Treating Chronic Pain: A podcast for therapists

Episode 88

Treating chronic pain is difficult on a good day. After the over-prescribing of opiates in the 90’s and early 2000’s, it’s become more challenging. Opiates used to be the treatment of choice, but the medical community has more research and information that show that this can’t continue. In fact the prescribing of these medications has dropped significantly since around 2010. The influx of heroin came right afterwards as there were scores of people in deep withdrawal from opiates. This also left people without treatment for their chronic pain. We will talk about this in today’s episode as well as what our role might be with our clients experiencing chronic pain.

Transcript

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 86. Last week, we started talking about marijuana and we addressed a number of things and today we’re just continuing that conversation. I’ve seen lots of questions online in groups and people who’ve reached out to me with specific questions. So I’m going to be answering more of those in today’s podcast.

Welcome back to the All Things Substance podcast. This is episode 88. Today we’re talking about chronic pain and treating it with opiates and without. I was asked some questions by some listeners regarding treating chronic pain. We all are well aware of the opiate crisis across the United States and I’m sure that it’s happening in other countries as well. Because opiates became super popular in the eighties and nineties for treating pain. The problem now is that we’ve got a bunch of people who have chronic pain and we need to treat pain effectively.

So the question was what can be done to treat chronic pain other than opiates. Another was what happens when somebody is addicted to opiates, but still has chronic pain.

There are a number of things that cause pain and usually it’s the kind of thing that over a period of time can be alleviated as the injury or as the condition is treated. The problem is when pain sticks around. Chronic pain is something that people live with. It’s an everyday thing where the pain goes up and down and there are lots of conditions that cause pain.

For the most part, people are able to treat their pain over the counter. When we have surgery or a procedure, we might have a prescription pain medication, but it’s usually pretty short-lived. Pain is something that is difficult because it’s not visually assessed. It is completely subjective. Because of that, it depends on the person’s ability to describe what’s happening, to advocate for themselves and to have a provider who believes them and is willing to treat the pain at the level that the patient says it is. Prescribers and patients are in a very difficult situation.

A little background on our treatment of pain. For the most part it’s opiate based drugs that have been used to treat pain. I did three episodes on opiates back in episode 23, 24 and 25. If you’re interested in more information, that’s going to have a lot of background history, discussion about heroin and medication assisted treatment.

For our purposes today, there are three types of opioids. Synthetic opiates, semi-synthetic opiates and opiates themselves. Natural opiates are things like morphine and codeine. Synthetic opiates are things like Demerol, Ultram, Tramadol, fentanyl, and levophorphenol. The semi-synthetic opioids, which are created in the lab, but from naturally occurring opiates are things like Dilauded or Percocet, otherwise known as oxycodone or Oxycontin.

What was happening in the mid nineties was, there was a movement about being pain free. There were prescribers who were being sued for not treating pain effectively. There was a lot of pressure on prescribers to treat pain and to not be stingy, I guess would be the word with pain medications. In the mid nineties, specifically ‘95 Oxycontin hit the market.

Oxycontin is oxycodone or Percocet, but it is designed in a 12 hour release. Oxycontin, as we’ve seen in the news, did some really shady shit in their marketing and basically straight up told prescribers that Oxycontin in its new formulation was not addictive. They’re paying for that in some ways, but litigation is still ongoing.

What started happening is that prescribers were getting direction from reputable sources in their professional spheres, encouraging them to make sure they’re treating pain. Pain became like the fifth vital sign. Where patients were being asked at every turn, what their pain was at even if that wasn’t why they were coming to the doctor to begin with.

At first, it sounds like a good idea. Treat people’s pain as though it’s real and treat them so that they can be pain-free. It would be lovely if people could be physically pain-free. Unfortunately opiates are not the way to do that and currently we don’t have a way to make that happen.

So I want to give you a basic structure of what we’re talking about when we’re talking about opiates, in terms of potency. When you talk with people who are using opiates or abusing them, there is a hierarchy of potency where some of the pills on the lower end don’t work anymore and they have to keep moving upwards and there’s a reason for that, that we’ll get to.

So think about over the counter pain medications like Tylenol or acetaminophen being the base level. Right above Tylenol is Tramadol. Tramadol is a fully synthetic opioid, but with a much lower potency. In fact, it wasn’t considered an opiate or a controlled substance until about 10 years ago.

