateboard, first of all? You don't even have a skateboard, and you don't even know how to ride it, and what do you do? And he says, I saw Tony Hawk doing it on TV, and I thought it would feel good. It'd look good. It'd look fun. So he was driven by that primitive response. He didn't think of, I don't have a skateboard, I don't know how to ride a skateboard, there's traffic down there, and I'm going downhill. That's what happens. So in reverse to that, and how this works now, I'm going to give you a very, very simple illustration of how this works when it's supposed to work. Anybody ever been on a diet? Every first of the month is when I start over again. It's like the third of the month, and I'm like, all right, that's right, pick it back up next month. So October 1st is coming around, so this is the struggle that I have, and this is how it works in my brain. So I'm walking past the table, and I see the beautiful chocolate cake right there. You could almost see it, right? It's a beautiful chocolate cake. My brain is telling me, oh, it's going to be so good, just get in there. It's soft and delicious, and you like that. No one's looking, just get in there. So it's going to send a message to my prefrontal cortex that's going to process that. Come on, you're really trying to drop a couple pounds. I've been really proud of you. It's been three hours, and you're holding firm to your diet. Just keep on walking. That's how this happens, and then you make the decision. So let's look at some of these things that you can get naturally and normally. These are your levels of dopamine that you can get. Hugging, connections, good families, reading and laughing and picking up hobbies, playing the guitar, going out for a jog, food. There's that chocolate cake, there's that nemesis that always gets me, 150 mics of dopamine. Sex and procreation, that's all we need, right? That's all we need to survive as humans, humanity. Procreate, have good relationships, protect each other, bond with your family members, eat, shelter, protection. That's it, 200 mics. So now we start introducing things from the outside. Tobacco, 300 mics. Alcohol, 350 mics. How many of you have tried to stop smoking or tried to get somebody to stop smoking? It's a known carcinogen. It's expensive. It has a bad social stigma. It's difficult to get. So with the reinforcement of 300 mics, it's enough to put all of that aside to continue the addiction. Alcohol, 350. Just stop drinking. You got your fifth DUI. I would love to, but I can't, and physically they can't, and emotionally and mentally they can't. There's one thing that fixes this connection, one thing and one thing alone. What do you think that is? Just one thing. It's not a medication. It's sobriety, sobriety, sustained sobriety. Heal your brain neuroplasticity long enough for that connection to either redevelop a new connection or to reinforce that connection. Sustained sobriety because I can promise you this. When I was in the treatment center, I still didn't think it was that bad what I was doing. I stand here today thinking people are dying. We got to get back out there and help them. It's horrible, horrible. The whole process is horrible. I didn't have the wherewithal or the insight because that pathway wasn't fully connected yet. Now we're going to get into the hard addictions we're talking about, cocaine, opiates. That's heroin. That's your fentanyl. There's your Demerol Dilaudid, methamphetamines. The amphetamines before it's methylated is about 800 mics. That gets your kids to call you in the middle of the night telling them they love you. There's a tip for you. This is what we're facing. This is why it's so difficult. This is why people can't just stop. This is why you can't just say don't do it again. Any questions thus far? Okay. Now we're going to switch the gears. The first two things, you just got to know it. You got to know what the characteristics are like. You got to know that it's more than just a bad choice. This is a compulsion. This is a disease. This is where it works in the brain. They physically sometimes can't stop. Emotionally, they can't stop. Now we're going to talk about what your role is in all of this. Today I work as a counselor. In my experience, the home families and the work families both struggle with enabling. For example, when Regal was in the throes of his addiction, I remember I used to wake up early every morning to make sure Regal was out to work on time. When he was at work, I would do rounds on his patients. I would peek through the OR windows just to see if patients, if he was nodding off or if the vital signs looked okay. I would oftentimes walk into the recovery room, and I would ask the nurses if Regal's patients were having pain because I wanted to know if he was withholding medication from them. The interesting thing is that Regal had a hard-to-fill position. He had to give a 90-day notice to terminate his position. And the day Regal was escorted out of the facility, none of our colleagues were at work. It was after hours when this happened. Nobody saw him get escorted. It was all quiet. The managers were not allowed to talk about it. So one day he's there, and the next day he's gone. And what was really ironic was that not one of our colleagues or coworkers came to me and asked where he was at. So he's gone one day. Maybe he's day off. Maybe he's on vacation. It's a week, two weeks, a month, three months. Not one person ever asked me where he was at. After a few months, I was going through my own counseling and getting help for myself, and I started to talk to people about what happened. I started asking our colleagues if they knew Regal was using. And every person I asked said they did. I then asked why they didn't speak up and say something. And they all gave me very similar answers. They said, Regal's a nice guy. He's smart. You're a nice person. You have a great family. I didn't want to get him in trouble. I figured he would get himself out of this if he could. So as you can see, we all enabled this behavior to go on. Everyone knew. I thought I was alone in the battle, that I was the only one that knew. I knew one of our colleagues knew about it. I remember during this time I realized that I was just as sick as Regal was. Because I remember Regal had done surgery. He was the anesthesia provider for a lot of my family members. So my brother came in and had a hernia surgery. My nephew's niece had tonsillectomies. I mean, he was always doing the anesthesia, so they trusted him, and they loved Regal. So this time, Regal's towards the end of his active addiction, my dad comes to surgery. And, of course, I didn't want Regal to put my dad to sleep because