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Thriving with Addiction with Dr. Jonathan Avery
July 4th Alcohol Series: Moderation with Medication with Jonathan Hunt-Glassman
00:36:05
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- [00:00]
Dr. John Avery
Welcome to the Thriving With Addiction podcast where we explore how recovery is not just about surviving, but about truly living. Each week we'll dive into the science stories and strategies that help people and families heal from addiction and build healthier, more resilient lives. I'm your host, Dr. John Avery.
- [00:18]
Let's get started. I'm John Avery and welcome back to Thriving with Addiction. Today we're joined by Jonathan Hunt Glassman. Jonathan is the co founder and CEO of OR Health. OR Health is a telehealth platform that helps people get started with medication to drink less or quit and provides ongoing support as they work toward their goals. Jonathan started the business after benefiting himself from treatment with medication for alcohol use disorder. Before founding or, Jonathan worked in healthcare as a product and strategy leader at Humana, Optum and Bain and company. Jonathan, welcome.
- [01:00]
Jonathan Hunt Glassman
It's great to be here. Thank you.
- [01:01]
Dr. John Avery
You also are, I'll say, one of the nicest guys in the business. I've had the opportunity to get to know you over these past few months and talk on a panel with you recently. I really appreciate you and the thoughtfulness that you bring to this topic.
- [01:14]
Jonathan Hunt Glassman
Well, that means a lot coming from you because I think you could be described the same way, but I think
- [01:20]
Dr. John Avery
that thoughtfulness comes from your personal experience. Like this founding or know came from your. Your own experiences. So let's start there. Tell us a little bit about yourself and, and your journey.
- [01:32]
Jonathan Hunt Glassman
Yeah. Well, as you summarized, I had a fairly traditional career in healthcare, but even as I was working on issues quite adjacent to addiction, I was struggling with it myself. In regard to alcohol, what started as binge drinking in high school and college became a pattern of drinking to blackout in my 20s. And, and then as I saw peers in our 30s start to put that sort of excessive alcohol use behind them, the opposite was happening for me. I was starting to have multi day binges and experience withdrawal symptoms, both mental health and physical on the back end of those. So things were pretty rough.
- [02:16]
Dr. John Avery
And what's your sense of why the drinking developed for you over time? Was that something that was in your family growing up or in your peer culture? What was it that do you think got you started in that way?
- [02:27]
Jonathan Hunt Glassman
Definitely in the peer culture in high school and college for drinking to excess to be almost part of some social rituals. But of course there are plenty of peers who didn't develop alcohol use disorder as I did. I think alcohol kind of fit me a bit like a lock and a key in two ways. One is that it allayed social anxiety, which I struggled with and heightened social connection. And then secondly was just a way of letting go of stress and pressures, both real and imagined. I've always struggled to kind of relax or be mindful. And at least in the moment, alcohol kind of somewhat seductively felt like it was providing that even if in the long run it ended up being not so great for my mental health.
- [03:27]
Dr. John Avery
And you would go periods without drinking and then periods with drinking a lot. How did things develop over time in that way?
- [03:36]
Jonathan Hunt Glassman
The pattern of excessive bidded drinking was fairly consistent. I wasn't drinking every day really at any point, and there were periods of time where I cut back meaningfully. But whether it was once a week or once a month, my main problem was that in certain settings, in certain states of mind, one drink felt good and so I wanted two. Two felt great, and pretty soon I wanted as many as I could get my hands on as quickly as possible. And I was kind of on that runaway train to blacking out, making bad decisions, feeling regret and shame the next day, and sure, kind of resolving to do better, or coming up with little rules, or seeking various forms of treatment, but always backsliding to that main binge drinking problem.
- [04:32]
Dr. John Avery
And after you hit a certain number of drinks, did it feel like it sort of just got out of control or how did it escalate from sort of two to many?
- [04:41]
Jonathan Hunt Glassman
Yeah, it felt great in the moment, which was the problem in that somewhere around if I were to say 3, 4, 5, 6, so getting into some heavy drinking totals that would often just feel so great that I felt what I think you could describe as a compulsion, something I didn't have control over, to drink more to encourage those around me to drink more as kind of a social bonding ritual. But if they didn't want to, I was going to keep going anyway. It just felt so great that I was compelled to drink more and more. I think you could compare it to, you know, being in a pleasurable sexual act. Like you're not going to, you're not going to stop. Assess, like at a certain point with alcohol, I just wanted to keep going.