There were people who are receiving a ton of Tramadol every month. I recall working with a person who had gone to treatment for opiate addiction, but was still taking 85 Tramadol a month. When I asked her what this was for, she told me that it was for occasional lower back pain. That much Tramadol a month is to get high.

Above Tramadol is Demerol, which was the first synthetic opiate to reach the market. Above that is codeine or what we call Tylenol three. Above that in potency is hydrocodone called Lortab or Vicodin. Above that is morphine. Next up is oxycodone and examples are Percocet or Oxycontin.

Above that is methadone. Methadone is often associated with heroin use as a replacement medication or a medication assisted treatment option, but originally it was used to treat pain and in some cases still. After methadone is a medication called Opana. Opana was on the market for a short period of time, but was removed due to opioid deaths because of the potency of the medication.

Above Opana is a hydromorphone known as Dilaudid. Above that. We have heroin above that we have fentanyl and above that we have carfentanil. From Tylenol all the way up to fentanyl these are compounds that are used to treat pain.

There was a Wall Street Journal article in the early two thousands that talked about a guide that was put out by the Joint Commission. The article stated that the Joint Commission were quoted as saying, “some clinicians have inaccurate and exaggerated concerns about addiction, tolerance, and risk of death. This attitude prevails despite the fact that there is no evidence that addiction is a significant issue when persons are given opioids for pain control.

We cannot place the blame on doctors. This is the kind of stuff that they were getting in even if they were hesitant, consumers are powerful. It takes a phone call to the board , to report a complaint. We know how careful we are with our licenses. Prescribers are the same. If you get in trouble for something and they pull your license, you’re done. Even if you have the degree in all the experience, if you can’t prescribe you, can’t work.

There are some basic problems with treating pain with opiates. One is that long-term use leads to tolerance and physical dependence. Long-term use and physical dependence leads to hyperalgesia, which is an increased sensitivity to pain.

Opiates are a godsend when you have pain from an injury, a surgery, something like that. I am really careful with those kinds of medications, based on my history, I did have them after I had hip surgery and I remember the relief from pain when I would feel it wash through my body.

It was as though someone had poured cooling liquid on a hot fire, and I could just feel the pain receding. It is powerful. When people are taking opiates for pain from an injury or surgery, that’s a short-term deal. They typically don’t get into tolerance and dependence and they also don’t have the hyperalgesia problems.

The problem comes with chronic pain. When someone is taking, say, Tramadol, that’s the lowest potency level opiate. While eventually when you’re up to 85 Tramadol a month, that’s not working and the pain is feeling bigger than it used to. Well, that is because there is a thing called hyperalgesia. It is darkly ironic that a pain pill can cause you to be more sensitive to pain. So that your pain tolerance actually goes down.

There is a rewiring of the brain that happens when someone is taking opiates on a consistent basis to the point that their body becomes dependent. When someone is taking enough of a particular opiate, and it’s not working they need to go up in dose or change medications entirely. That’s how we get from going from Tramadol to Lortab, to hydromorphone and on and on. Eventually you get to the top, which is Oxycontin or fentanyl, and even that’s not working. By that point.

Your body is completely dependent on opiates. I’ve talked about this in numerous episodes. If you haven’t heard them, please go back and listen to them because I feel like we need to really understand where the opiate thing is coming from. Because that is the first time that we started seeing people addicted to a substance who had never had problematic use history before. They might’ve been a normal drinker or never a drinker, got an injury, got some pain pills. And all of a sudden they’re in a world of trouble.

The complicating factor about all of this is not just the hypersensitivity to pain. It is that the withdrawal, even if you’re not abusing them, even if you’re taking these pills as prescribed, the withdrawal is the most excruciating thing that can be experienced, that we are aware of.

It is like your bones being on fire and breaking inside your body while every single nerve in your body hurts and the kind of body pain and ache that is unbearable. So even a person who is really committed to getting off of opiates, helping their brain rewire itself so that they can treat pain without it. They often don’t make it through the withdrawal because of how terrible it is.

Not to mention that once the physical withdrawal is over, which can take quite a while, including protracted withdrawal, then there are the physical cravings because the opiate receptors are loud for lack of a better word. They yell. They want that there. From 1995 to about 2010. The number of prescriptions in the United States for opiates is staggering. We started having average people who had no use history being addicted. We had people dying from overdoses. We still have people dying from overdoses.