I knew he wasn't well. So I tried to make up some stories to my dad. You know what, dad? I know you're in pre-op. Doctor's here. Can I just get you somebody else to do your anesthesia? Regal's busy. My dad was being a stubborn Mexican. He's like, nope, I'll sit here and wait. I'm not in a hurry. So I couldn't convince him. Then I had the angry surgeon who was like, come on, Claudia, let's go. We've got to move. So I let Regal take my dad. I remember he's in surgery, and I'm peeking in the center core, just peeking, and just watching as my dad is drifting off to sleep. And one of our colleagues, someone who's a very dear friend of ours, was there. She was the only person that knew what was going on because I confided in her, and we were both trying to figure out how to get him help. She came right behind me. She put her hand right on my shoulder, and she whispered in my ear, and she said, What are you doing? What the hell are you doing? And I looked at her, and I said, Excuse me? She said, Why in the world would you let that man put your own father to sleep, knowing he's sick? She's like, I would never. I would never do that. I was like, What is wrong with you? And she walked away. And I remember standing there, started crying. And I thought, Wow, I'm just as sick as Regal. And that was really, for me, my turning point where I'd had enough. And I remember the next day I reported Regal because I couldn't take it anymore. So you can see how this affects everybody. I mean, it's concentric circles. Those that are closest to the addict are the ones that are going to feel it the most. They're the ones that are going to get sick the fastest. They're the enablers and the codependent ones closest to it. You know who catches impaired providers more than anybody else in the hospital? Who do you think it is? Take a guess. You have a lot of providers to pick from, a lot of different departments. Who catches them more than anybody else? Pacu? Close. Not Pacu? Pacu's a good guess, though. Pharmacy. Why pharmacy? Because to pharmacy, I'm not this tall, dark, good-looking, handsome guy that you see today. I'm just an outlier on their bell curve when they pull their reports. I'm just a number to them. Pharmacy. So my job when I was going through the addiction was to befriend the pharmacist. That's what I did. Sent her kids birthday cards, wished her welcome back on your vacation, things like that. But it's the pharmacist. It's the ones that can look at this as objectively as possible. Well, Claudia and her team with the family therapy program, what they work with the family members is take a step back from being mom and look at this objectively. And it's one of the hardest things to do when we're talking about support systems for those that are addicted. So let's take one big step back and let's look at this is not just a Regal and Claudia individual case. This is not just how it is with family members. This is how we're at in the entire country. And let's take a look at this. So in the 1970s, this is what happened. President Nixon said we have 20% of our veterans coming back from Vietnam that are addicted to heroin. We have to do something about this. We're going to write a $300 million check. We're going to put this big initiative on the opioid crisis for these 20% that are coming back from the military. The red line that you see here is the addiction rates since they came back. The yellow line is how much we have spent on this addiction and this war on drugs since 1970s. So you can see the precipitous increase here in 1985. What happened in 1985 that the U.S. government just said here's the checkbook, do whatever you need to do, get it done? What happened in mid-1980s? I'll give you a hint. It had to do with the first lady at the time. Just say no. Just say no. That's the solution, right? Just say no. Just say no. The whole just say no campaign. Just say no. It's that simple. And you can see $1.5 trillion since then. But the addiction rates overall have not changed at all. They're the same as they were in the 1970s. The same rates. We're having more people die. We're having more accidental deaths and overdoses, but the addiction rates have not changed. The question that I have is, where did all of this money go? Right? 1.5 trillion dollars, where did it go? So 60% went to incarceration and prosecution. 10% to border control. 5% to the gangs. 15% to the Just Say No campaign. And 10% goes to treatment, education, reentry, medically assisted treatment, and aftercare support. So the part that we know works, we have data that shows that getting people help, education, training, aftercare support, proper treatment works, and only 10% of that has been allocated to fight that. So this has to change, obviously, and believe it or not, every presentation that you guys hear or go to or participate in or do is starting to change the needle. We can see it. We can't see it day to day, but where we're at today as a society from where we are when we started this 5-6 years ago, the needle is changing in the right direction, but it's going to take the momentum of everybody in here to do your part to get this flipped around the other way. One of the things I want to ask you guys here is, think about this. What do you do when you catch them? So you guys are co-workers or program directors or employers. What are you going to do when you catch them? You have somebody that you caught, overdosed, diverting medications, but one question I want to ask you guys first is, think about the place that you work, your employer. Maybe it's before school. Think about that place, because I know that the program here at the school is pretty supportive, very supportive. So think about the job that you did before you got into this school. Think about the job that you're working at now. Think about the social stigma of addiction. Think about what that would mean in terms of embarrassment for your family. Think about what it means for access to care and maybe having to pack up for 30 days and go to an inpatient treatment center and coming back with a scarlet letter of addiction forever affixed upon you. If you guys were struggling today, right now, individually, if you guys are running out to the bathroom to get another fix because you can't make it through this day, if you guys can't wait to get out of here to have one more pill or one more drink and that's what you're thinking about, how many of you would voluntarily raise your hand and say, I'm an addict, I'm in big trouble, I need some help? How many would do that right now? Thank you for your honesty. So I think, look at the people sitting next to you. You love them, you care about them, they're your