- [05:36]
Dr. John Avery
Right. I think that's, that's well said. And I think people who haven't experienced that sometimes can't understand why people keep drinking in a binge way. And we're understanding that more and more people binge than, than commonly we recognize as their main issue with, with alcohol. And it really just takes over in a way that's just very hard to stop and, but you eventually knew you needed to stop. So tell me how, how Things transpired in your 30s when you realized you, you needed to, to curb this. What did you try?
- [06:05]
Jonathan Hunt Glassman
Yeah, I tried even Starting in my 20s, I, I tried a lot of places because, you know, one of the, one of the things that I think a lot of us binge drinkers experience is regret, reflection, a desire to change on the back end of those, because you feel physically, mentally, you know, terrible and, and want something different. And so over time, I, you know, tried a lot of the options that first come to mind. Attended Alcoholics Anonymous meetings, did individual psychotherapy, asked a primary care provider for help, ended up in the emergency department a few times for alcohol related issues. And each of those was helpful in their own way and certainly gave me tools and approaches that I still use. But none of them put too much of a dent in the drinking. None of them put a stop to that pattern of getting back to binges I couldn't control.
- [07:01]
Dr. John Avery
I see. And what was it that finally clicked things to a better place for you?
- [07:07]
Jonathan Hunt Glassman
It was yet another attempt. I had the good fortune to connect with a primary care physician who did a few things differently than I'd experienced so far. First, he listened to what I was telling him with a very non judgmental approach, in his words, but equally importantly, on his face, kind of like the look on your face as we talk today. Secondly, he accepted my goal of moderation rather than sobriety and was willing to work with it. And then third, he suggested prescription medication as a tool in the toolkit that might help me achieve that goal. And although I had a vague sense that maybe there was some sort of medication for helping people quit drinking, I didn't know much about it. And so it was an eye opener and it ended up being really effective for me.
- [08:05]
Dr. John Avery
And that medication was naltrexone, I believe, right?
- [08:09]
Jonathan Hunt Glassman
That's exactly right. So I got an naltrexone prescription after that visit. Did sit on my shelf for a month or so. But once I got over the hurdle of starting, had great results. I was able to have a drink, feel some of the relaxation effect, but not feel the same urge for a second. And if I did have a second, in the circumstances I was in, I usually drank it slower, not faster, which had been the experience before, and was able to just stop short of that 3, 4, 5, 6 range that we were talking about earlier that I knew from experience was where things went from in control to out of control. And of course, I supplemented this with some, you know, specific goals and new strategies. No more shots. But the medication was the Real game changer.
- [09:06]
Dr. John Avery
So it felt like whereas before things were out of control or we just had to keep escalating it, it felt like you were sort of satiated at almost a lower dose of the drinking. Is that right?
- [09:15]
Jonathan Hunt Glassman
Exactly. It just wasn't as exciting, appealing, and it certainly wasn't a necessity. I still remember the first time I, like, left a bar and looked back and saw, gee, 2/3 of my beer, which is probably my second beer. Two thirds of my second beer was sitting on the table. And that may sound normal to some people listening, but nothing could be more atypical for me. I was probably more likely to finish somebody else's beer than to leave mine behind. It was just as you said, a lower dose of alcohol was sufficient. And I wasn't craving or seeking or really doing whatever it took to get that higher and higher dose.
- [10:01]
Dr. John Avery
And as you mentioned, you had tried 12 step. You had tried therapy. I'm sure people in your life were a little concerned about drinking. Tell me how people felt with the goal of you moderating and using medication versus being abstinent, given the troubles that it had caused you.
- [10:20]
Jonathan Hunt Glassman
Overall, the folks in my life were supportive, which I think speaks well of them. They were mainly happy I was doing something. One of my concerns, starting treatment, any form of treatment, was how friends and family would react when I told them that I felt like I needed to drink less. And it wasn't as much of a surprise or secret to them as possible. And I think they, you know, whether whatever they thought, you know, did something right in kind of supporting a step in the right direction. And if they had worries about the goal of moderation, which are not unreasonable, they more or less kept them to themselves.