In the United States from 95 to 2010. We had an incredible amount of opiates being prescribed. There were pill mills they called them. Places where doctors would accept cash for a prescription or people would be getting them from chronic pain clinics that are just running them through. Then there were prescribers who were prescribing what they thought they were supposed to, and they wanted to help people and they didn’t want their patients to feel pain. So we had an epidemic on our hands.

What started happening across the United States is a crackdown on prescribing. So all of a sudden you have a ton of patients who are physically dependent on the opiates that are prescribed. And all of a sudden the information’s coming out about overdose and addiction and tolerance and death. And the prescribers pulled back and they pulled back hard. The pills dried up. I remember it happening in the area where I live. All of a sudden people couldn’t get pills. And then we started having heroin.

In 2012, our local police department said that heroin was so rare that when they got it, the officers would want to see it so they could look at it. That’s because heroin wasn’t in our smaller city. In 2014, we were number three in the state for submissions to the crime lab per capita. That is because of the pills. All of a sudden they dried up and you got a ton of people who are in an incredible amount of pain with no access to pain medications and they’ve been taking them for 15 years. Now what are they supposed to do?

And the doctors didn’t know quite what to do either, because all they knew is people couldn’t be on opiates forever. And so the people who were on opiates forever couldn’t have them anymore. I’m sure that many of you saw this happen and that you’ve had clients who struggled with this, who got cut off of their medications.

Then in addition to that any of the medications that have any kind of addiction potential got pulled back as well. And so the benzodiazepine started getting pulled back. I’m not saying they shouldn’t have been pulled back or that they should have. What I’m saying is all of a sudden we had clients who had been on four milligrams of Klonopin for 10 years and all of a sudden their doctor’s saying that they have to go off.

The withdrawal from benzodiazepines, specifically from Klonopin is super bad. Like incredibly bad. We had a bunch of highly anxious people who were taking these benzodiazepines on a daily basis just to function. It didn’t really help their anxiety anymore, but without having it, they were in total panic.

The withdrawal can last sometimes like six months until they feel better. It is also an incredibly dangerous withdrawal. In the episodes about substances, I say a lot that there are two withdrawals that have a risk of killing you. One of them is alcohol withdrawal and the other is benzodiazepine withdrawal. Heroin, and opiate withdrawal makes people want to die but typically isn’t the thing that’s going to kill them.

So we’re at this place where we have clients who come in, who have chronic pain that is not being well-treated. Many people that you would never suspect are buying pills from neighbors, friends, or even off the street so to speak.

I remember working with a client who didn’t really realize she was addicted. She had a quote friend who was giving her medication for money. The first time I referred to him as a dealer, she was really taken aback. She called them her friend, but they never hung out. They didn’t talk unless it was for her to pick up pills from him and it just hadn’t occurred to her. But she needed these pills to get through the day. She couldn’t get out of the house without them. She wasn’t crushing and snorting them. She wasn’t shooting them up. Taking them in pill form.

When these people show up in therapy now we are faced with first of all, what is their use level? Second, where are they at with it? Do they want to get off of those pills? And thirdly, then how do they treat chronic pain?

Getting clear of opiates is possible. It is possible to deal with pain without opiates and to help the brain rewire itself. Even after years of opiate use. It is difficult and the idea that we should be pain free as a species isn’t realistic. There is a level of pain that many people just live with.

People who have migraines all the time, or people who have arthritis. They have to live with a certain level of pain. And they will tell you that there is a level of pain that they can ignore and then there is a level where it gets above. For myself, I’m prone to headaches and I really don’t take anything unless my pain is over five. Because if I did, I kind of be taking things a lot and I can ignore it pretty much if it’s under a five. My husband is of the opinion that my pain tolerance is off the charts, but I don’t know that to be true. It’s just how I experience pain.

The first part of what we’ll talk about here is what to do if somebody is addicted to opiates and still has chronic pain. The very first thing I would do if somebody was prescribed opiates or taking them is find out exactly how they’re taking them.

This is a little bit like when we do an evaluation of somebody as depression or anxiety. When were they first prescribed them? What was it for? How are they taking them then? What was the longest that they were without. When did they have to move from whatever the medication was, say, from Lortabs to oxycodone because the Lortab wasn’t working anymore. Find out the progression, find out if they feel like they started taking it a little more often than they should have. Which is super common.