friends, they're your co-workers, you like their families, you're the godfather to their kids, whatever that relationship in. You're Claudia. How many of you would help the person next to you? They're struggling. I saw them five nights in a row and they're falling over drunk. I saw this guy shooting up in the car before he came in here. How many of you would do the right thing and stand up and say, this guy needs help, let's rally the troops and get him some help? How many would do that? Keep your hands up for a second. See everybody with their hands up? These guys are saying, I wouldn't go in the system, but I'll throw you into the system. That's what they're saying. That's what Claudia said. And that's what it takes. But you see how the system is broken, that we won't ask for help but ourselves, but we'll help somebody else out. And when we're talking about stigma and we're talking about shame and we're talking about codependency and enabling and guilt, all of those things play a factor to why I couldn't raise my hand and say, I need help, I need help, I'm dying here. So we have to start looking at this more as a disease process. So I'm going to take you down the path of what happens with an impaired healthcare professional when they have the addiction. But before we do that, let's talk about what works and what doesn't work because we already know. So we know that if someone goes through detox, meaning they stop using, maybe they're put in jail and they're forced to stop using or they're in a treatment center for withdrawal management, we know they have a 10% success rate. So 90% of these people will return to using. Now if you detox them, they stop using and they're being monitored. Monitoring could be an alternative to discipline program in the state or maybe it's the court system. But someone's watching this person. Now they have a 60% success rate. So 40% will still return to using. Now we have detox, they stop using. They're in treatment. Treatment being, maybe it's a specialized treatment center for healthcare professionals. Maybe it's a dual diagnosis center that can treat their depression and anxiety. And they're also being monitored. At the one-year mark, they have a 85% success rate. At the three-year, 90%. And if we can get them to the five-year, they have a 95% success rate. So a lot of programs across the country are now moving towards a five-year monitoring program because we know the longer we can keep someone engaged in treatment, in structured treatment, and give them some accountability, they're more likely to stay sober and not return to using. So the formula's there. It's a relatively simple formula. Some states will subscribe to this formula. So the Physician's Health Program, it's a monitoring program in just about every state. They'll say if you're a physician, you call one number, we're going to put you on that bottom line. Stop using, get into a treatment center, we're going to monitor you for the next five years. And sometimes it's lifetime monitoring. We have moved because we're blessed to be able to have a say in what happens in Indiana where we run the program. So we subscribe to that same model. If you're a healthcare professional, we don't want to throw you in jail and ruin your career, but stop using, get into treatment, we're going to watch you and drug test you for the next five years and tell you when you can go back. It's the same formula that works in the very successful states and it's what is absent in those states that does not subscribe to it. So when you're looking at nursing in particular, maybe a little bit on pharmacy, but mostly nursing, there's a lot of options that these hospitals will have. This is who they can report you to. And depending on what state, what hospital, who's working that day at that hospital, this is all their options. These are all their options on who they can report you to. The medical board or the nursing board, the office of the attorney general, any legal component, call the police, they stole from my hospital and we see that quite a bit. The alternative to discipline program, if they're lucky, they'll send them to the alternative discipline program so we can get them the treatment and then the advocacy that they need to follow. The employer's going to have some, maybe they're going to terminate them, maybe they're going to report it to the national practitioner data bank, which you see on there. Office of the inspector general is an old player who just came in the last few years and said, you know what, he's like the bouncer at the end of the club. Everybody out, it doesn't matter what you want, I got it from here. And when you get on that office of the inspector federal list, you cannot work anywhere and under any capacity at any facility that takes federal funding. Medicare, Medicaid, Tricare, any of those. So as an anesthesia provider, if I was on that medication list, I could not work at Mass General mopping the floors because they take funding. And that's a ten year restriction, five to ten year restriction on that list. And then of course the treatment center's going to have some. This is part of the problem. This was incredibly daunting to me when I was contemplating should I ask for help because I knew that I was going to get stuck somewhere in this. And I did. I did. I got thrown into this nebulous activity of everybody wants a piece, everybody wants to tell me what to do. And I got very, very fortunate that I made it out to the other side after I had to do. But we see so many people that get stuck in this system. And this is part of the problem. And we put this slide in here because this is part of the solution. This is what we have to do. We have to fix this so this doesn't happen, continue to happen. So now we're going to look at point number five and then we'll open it up for some questions. This is something that falls on each and every one of us in here. Expert knowledge. You have to learn more about this. We can't have the ostrich syndrome anymore and just bury our head in the sand. Those days are long behind us because everyone in this room, if you're in direct healthcare, I can promise you at some point in your career you're going to deal with this. Anyone who's been in healthcare have to deal with this already? An impaired provider? Working with a colleague? Yeah? More than once? It's going to happen, guys. It's going to happen. So one of our huge objectives about leaving today is twofold. Number one, just open everyone's eyes saying, hey, this is going to happen out there. And number two, this is a call for action for those of you who may need help or if you know someone who needs help. There's resources, there's