- [11:09]
Dr. John Avery
I see. And when you were in the 12 step rooms, presumably you heard a lot about abstinence and were told abstinence should be your goal. And that didn't resonate for you as much?
- [11:20]
Jonathan Hunt Glassman
No, it never fit. I tried it and it never fit. And while I would never discourage someone from the goal of abstinence, given that probably the safest level of alcohol use for any of us, you would know better than I. The reality was alcohol was and is present in a lot of my life social situations, it is part of social relationships that I continue to value. And I just wasn't willing to give that up. And one could view that as a bad decision, as a risky decision. I respect that point of view. But what I was looking for was a path that allowed me to address my very real alcohol problem. And at the same time, not disrupt some of the relationships and social rituals that were important to me.
- [12:24]
Dr. John Avery
And so the medication helped. And you also put some rules in place. Tell me what sort of moderation rules you had for yourself.
- [12:32]
Jonathan Hunt Glassman
Yeah, I've. Everyone's, you know, are going to differ a little bit. But I think, you know, one of the things I thought about was like, gee, moderation can be a slippery goal. That was obvious to me. And I was worried that, you know, it would just kind of be another backslide. And so I set some specific goals and strategies. I drew a bright line around no more blackouts. That had always been where I'd had the worst experiences. They're dangerous in and of themselves, but also where I'd ended up acting in ways that I really regretted and making even more engaging in risky behaviors. And so that was my bright line goal. And then to get there, adopted some common sense strategies. I mentioned no more shots before,
- [13:26]
Dr. John Avery
no
- [13:26]
Jonathan Hunt Glassman
more than one drink, before eating something substantial. And then enlisted my wife in places we were present together as a little bit of reality check, early warning system, and just kind of asked her to let me know if she felt like I was starting to get too close to a danger zone or drinking too much. And what I found is even with the benefit of the medication, there were and are certain situations that are a little more challenging. The environment still kind of matters. And so particularly in situations where drinking is kind of the main event. So a New Year's Eve party or a birthday party that is slated to go from 2pm to 2am in those sorts of situations, those sort of complementary strategies end up being really important.
- [14:24]
Dr. John Avery
And, you know, I've been doing the podcast for about six months now, and about every other week is someone telling their recovery story. And all those recovery stories to date have been people who have been abstinent because they're the stories that are most out there in the world that people have stopped using and they share their story. It's almost part of 12 step tradition to share your story forward. What I struggle with is finding people that have entered recovery through moderation at times. It's not a crowd. When even when my patients are trying to get to moderation, it's hard to point to other people that they know or that are in popular media that have entered recovery through moderation. Did you feel alone with it or did you know other people? It sounds like you sort of just got lucky with this primary care doctor but weren't getting that story anywhere else.
- [15:10]
Jonathan Hunt Glassman
That's right. And that is something that we try to Change a bit in working with our members at OR Health is to get more moderation stories out there and to allow just more broadly a broader diversity of recovery or improvement stories to be told. I do think we have a narrow, culturally received story of what recovery looks like that's replicated again and again and again in television and movies. It's not very original. When we can all picture the scenes. We all know what I'm talking about. The person, you know, person shot from behind, walking into the room with the chairs in a semicircle, and then from rock bottom. It just gets better and better. And look, that's a real story for sure. But there are also stories of people using a different set of tools to achieve their goals. And there are stories of different goals. I felt like I had some clarity that moderation was my goal. But I talked to others who are at various stages of this process. It can be a real question in their minds if, you know, they kind of feel some of the things I was feeling. I know I need to drink less. I'm not ready for sobriety. Sometimes it does come out as a question which is like, is that possible? Is that okay? And while no particular approach is going to work 100% of the time for anybody, I think we can bring more people into recovery journeys if we accurately represent the diversity of what recovery looks like.
- [16:57]
Dr. John Avery
Right? No, I think that's spot on. And what did you learn as you made your way into recovery? About how many other people were out there who entered moderation through drinking or used meds like naltrexone. It seems like you then discovered that you weren't alone. There was this. A tool that more people should have. And then you made your way to creating a company that gave this tool to folks. So talk to me a little bit about that discovery process and how it led to aura.