Pain is scary. When you get relief from staggering pain, there are a lot of things you will do to keep from having that pain again. Once the pain happens, it can be hard to bring it back down and so the idea is not to let pain get to that level. It’s kind of the same thing as anxiety. Our goal is to keep anxiety low enough, rather than letting it get to a panic level because getting panic back down to an average level of anxiety takes a lot. So prevention is the key.

Finding out how they were taking pills and when it started stepping over into more complicated use. A lot of times, what people would have to do is get multiple prescriptions from this doctor or that doctor. They would have to figure out how to make up for the fact that they were going through their pills faster than they could get refills. Sometimes this was when doctor shopping became a thing.

I would want to know if their use of these pills was at a higher level than it is now, or if this is the highest. And then I want to know what they’re doing right now. How often do they have to take them? What is the level of milligrams that they need? What is pointless to take? Because there’s a certain amount of a pill that is pointless and won’t do anything for them. How long until withdrawal sets in and what their withdrawal symptoms are.

I also want to know what their pain is like, even when they’re medicated, is it totally gone? What is their pain like in general and what are their feelings about these pills? The majority of people I’ve worked with who struggle with chronic pain and are struggling with opiates and with opiate addiction and dependence, want to get off the pills and don’t want to be beholden to them, but they are terrified of doing it and they’re afraid that it will never happen.

I can tell you that it can happen. It is possible. That most people will be able to get to a place of being able to put opiates aside. That doesn’t mean that they’re not going to have pain. That doesn’t mean that it’s easy cause it’s super hard and it really sucks. Undoing years of treating pain with opiates is complicated. The medical community, of course, would tell you that the best way to prevent that is to not have people start taking opiates.

That’s great and I definitely think that we need to do that. However, we’re going to get people who have been taking them. For us, what we need to know is that it happens with people that we wouldn’t expect to have some kind of dependence or addiction. If you have somebody come in who is taking pain medication, our job is not to get them sober. Our job is to find out the role that these pills play in their life and find out what they want to do about it.

You also want to make sure they’re not coming into your office, where they’re nodding out, which is dropping their head and falling asleep randomly, or that they’re insignificant withdrawal because that’s a struggle too, as you can’t focus when you feel like you’re going to die. Which I know sounds dramatic, but it’s not in this case.

There are good treatment options for people who have a physical dependence on opiates. If the person had chronic pain and that’s why they started using them, my suggestion would be to find a pain clinic in your area and hopefully there’s one available. Where I am, the pain clinic that’s here is small and very, very overwhelmed. And so that can be challenging, but that is what I would recommend is finding a pain clinic because they specialize in this.

If the person is clearly abusing the pills in terms of buying them off the streets, spending more than they can afford, nodding out, sometimes having bad reactions because it was mixed with fentanyl and they didn’t know et cetera. At that point, you’re going to want to connect them with a substance use specialist. That is above our pay grade, unless you have a specialty. And I do, but most of us don’t. Daily abuse of opiates is not outpatient mental health material.

That doesn’t mean that you wouldn’t stick with them because they’re going to have mental health needs while they’re getting off of those pills. But there needs to be a specialist involved.

So basically when you’re dealing with chronic pain and somebody who’s already addicted to opiates, the focus isn’t on managing pain without opiates, not yet. The first step is they need to figure out what they want to do about it.

Cutting back. Isn’t really an option at that point and the person will probably tell you that. Because if they’re not taking whatever amount they’re taking right now, the pain will be intense and they will be sick as a dog and not able to do anything. That’s one of the reasons that I suggest that they need a substance use specialist and specifically a medication assisted treatment program option.

You can check that out in the episodes I named earlier. In the medication assisted treatment episode, I’ll talk about the options for people that are addicted to opiates, managing pain without opiates is not something you are going to be able to work on if they’re already at the point of abusing the substances in order to keep withdrawal and pain.

They are going to need mental health help though and you can absolutely be a part of that. Most people who are addicted to opiates are terrified of being without them. My hope is that they will be more open to seeing a specialist if they know that there’s a way to get through withdrawal and have treatment options that they’re not going to have to be in excruciating pain.

There are some really good treatment options when it comes to medication assisted treatment and I absolutely endorse it a hundred percent. If you have someone who is using opiates and struggling because they have breakthrough pain, that’s a little bit of a different conversation.