assistance, there's support that's widely available through the AANA and through your various organizations that we'd like to make sure that you know before you walk out of here. I know we have a couple of informative brochures and stuff like that, but you've got to make the call. You have to. So expert knowledge. This is the one that is constantly changing, right? You can't read the pamphlet in the book on addiction today because if you do, next week it's going to be different and the week after. You have to stay current and embed this in your rational thinking. We just checked in a nurse from southern Indiana and the dad who was in tears said, this doesn't happen to us. This happens on the news. This happens to the family members down the street. This happens to the next neighborhood and now it's right here. This is happening all the time. So expert knowledge. You have to learn more. When we started, the first week that we started, we had about six people in the treatment center and Claudia and I were just happy that we had one person that actually came into the treatment center. And we're all sitting there. So there's about six of us that had been through the story before. We were recovering addicts or newly recovered addicts. Claudia was there. She was the only non-addict. There was one other family member who was not there. And we're going around and we're just talking about how it was done. And my story would have been something along the lines of I had the waste medication. I took the waste medication, et cetera, et cetera. Somebody else would say I volunteered to do all the big cases and I took extra out and that's how I used it. And then the first SRNA, he was actually an SRNA when he came in at the time, he said, you know, what I used to do is I used to go up into the ICU, find the patient that was on the ventilator that had the fentanyl drip. I would take about 20 cc's of the fentanyl and that's what I would use the entire weekend so that I wouldn't go through withdrawal the entire weekend. And all of us there, you know, we have done this and we've pushed that line and we're all like, oh man, that's kind of risky and I'm not sure I would have crossed that line. But his rational thinking at the time was the pump runs out, they fill up the bag, no harm, no foul, nobody even misses it, nobody even knows. So we get around the table and it comes back to him and he says, well, I have a little bit more to tell you about that story. I wasn't even doing my practicum at that hospital. I didn't even work at that hospital. I put my scrub coat on, I put my badge on, flipped it backwards, I befriended the candy striper and the security and I just walked into a random hospital and that's how I had it done. Unless we stay on the forefront of how this is happening, this is how it's going to happen. It took about five months of being in this, with the treatment center opening, interviewing every single practitioner, it took about five months for me to say, where did you think of that? That's so beyond what I can even comprehend. But this is where it's going and this is the point why we have to stay one step ahead of them or at least keep even with them because this is happening over and over again. While you're sleeping and you have these policies that are beautifully crafted and vetted by your legal team, they're reading them for the blueprints because the policies and the procedures work for the 90% of the people that are never going to divert. For the other 10%, it serves as their blueprint. I got called in and Claudia was there and it was one of the times that I was able to wiggle off the hook, one of the several dozen times that I was able to wiggle off the hook. And my director was there and Claudia was there and the CEO and human resources and security and they were all there and they said, we're going to need you to submit to random drug screen tests. And I said, there's no way that I'm going to do that. And they said, yes, you have to do that. And I said, no, I'm not doing it. They said, well, you're so brazen about this. Who said that you don't have to do it? And I said, you guys said. If you look on page four of your policy and procedure manual about the third paragraph down, it says that I have to have three discrepancies in my charting in a six-month period for you to ask me to do a random drug test. Show me my discrepancies and I'll give you the drug test because while they were sleeping, I was looking through that book just in case of what's going to happen. And this is how it happens. This is why we have to stay objective and this is why we have to stay current. So we do an entire day-long presentation in education and training on what's new and what's out there. And we talk about how to beat drug tests. Drug tests are just one element. Claudia and the CEO and no one else knew that the fentanyl wasn't part of the profile, but I knew that. I knew it wasn't. That's why I continue to use that. U47700, any idea what that is? That's the fentanyl coming over from China. They change one little molecule of that and now it's not detectable. Policies and procedures, I gave you that example. What about propofol? That one should scare everybody in this room. We're seeing more of a rise in propofol overdoses and part of their polysubstance diagnosis than anything else. It's easy to access. It's difficult to track. It's difficult to detect. Their waste requirements are very different at every facility. You know how you find somebody who's using propofol as a drug of choice? How do you think you find those folks? Overdosed and dead. Yes. We get them post-overdose. They overdose, they get found, they wake them up, they arrest them, they send them to treatment. That's how we're finding the propofol folks. It's very scary. The testing schedule. This is more so for the folks who are going to be ordering the test. So when you say, hey, come in next week, I'm going to test you for that sufenta that's been missing. It's long gone since then. But your addicts know that. And then the mass spec. So you're familiar with that concept? They take the substance and they emit the light rays through it. They quantify what's in that syringe. We did this presentation for Indiana Pharmacy Association. 300 people in the room, pharmacists. We asked them, who has a mass spec machine where you're wasting and testing this waste medication? 