- [17:24]
Jonathan Hunt Glassman
Yeah, totally. So I. Yeah, this was all. This was all happening for me. It was the era where we were just starting to see commercials on TV for hair loss or erectile dysfunction medications that one could get started with from the privacy of their own home via telehealth. And it just kind of struck me. Huh? This medication that's been so helpful to me that I had never heard of, despite being a pretty informed healthcare consumer, could probably be prescribed the the same way like hair loss and erectile dysfunction. You don't need a physical exam to know that there's an issue. But that was just an idea. And got some advice from folks who were experienced in starting new businesses. But one of the most important things you need to do is figure out, is there anybody else like you who might want this? And what was really helpful to me was on Reddit and other forums for where people self organize around all sorts of interests and pursuits, there were small but very passionate groups of people who were exploring pathways to recovery other than sobriety, other than aa, and even specifically around medication. Alcoholism, underscore medication is the subreddit, if I remember correctly. And it was just amazing reading the stories there. And then, you know, interacting with some individuals from that subreddit who had many similarities in their experience to mine. Typically a problem that had gone on for years, that they were aware of for years and sought help for in many ways that they were finding or had found medication to be a really helpful tool in and had some of the same reflections and passion that I did around, gee, I had to wait five or 10 or 15 years to find this tool that fit me. It should be shorter for somebody else. And that sort of, even if it's small, that sort of existence of a authentic community that represents real need and that has passion around a solution, it's really exactly the sort of thing you're looking for when you are considering starting a business in that it suggests there might actually be customers for that business.
- [20:02]
Dr. John Avery
Right.
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And how did you settle on this
- [20:06]
virtual platform to do it? Which I think is so key because I think what you're describing earlier being sort of relieved that the primary care doctor had a friendly face. My research is on this stigma of addiction that exists among healthcare providers. And it shows that, that we don't often have friendly faces when people come in with drinking and people don't feel like they can come to a provider. So I think deciding on it, being virtual was just so key to getting this meta into more people's hands who have previously felt stigma from healthcare providers.
- [20:36]
Jonathan Hunt Glassman
Yeah, that is definitely a theme that as I started talking to more folks in this situation, or folks who are struggling with alcohol use and hadn't found yet the solution that worked for them, a few themes emerged. One was trepidation about discussing with their primary care doctor if they were connected to primary care. The second was motivation, waxing and waning. And this is a undermining of another narrative in our culture that things just get worse and worse and worse until you hit rock bottom. You have a quasi religious or religious experience at rock bottom, and then things get better and better and better. Most of the people I talked to, they knew in the background they had an issue. Sometimes they were ready to Deal with it. Sometimes they weren't. Telehealth felt like a really good fit for that too, in that you could get started at 7am from your couch on a Sunday morning if you'd had a particularly tough experience the night before. And then the third thing that I was surprised to learn more so from the first doctors that I started speaking with about this was that as much of your research touches on the level of expertise, comfort, confidence in treating alcohol use disorder, in prescribing the approved medications is not as high as one might guess given the prevalence of the condition. And so telehealth also felt like a way to round up in one place clinicians with training and passion around this topic, so that when folks did reach out in that moment of need, they could have confidence they were going to connect with somebody who was ready to discuss the healthcare concern that they had and ready to offer evidence based options.
- [22:38]
Dr. John Avery
Right now. That's great. That or health can meet people sort of where they're at, wherever they are in their journey, and then prescribe naltrexone. And we sort of describe naltrexone as a moderation med, but it's also for people that want to be abstinent as well and can also be a part of that classic journey where people hit rock bottom and then want to stay abstinent. And so tell me a little bit about what kind of clients you see at or and how naltrexone is used by different groups.
- [23:07]
Jonathan Hunt Glassman
Totally. So about 2/3 of our members have a goal of moderation at outset, about one third sobriety. We've done some surveys as of others of kind of a general population. And among those who want to be drinking less, the goal maps pretty closely that 2/3 seeking moderation, they tell us one third seeking sobriety. So in that regard we do feel like we're meeting people very much where they are in terms of why they're here, why they're reaching out for help. Those, those goals do evolve over time in both directions. We have folks who start out with a goal of moderation and then either because they like the results so much, or because moderation is proving unsustainable, unrealistic, migrate to a goal of sobriety. I think that's terrific. And then we also have examples of other members who start with a 30 or 60 or 90 day period of sobriety and then over time find that they are able to have a drink selectively or in moderation. I never counsel people in the direction of more drinking. We counsel people in the direction of less drinking less. But in the real world, people's stories are way more complex than what we can write down or tell them to do.