It may not be that they’re addicted yet. You’re going to want to evaluate that. Are they using more than prescribed? Are they running out at the end of the month? Are they supplementing their prescription in any way? Are they getting them from multiple places? That sort of thing? Those behaviors are normal for someone who is in chronic pain and can’t get relief, but they’re also a part of an abuse pattern of the substance.

Remembering that there are a ton of people who were given opiates in huge quantities and then all of a sudden that’s getting scaled back. We’re kind of over the crisis part of it, I guess, because that crackdown started around 2010 and people have adjusted somewhat, but you may find people who fell through the cracks, so to speak and are still on those levels of medications. What you want to look for in your area is called medication assisted treatment, or you could look for Suboxone treatment.

Suboxone I believe is one of the medication assisted treatment or mat options that exist. If you can find one of those treatment centers, that would be a great place to start. If all you’re finding in your area is methadone. I would suggest going to listen to the mat episode and being able to hear about the different options so that you understand a little more about methadone before referring your person there.

So let’s talk about non-opiate pain management.

The other question I was asked, talked about what to do to treat chronic pain besides opiates. And there are a number of things and whether or not they’re effective, it depends on the person and it also involves management by the client. It’s a little like having diabetes or any other chronic illness that you just have to get used to how to manage your life in a way that helps reduce the pain.

According to the CDC, which is the Center for Disease Control in the United States, their statement about chronic pain is this: “patients with pain should receive treatment that provides the greatest benefit. Opioids are not the first line therapy for chronic pain outside of active cancer treatment, palliative care and end of life care. Evidence suggests that non opioid treatments, including non opioid medications and non-pharmacological therapies can provide relief to those suffering from chronic pain and are safer.

So according to the CDC, effective approaches to chronic pain should use non opioid therapies to the extent possible, identify and address coexisting mental health conditions examples are depression, anxiety, PTSD, focus on the functional goals and improvement, engage patients actively in their pain management, use disease specific treatments when available. What they mean by this is that different illnesses have different protocols for what they believe works best in those situations. We’ll talk about that in a minute. Additionally, they recommend considering interventional therapies like corticosteroid injections for patients who fail standard non-invasive therapies. And finally they recommend using a multimodal approach, including interdisciplinary rehabilitation for patients who have failed standard treatments.

They also list non opioid medications. Unfortunately there’s not a lot, but there are some options. When it comes to low back pain, they recommend the first line to be acetaminophen and NSAID’s like ibuprofen. A second line of medication options would be SNRIs and tricyclic antidepressants.

For migraines they talk about preventative treatments like beta blockers, antidepressants anti-seizure medications, and calcium channel blockers. The acute treatment phase is aspirin, acetaminophen and NSAID’s, anti-nausea medication and triptans that are migraine specific.

For neuropathic pain they recommend tricyclic, antidepressants SNRIs. Gabapentin and topical cane for osteoarthritis they recommend acetaminophen and NSAID’’s of course, topical NSAIDs. The second line they recommend what’s called intra-articular hyaluronic acid. Which is another name for a very specific injection that’s supposed to provide anti-inflammatory effects, reduce pain and swelling in joints. For fibromyalgia they’re recommending Gabapentin, duloxetine, which we know as Cymbalta, tricyclic antidepressants and a medication called milnasipran, which is an antidepressant along with nerve pain medication. This is just naming a few of the things, and of course we would not be prescribing. I list these to let you know about the options out there.

They’re not awesome. But in conjunction with other things may be helpful. I find that people with chronic pain feel resistance to trying other non-opioid medications. This is not because of some sort of non-compliant attitude. It tends to be because they’ve tried something and the pain has been unbearable.

Getting providers to hear them and take their pain seriously is complicated. Research tells us that it is particularly difficult for women to feel heard and feel like their pain is treated effectively. For us what’s in our mind is going to be a multifaceted approach. There are a lot of things that people do to manage their chronic pain that work when combined, but also require a lot of action. Things like acupuncture, chiropractic, yoga, meditation, using a tens unit or an alpha stim unit, dietary changes, good sleep hygiene and stress management.

Where we come in is around sleep hygiene. The mindfulness, sometimes about the meditation, depending on what kind of meditation we’re talking about and digging into whether there is a trauma history, as well as the level of stress and anxiety.

We know through research that the body holds stress and can increase pain. Many of us are trauma therapists and have seen this firsthand. What I do when I have someone who has chronic pain is I try to establish a good working relationship with their team of providers. And if they don’t have one, I do my best to refer them to providers that I have worked with and know, really listen to clients.