300 hands went up. And I said, which ones are quantitative and qualitative? And they all looked at each other. What's the difference? One is going to tell you there's 10 cc's of saline and there's 43.7 mics of fentanyl in that. The other one's going to tell you there's 10 cc's of saline and yeah, there's fentanyl present. I knew that. I was six floors away from pharmacy. In the bowels of surgery, I shouldn't have known that, but I knew that. I knew which one it was. So these things, you have to stay on top of one step in front of the other here. So what now? Now that everyone's depressed by that. But the truth be told is that we stay a step ahead of them. There's people out there in treatment centers and resources and advocates and ANA peer assistants that stays a step ahead of it. You just have to keep up with the information to be able to help your colleague. It's relatively simple. At least on this slide, it looks simple. In terms of characteristics, accept what the new face looks like. Consider that it's a compulsion and just say no will not work. A threat of a divorce and a termination will not work. Use objective parameters. If they're on the bell curve and an outlier four pages to the right like I was, they're probably doing something that they shouldn't do. Objective parameters. Unify the system so that every hospital and every department and every school and start small. Start in your own department. Everybody here in this department, we start with this room. If I was the charge nurse of this department, I would say everybody here, I want to make an announcement. It's loud and clear. If any of you need help at any time, this is the process you follow. It's going to happen. If you think the guy sitting next to you needs help, at any time, this is the process you follow. And it would be my job to go talk to all the directors of all the departments and say, huddle. We're going to have a huddle. This is what we're doing downstairs. Let's do this everywhere. That's how it starts. Because I can tell you, if you don't think that you guys can make a difference, you're mistaken. Every one of you. It wasn't too long ago that I was an unemployed opioid addicted anesthesia provider and Claudia was the codependent enabling nurse that let this happen. And if we can make changes and get back into this, all of you guys have a power within you that you may not even know that you have. So don't let that damper down. Expert knowledge, you just have to learn more. We'd like to leave you with one last thought. Every 20 minutes in our country, someone dies of a prescription drug overdose. This doesn't include the deaths related from heroin, hepatitis C, HIV, or suicide related to addiction. In 2016, for the first time in U.S. history, drug overdoses are now the number one preventable cause of death, surpassing motor vehicle accidents. Thoughts? Questions? Concerns? I had a little bit of discomfort and I decided to take one and puked my guts out for four hours. I called Janet to talk to her and she goes, the good news is, Connie, you will never be an addict. So that's just a funny little side story, but I know in the state of New Hampshire now, there's just a bunch of paperwork you have to do in order for them to even give you any prescriptions whatsoever and they're only allowed to give very small amounts. Have you seen any effect of this? Has this made any improvements in what's happening? Thank you. Thank you for that. That's a great question and it's a great point. So I told you a little bit about the work that we did with the Office of the Attorney General and one of the initiatives that he had was prescription, minimizing the prescriptions for prescribers throughout the state and he really kind of put the nails to it in Indiana. You could only do it for seven days, you have to come back in and be received by your physician, there's no refills, et cetera, et cetera. So he wins an award a few years back and he was Attorney General of the Year for the entire country and we're sitting at the luncheon with him and he comes back to sit to our table and he looks a little bit somber and we ask him about that. Well, you should be excited and he said, we have just opened up Pandora's box because what we have done is we have taken all of these addicts and all of these people that are addicted to these medications, we have handcuffed their supply source with no remedy for treatment or access to care or resources to care at all. So what we have seen as a direct result is that heroin use has increased dramatically and everything that comes with that, communicable diseases, crime rates. In Indiana there's a lot of counties that are doing a lot of case study work on this exactly and when they track it back, they tracked it all the way back to limiting the prescriptions without considering the treatment that's going to be required for those that were addicted because of chronic pain. That's a great point. Yes ma'am, Lynn. Thanks Rigo, thanks Claudia. No matter how often I hear your story. Adding on to what Connie said, in health policy class we're looking at just a virus scan. The DEA is proposing reducing opioid production this year, 53%, back 53% of 2016 for the five opioids we probably use the most in the hospital and that are prescribed. And I can only, what are the unintended consequences of what they think is a positive move? Yeah, and I think we're going to see a continuation of that, so I think it's- Well, comments open until October 10th, anyone who would like to comment to the Drug Enforcement Agency. Lynn is always working. But there are going to be unintended consequences, but we have to look at it in kind of two different ways, in two different mentalities here is, how much opiates do we really need here? Especially folks that are just coming out are much better at the opioid-free anesthesia than I am, because this is kind of what you're learning, and this is what's going to be commonplace. But when you hear stories like Mr. Martin, and you hear stories around the world, and what are they doing for chronic pain management in particular, and it's not to diminish anybody's diagnosis of true chronic pain. We're not advocating for suffering. We're not advocating for pain just because of the sake of a policy being written. But what we're advocating for is awareness and being logical in how we prescribe these medications. There are definitely going to be consequences that are- We know them. In discussions like this, we know that it's going to happen. You minimize the opioid accessibility without doing anything for the treatment, you're going to have people looking somewhere else for those medications. And that's when we talk about staying one step ahead. So now we have to, we have to, and in our industry, we have to position ourself for this outfall that's going to happen. Yeah, we don't have the drugs for all the multimodal pain management, the skill set, does the public understand? There's just unintended consequences of public