- [24:33]
Dr. John Avery
Tell us the experience of going to or health. What is that like for someone?
- [24:37]
Jonathan Hunt Glassman
We try to make it a simple place to get started with ongoing support in the moments that matter throughout the journey. So at the outset folks can learn about alcohol use disorder and medication assisted treatment. We don't consider those to be household names. If it feels like a fit for them and their goals, they can consult with a doctor or nurse practitioner licensed in their state, get a diagnosis, a treatment plan, and if appropriate, a prescription for an Altrexa. The medication gets shipped directly to their home in discreet packaging and then we provide a set of support tools that are available to folks not on a schedule but in the moments that they find most helpful. So that includes tracking progress through digital check ins with dynamic feedback, ongoing access to the medical team for follow up questions, dosage adjustments, side effect management, one on one coaching from licensed counselors, and some peer connection and support opportunities as well. We really encourage each member to mix and match the supports that fit them. Taking naltrexone to drink less is something that unites all of our members, but what those complementary tools are vary. Sometimes they're the tools we provide directly that I just described. Sometimes it's adding on tools like AA, other 12 step programs, non 12 step mutual peer support, individual psychotherapy, or even things that I don't think we'd call healthcare but that can be very therapeutic in their own way. I'm thinking of things like exercise, community service, gathering with friends, family, people in our community in ways that don't revolve around alcohol. Just as the goals of treatment can be flexible, the toolkit that helps someone achieve them varies so much individual to individual, at least in my experience. I don't know about you.
- [26:42]
Dr. John Avery
Yeah, no, I agree completely. And I wrote an American Journal Psychiatry article saying that naltrexone is the most under prescribed med in medicine. I think it was the GLP medication before there were GLP and much better tolerated and accessible and flexible in the dosing use for opioid use disorder. We talked about it in a earlier podcast with Ben Westoff on the most under prescribed medicine. I feel like all this education is needed, including the work you're doing because a lot of people do still have some concerns though about naltrexone or get into different subreddits talking about some of the side effects. Are there any concerns about being on NALTREXONE as much as we're plugging it.
- [27:25]
Jonathan Hunt Glassman
Of course, all medications, like all forms of treatment, have potential benefits and concerns. I think it's fair to say we both think for most people the benefits are likely to outweigh the concerns. But there are certainly things to be aware of. The most common side effects are nausea, headache, fatigue. We see that in our members most frequently in the first week or two as they adjust. Sometimes they can dissipate, even if fairly strong at the outset. And we do focus a fair amount of our support and coaching around those first few weeks. A lot of it is common sense strategies, maybe starting with a half dose and working one's way up, taking with food and water, not taking that first dose dose right before you're walking into a high stakes meeting or getting in the car. And then beyond the side effects, the most important safety concern is that it cannot be combined with opioids of any sort. We see that most commonly in members who are taking a prescribed opioid based painkiller. They're just not candidates for treatment with naltrexone. And then lastly, the third category of concerns that I think we hear, but try to push back on a little bit, is the notion that this is replacing one drug with another. I think it's kind of unfortunate that in English we use the same word drug for really damaging destructive substances like alcohol and safe, effective medications like naltrexone. Unlike some medications that are used and useful in addiction, naltrexone does not build physical dependence. It's not subject to abuse. You don't get high off it, basically. And so it's never struck me as particularly coherent to think of it as a drug that's replacing alcohol. It's more so, in my mind, a tool to move away from destructive and damaging drugs.
- [29:38]
Dr. John Avery
Right.
- [29:39]
And then sometimes people hear us talk about it and they think it will be a magic pill. And for some it is, but for most it helps a little bit and allows them to do all those other things you were mentioning in terms of healthier living, the exercise, the connecting with peers, and being able to set the goals and actually follow through with the goals, which I think is an important part of using naltrexone as well, is to combine it with everything else.