I go over a plan of care with them that they feel like if they did these things, it would help a little bit and trying to help them establish those routines. In the meantime, making sure that we have their mental health symptoms at a good level, which probably at this point includes antidepressants and specifically some of the ones that are listed in terms of helping with pain or have the potential to help with pain like Cymbalta.

Then I’m focusing on trauma. I’m focusing on finding out exactly what’s happening in their mind and the intrusive thoughts, the negative self-talk, the stress and finding what therapy they are comfortable with so we can get started on moving that reactivity level down.

I personally am an EMDR therapist and I love EMDR. I had no idea I would like it and frankly refused to train in it for a few years because I thought it sounded like some voodoo magic bullshit. And I was completely wrong. I am a big believer in EMDR as I really feel that a lot of clients are just not helped by having to do a narrative version of their trauma stories. I didn’t think that I would believe that way because I happen to be a very narratively based psychodynamic type approach person. But I’ve seen huge results.

When we are working with someone with chronic pain, there needs to be a team around. Who is on the team depends of course. If your client is pretty highly functional, they’ll be able to do a lot of that advocating for themselves and case management type stuff that needs to be done. A lot of times though, the medical system isn’t really working well together in terms of communicating and you may have to help them remember and work on advocating for themselves.

Once there’s a plan in place, of course your job is to work on their mental health. You do need to know if they are using anything extra in order to help with their pain. If they are smoking marijuana to deal with pain, whether or not they keep using that, isn’t necessarily the goal. If they don’t see a problem with it and you don’t see a problem with it, it may not be something that you address.

You do, in my opinion, need to address them coming to therapy while they are not actively high, because it does interfere. And I would not do EMDR. If someone is actively high at all, I have seen those processing sessions go badly. I don’t know that I think marijuana is the best option for chronic pain long-term because of tolerance. I think that potentially there’s some THC low dosing on a consistent basis that could be helpful, but that’s going to be a very different situation than having a medical marijuana card and they’re smoking. This is more about taking the lowest dose needed to get the effects of it. Talked a little bit about that in last week’s episode.

Basically the messages there cannot be just one thing that they’re using to treat their chronic pain. It will give out and they will have more pain breakthroughs, and that sucks. Opiates are not the only option and frankly, can’t be the only option. The reason that we’re in the place we are today with a lot of clients is because opiates were the treatment of choice.

I hope the information and conversation about chronic pain has been helpful. There are a lot of resources on the internet talking about chronic pain and treating it naturally, or without opiates. You will need to help them get a team around them. Because a lot of this is just not in our wheelhouse. However, you can be a huge part of this team in helping them shift their mindsets, be willing to try things, using good old CBT to help reframe things and allowing them a place to just express how they feel.

We are great problem solvers and we have the time as providers in our sessions to be able to work through a problem and find some solutions. I think we can be a huge advocate for our client and a big part of their team when it comes to working with chronic pain.

Now is the moment where I usually tell you what’s up next on the podcast. Well, I’m going to do that, but it’s going to be a few weeks before you hear from me again. This is about the time of year where I take a couple of weeks off.

In the past, I have tried to keep up on the podcast episodes so that you wouldn’t know there was a gap, but it’s kind of a lot. Anyone who’s been on vacation for more than a couple of days knows how much work has to go into preparing to leave. When you have a full caseload, you have to make sure that you’re seeing people before you leave and that when you come back, everybody’s on the schedule and knows when they get to see you next. Then there’s catching up on notes and phone calls and all sorts of things. I believe it’s totally worth it because we need our time off. But adding the podcast to that can be a little much, even as much as I love being able to share information.

So I’ve decided to take two weeks and when we come back, it’ll be on the first Monday of the month, which is July 4th and we’ll have a recovery story. I have a few things in the works and so I’m not certain which recovery story it’s going to be that day. But the two men that I’m talking with and setting up a schedule with have great stories that are very different and I am excited to bring to you.

So I hope you have an excellent last couple of weeks of June, please feel free to reach out via email if you have questions or comments, and I will be checking them upon my return and bringing you that recovery story on the 4th of July.

For those of you not in the U S the 4th of July is our Independence Day and so it’s naturally a day off of work for us probably, but mainly it’s a time for watching fireworks, grilling out in some kind of barbecue way and celebrating America’s Independence Day. I hope to see you on the next podcast and until then have a great couple of weeks.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

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