policy. Absolutely, absolutely. It's going to affect every other aspect. It's like a domino effect. And what we try to do is just stop the domino fall at some point that we can. Yes, ma'am. So this presentation has mostly focused on opioids and substance abuse from that angle. And all the people that get reported to should a provider be impaired. What about those that are impaired with alcohol? Because I don't see that that having the stigma or the association with alcohol. Association or the consequences afterwards. And I can tell you from personal experience, because my brother and my ex-husband are both dead now from alcohol-related issues and diseases. And that, you know, has a lot of issues with providers also. So what's happening in that field? Thank you. Thank you. Yeah, fantastic observation and fantastic point. When you look at the annual statistics on opioids and opioids-related deaths, and you look in diagnosis in particular, you're looking about a million and a half a year. When you look at alcohol-related deaths and diagnosis, you're looking at near 15 million a year. So the opioids and everything that we talked about, and the gravity when it comes to your profession, pales in comparison to the effects that alcohol is going to have on the society. We are hindered by exactly what you said. The social acceptance of alcohol. The celebration of alcohol. I mean, how many billboards can you see on the way out here? Come and do this. We look at it from the treatment point of view in two different ways. We look at it as the hard and adjustable medications, and that includes your opioids, your methamphetamines, anything you can ingest. Alcohol, you treat it the same way, you manage it the same way. It occurs the same way. It's going to affect your profession the same way. And then we look at what we call the process addictions. Anything that develops in addictions through repetitive processing, like internet, shopping, gambling, pornography, those things. It's a little bit of a different take. But anything that's ingestible, those hard addictions, they're going to affect your career and your license the exact same way. So Claudia kind of alluded to it in the presentation, but being impaired doesn't mean showing up to work drunk. It's really important. And when we're talking about fallout from policy, we're talking about hyper awareness now of employers, of pharmacists, of co-workers, and they're going to jump on these opportunities to intervene to protect the public. So what we're seeing in terms of impairment at work, you had a long night party and you're coming over hungover. You get the shakes around 3 o'clock in the afternoon, but you haven't drank in 12 days. So necessarily, a clean drug screen doesn't mean you aren't impaired, and that's where the push is. It's a very aggressive push. They're looking at fit for duty, just as much as they're looking at positive drug screen results, with the same implications on your licensure as well. So if you're going to be partying hard tonight, don't go in the next day because you're going to be in that category. Great question. Yes, ma'am. I think a couple of things that, when you think about that big file side of pain, my dad had bilateral total needs. You're going to be in pain. You're going to get a lot of medicine. Five years later, my mom and I are going to be in replacement. You're going to have pain. You're going to expect to have pain. You're going to get up and move. We're going to do these things. So the preemptive awareness of the patients and the expectation that you're going to have pain and you have to move has to be put forth. When you think about U.S. protocols and preparation for surgery, you aren't going to be pain-free. We aren't expecting you to suffer. But this is, no, this is what the plan is. I think that's just a teeny tiny part of the process. It's an incredibly important part of the entire process, is setting the expectations for your patients. And when you get around patients and your students, when you start interviewing your patients, it will, you will be surprised. And I still am surprised. And it's changed my perspective on how much that's going to change their outcomes when you set their expectations. I'll tell you a real quick story. When I got out, I had to take a year off of practice. I go back to work and one of my claims to fame was that I can get an epidural on anybody. I was, I self-proclaimed, of course, really good at it. But what I had noticed was that, so we worked together and she would see that. They can't get the epidural, call Rego. So what I would always notice and I would, maybe it was my codependency, but I always overly cater to the woman who was pregnant. And Claudia said, if she says it's a 12 out of 10, believe it, don't ever argue with a laboring pregnant woman. I said, got it. Yes, ma'am. So I'd put these epidurals in and they'd work. I'd get called out at two o'clock in the morning at three o'clock and I would call her and they called me back out because I have a little hotspot or I got a pain in the back. So when I got back to work after I had been off for a year, I had to reorientate with one of my colleagues, another CRNA who had been doing it for 40 years. And he said, Rego, you're doing it all wrong. That was horrible. That was the worst interview I've ever seen. And I said, I got it. And your loss of resistance, we're good. I've done this. I know this. He goes, it's horrible. Of course, I got called out three or four times that night to pull it back, to redose, to give the bolus, to reposition, all of these things. He said, next time I'm going to do it for you. So he gets up there and he does. And he said, hey, how's your pain? 14 out of 10, it's horrible. The worst pain I ever had. And he said, all right, this is what we're going to do. I'm going to get this epidural in. And if I get a really good epidural, it's going to drop that 14 out of 10. We're going to get you to about an 8 out of 10 pain. That's a good epidural. If I get a perfect epidural, and it doesn't happen too often, but we can get you to about a 5 out of 10. Best case scenario, this is a beautiful epidural, the best one I've done in my career. You get about a 3 or 4 out of 10 because you're having a baby after all. And it's going to hurt. So you might have a little aching, a little pressure, a little hot spot, a little this and a little that. She said, all right, anything is better than this. Never got called out the entire night. The next morning, we go to check on her. I said, hey, how was it? It's perfect. It's just like you said. What was your pain level? It was like a 4, 5 out of 10. It hurt just like what he said, completely