- [30:06]
Jonathan Hunt Glassman
Yeah, that's definitely been our experience, is that if we think of the broad population of people who take naltrexone, not as broad as we'd like, but all the people who take naltrexone, and that's up to more than 50,000 through. Or there are small groups at the tail ends of the distribution who would, on the one hand describe it as a magic pill, which is wonderful for them, or at the other end, who, you know, take it quite faithfully and try their best and really just don't notice any difference whatsoever in their experiences with alcohol. And then most people fall in between where it makes a meaningful, noticeable difference but doesn't do all the work. And that's kind of somehow sometimes how I describe it to folks who are thinking about starting with naltrexone is that our hope is that this does some work biochemically. It just makes it a little easier to achieve the goals, achieve the sobriety or moderation targets that in most cases individuals have been trying really, really, really hard on on their own. And in many cases, not all. Naltrexone ends up being that little helper that just makes it a little easier to achieve those goals. And even that nudge, even that booster can be really transformative in people's lives.
- [31:29]
Dr. John Avery
Yeah, and you and I were talking before we start that it would be nice, and hopefully we'll accomplish this with time to know which individuals will have a more robust response to naltrexone versus other interventions and be able to understand exactly each individual's genetic profile, neurocircuitry profile, and we can say, oh, you use naltrexone, it'll help this amount. We hope to get there with time. And there's certain genes that have been studied that may indicate who's more responsive or not. But for now, it sounds like everyone, I believe everyone who's struggling with drinking and doesn't know where to turn, It's a pretty good first step to try to moderate. If that's where you're at with Med Lake, naltrexone and super safe, I certainly
- [32:13]
Jonathan Hunt Glassman
can't argue with that. But I do have a question for you along these lines, which is if you were to look into your crystal ball, is it within our lifetimes that we'd kind of be able to a little more precisely do some diagnostics, whether biomarkers or more psychological in nature, and steer people towards naltrexone versus GLP1s versus the other approved medications versus agents in the pipeline. We're about the same age, I think. Do you think we're going to see that or are we going to be kind of naltrexone going to be the right starting point for the rest of our careers?
- [32:53]
Dr. John Avery
I don't know. I mean, that's sort of been the hope for psychiatric conditions and for conditions in addiction that we will be able to be more targeted, but I'm not sure we'll get there. Maybe it still requires so much trial and error for depression, anxiety and alcohol use. And I think there's hope. But the brain, unfortunately our understanding of the brain is way behind our understanding of the rest of the body in terms of how we can make targeted interventions. Maybe. And that would be the hope. But yeah, I'm not sure in our lifetime, to be honest.
- [33:30]
Jonathan Hunt Glassman
I appreciate the honesty. Gotta have some hope. No matter what.
- [33:35]
Dr. John Avery
You give me hope. I mean, you've made such a great leap. It must have been anxiety provoking to jump from sort of traditional healthcare roles to doing the startup. But it feels like think it's led to a better life for you overall.
- [33:50]
Jonathan Hunt Glassman
That's certainly fair to say on all counts there is a little bit of psychological growth required to deal with the uncertainty in starting a new thing, in putting on pause a more traditional career trajectory that I found a great deal of satisfaction in. But like most new experiences, leading a small company has brought intellectual growth and emotional growth opportunities and has also brought me much closer to the individuals in recovery than I think ever would have been possible at a massive health insurance and services company. And that is a enduring source of energy and motivation is hearing people's stories. Certainly the success stories and the ways in which medication and other effective tools have changed their lives. But also, quite frankly, the stories that are in progress, imperfect, or in moments of struggle. Those are great motivation to keep going too, both in terms of helping to understand the nature of addiction so that we can develop more options and where we focus the most at or which is increasing access to the best available tools that we have today.
- [35:21]
Dr. John Avery
Well, Jonathan, you're great. OR Health is a fantastic resource for anyone that's struggling with drinking and wants to explore different options. And I really appreciate you coming on and sharing your story and telling us about OR Health Today.
- [35:35]
Jonathan Hunt Glassman
Thanks so much for having me. Really nice talking with you.
- [35:38]
Dr. John Avery
Thanks for listening to the Thriving With Addiction podcast. If you found today's episode helpful, please follow and subscribe wherever you listen to your podcasts and share it with someone who might benefit. You can also connect with me on Instagram, LinkedIn and YouTube or visit thrivingwithaddiction.com to learn more. Stay tuned for next week's episode and remember, thriving is possible.