fine. Setting your expectations for your patients is going to be crucial, crucial into what they're going to expect at the back end. If you tell them they're going to need three months of prescriptions, they're going to be asking for three months of prescriptions. How did your mom do? Excellent. She was healthy three months later. Yeah, about that. Perfect. What other questions you guys have? Yes, ma'am. So I think it's really important to reiterate the importance of we as practitioners policing our own and really getting our colleagues into treatment. I'm a program director in Connecticut. Many, many years ago, I had a student who had been suspected of using and diverting. And everyone in the operating room was kind of aware that there were things going on. But nobody said anything. And it wasn't brought to the attention of the program administration. And one day, she went into the bathroom. And when she left the bathroom, someone went into the stall that she had been in. And there were bloody alcohol wipes and syringes and things of that nature left there. And this was one of the nurses. And this was reported to pharmacy. And it was reported directly to the DEA. And the DEA came in. And the student was pulled out of clinical. And I went down with the student to meet the DEA agent. And I can't tell you what a frightening experience that was for me. And I was not on the hot seat. And this led to really an unbelievably horrible experience for the student. It was traumatic for us. And it really led to the end of a career that maybe didn't need to be derailed the way it was derailed. And it really left a huge impression upon me as a program director to never, ever let that happen again. Yeah. Thank you for sharing that. You know, when Regal was in the throes, if I knew then what I know now, I would have reported him right away. But I didn't know. I thought that he would end up in jail or he'd end up on the news. So I didn't speak up. But I would have reported him. Most states have alternative to discipline programs that you can call. And they can help you navigate through that. Because you're right. If you get the DEA involved or the police, sometimes it's a really hard path for this person to ever get back into any level of practice, and especially in health care. They're not the DEA. You are guilty until proven innocent. They do not come in there. I mean, they hammered this poor girl for three and a half hours trying to get her to admit to using. And it was just one that I left there. It was so traumatic for me as the program director. Because there was really nothing I could do. No one had ever brought this to our attention. We didn't know what was transpiring, what was going on. And it was just, that whole experience was just traumatic. Thank you for sharing that. It's going to help somebody. And that's what the goal is, to not let it get to that point if we can. Ask for help before the DEA is knocking at your door. Yes, ma'am? I think we've talked a lot of important topics about helping the addict. I'd like to say something about protecting the reporter. I've had an experience where it took a long time for me to ethically and morally come to the decision to report somebody. And what happened was, they didn't discipline her. And they told her that I reported her. And that became a really, I mean, it didn't change my philosophy or the fact that I would report. But it became a wake-up call to me that I had to protect myself in some way. Because she was using alcohol. I was the educator. And she would call me during the night at home, completely drunk, totally inebriated, to call in sick in the morning. Or she would come into the hospital. And people would tell me that she had been drinking. I reported it every single time. The final time I actually witnessed her come into the hospital during the night shift drinking, I called the police because I knew she was driving. I was disciplined. And she was not fired. So I just want to just kind of throw that out there. And I know that's kind of a shock and awe story. But I'm sure that that happens. It does. It does happen. Yeah. And so I'd like to just have you mention what's a safeguard for some medical reports. Well, the easiest thing here would be that you can just all throw it on Maria. And she'll take care of it. So she'll be the reporter. Any concerns, get funneled right to Maria. But this is something that's kind of transcended across the country. So you'll be happy to hear that in some states, like Tennessee in particular, they have a confidential reporting mechanism in place for their alternative to discipline program, not necessarily for their board. So if you suspect somebody is doing something, you call the alternative to discipline program. You say, yeah, hey, I think Claudia, she's acting a little bit goofy. They'll call Claudia in and say, we had a report. Come on in. We're going to do an evaluation. We're going to do a drug test. We're going to give you one opportunity. If you raise your hand and ask for help, it'll be non-punitive. We'll get you the help that you need. And it stays confidential, not anonymous. So they use that reporting, that confidential reporting, to see how many times you as the reporter are popping up. Like, wait a second here. She's called 15 times and 14 times was for her ex-husband. So maybe it's her that's the problem. So that's why they keep those numbers. So we just instituted that in Indiana as well. So Indiana now has it. Tennessee has it. I asked them in Tennessee when we were deciding how we're going to institute this mechanism, how many of them are frivolous claims? How many of these people that call in and you do the evaluation, it turns out to be nothing? And he said 90% of the time, they're right. 90%. 10% of the time, they're acting that way for a reason other than substance use or other than alcoholism or other than diversion. But 90% of the time, they put them right into the alternative program. So that same mechanism needs to start at the schools. Come and tell me. I'm not going to mention your name. And then from there, you can grow into state changes and national changes. But you're absolutely right. That's part of the reason why Claudia didn't ask for help. So she found the person that would. Well, she got to the point where she didn't care if I knew. She said, I'm going to let you know. But I'm back in anesthesia. We've both gotten back to the point now where we have to very, unfortunately, think about that. We know someone is using. What are going to be the implications to me if I tell on this person? But the good news is that that can change through policy at the very local level. At the schools, in the departments, you'll have some say in how that happens. But yeah, great point. Any other questions? Yes, Lynn. Quick one. That's terrific. Are there other learnings you've had from Parkdale for the students or the school faculty here that would be important for us to take home? Yeah, Parkdale, obviously, was built by nurses and CRNAs. And we have interfaced a lot in these cases where we serve as the reporter. So we'll give them one shot. So if you're a program director, you're a program director, and you call me and say, hey, I got this student. I'm not sure what to do with him. I said, give him a call. So us and the team on the intervention side, we'll call the student, try to appeal to a sense of common sense or her sense of common sense, give them the options, and have them come in to be non-punitive. And if they don't, we become the reporting agency on your behalf. So for everybody in this room who's looking for another option, that option is always going to be present. There's the contact information there. And we don't mind putting our name out there if it's going to mean saving someone's life or saving someone's career. And the good thing is that we have relationships with every state organization already, boards of nursing, and alternative to discipline programs. So that's just another option. If you guys don't feel comfortable as students talking to your program director, give us a call, and we'll help you out. Absolutely. Thank you, Lynn. Any other questions? I do have one more quick story that I'd like to share with you. And then we'll be around a little bit after this. If you guys have any other questions, please copy down our contact information. You never know when you're going to need it. You can save it as your phone as, I hope I never need to make this call. Save it like that. But save the numbers, because there's some time in your career you're going to need. And you're going to remember back to this day. So as I said, I was in the treatment center. And I had to be off work a year before I went back into practice. And I was so grateful for a lot of reasons when I got out. I had felt better than I had felt in a very long time. And Claudia stayed with me. And I felt pretty good about that, at least for the interim. And I said, I can't be off a year. What am I going to do with the bills? I'm the man of the house. I have to be the provider. And she said, don't worry about it. I got it. I'll take care of it. And I said, oh, man, that makes me feel even worse. But OK, it's still death to us part. I got you on this one. I said, all right. So month number two, and then three, and then four. I start doing the math. And I'm like, all right, savings is gone. 401k is gone. She's really kind of budgeted it down. But we should be out by now. So I asked her about month number four. Are you paying these? She said, well, I picked up a little extra. And I don't want you to worry about it. You're doing so well. And I'm so proud of you. Just keep doing what you're doing. And I felt really bad about that. So she picked up another job. And she was working two jobs, probably somewhere between 70 and 80 hours a week. And I felt horrible. So just shame-filled, even at that time. I remember she came home one day. And I was so proud to show off that I had cleaned the house. And I had washed the dishes. And the kids were like, and I said, I'm going to take care of these kids. And I'm going to babysit the heck out of them. And I'm going to. And she's like, they're your kids. You can't babysit your own kids. And I'm like, all right, all right. But I'm going to take care of them. Really good. Like that's called parenting. Parent your kids. I'll be the dad. I said, yeah, that. I'm going to do that really good. So I tried to do my part as best as I could. So now we're at number seven and eight. And I'm like, I'm chomping at the bit. I've got to get some applications out there. And I know no one's going to hire me. It's going to take a long time. And you've got to tell me. You've got to tell me where this money is coming from. Because it's not adding up. Even at 70, 80 hours a week, it's not adding up. And she just refused. She just locked down. She's like, I don't want to affect your sobriety. So now as an addict, we have these tendencies to catastrophize worst case scenarios. So now I'm like on Craigslist looking up her ad. I'm like, does she have an ad on Craigslist? Is that how she saw me? She's a pretty girl. You know what I'm saying? So she pulled it off. And so finally, it was like month number 10. And I'm like, I'm in tears. And my heart right now is racing because I'm thinking about that time. I'm like, you have to tell me. I can't go on. Where are we getting this money from to pay the bills? And everything was so smooth. We didn't miss a beat on anything. So she sits me down at the table. And she makes that deal, the deal you never like to hear, but everyone always takes. I'm going to tell you, but don't be mad. You got to promise not to be mad, right? You know you shouldn't take that deal, but you do anyway. So I did. I said, all right, whatever it is, I can handle it. So she sits me down. She holds my hand. And for some reason, she sat across the table from me instead of next to me. She wanted to look in my eyes, I think. And she said, I just want you to know that I sold the gold. The gold. We're Latinos. We have a lot of gold. But I start crying instantly. I'm like, the christening bracelets and the baptism bracelets. And she had this watch from her dad that they saved five years. So when she graduated college, she was the first college graduate on her entire side of the family. Everyone chipped in and bought her this gold watch. And I was just crushed, absolutely crushed. And I started crying inconsolably, not like the pretty Instagram cry, but like the ugly one with the mouth open, right? And I'm going on and on and on. And my lips are getting numb. And I'm like, I'm going to go to every pawn shop. And I got you, girl. I'm going to get all of it back. As soon as I get on my feet, I'm going to do all of this stuff for you. I promise. And I'm such a bad husband. I'll never let this happen again. So after about what seemed like three hours of doing that, she leans in forward. And she says, I sold your gold. I have all of my gold. It's a true story. I still have my gold. I still have my watch. Plastic bracelets now. But with that, it's been a pleasure to spend the afternoon with you guys. Thank you guys so much for your time. Thank you.

Rodrigo Garcia

Claudia Garcia

addiction

healthcare professionals

personal experiences

stigma

intervention

support

accessibility

necessity

disease

treatment

overcoming stigma