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Hosted by Dr. Val Civelli, White Coat Black Sheep explores physiology, functional medicine, and the medical questions most people are told not to ask.
This is where evidence meets curiosity, where dogma gets uncomfortable, and where real world medicine takes priority over headlines.
From understanding your lab work to debunking hormone myths, medication misconceptions, and optimization strategies, this podcast helps you understand what is actually happening inside your body.
If you care about health and think there might be a better way to practice medicine, you’re in the right place.
Welcome to White Coat Black Sheep.
I'm your host, Dr. Elli,
and today I have with me Dr. Matt Bear.
Yeah, thank you. Welcome.
Addiction medicine specialist.
Yeah, addiction and family and street medicine. So, yeah.
How's that going? Really
Well, I feel like ridiculously blessed, to be honest.
It feels, uh, it feels like I cheated
to get some bonus in life.
Like I'm gonna quote you right now. Yeah,
Yeah. You said,
my days all look good,
man. I'm incredibly lucky.
Yeah. I stand behind that.
I feel like, honestly, I, I got
like straight outta residency.
I just got, I landed like a really good position,
and Clinica has let me sort of like,
take every little brain child I had and just run with it.
And so when I came to them
and I was like, Hey, I wanna start the street medicine,
and we're just going to, we're gonna take a backpack
and we're gonna take medicine out of the clinic,
and we're just gonna take it into the homeless
encampments and see patients.
I thought for sure they're like, the hell you are.
But they were very much like, yeah, yeah, let's do that.
Supportive. Yeah. And then it was like, Hey,
I'm gonna start doing addiction treatment,
and like, yeah, let's do that.
So they really, every single step along
the way, I've just been very lucky.
And then because of, I think the patients that we serve,
it's just very like, um, underserved and marginalized.
Oh, yeah. And so that brings a ton of like,
just satisfaction day to day satisfaction.
Yeah. I mean, like, you know,
if you think about traditional like medicine
and what that looks like in terms of your relationship
with a patient and your relationship with their pathology,
a lot of what you do in medicine, it's like, Hey,
I'm trying to prevent mm-hmm.
I'm trying to prevent your A1C from getting so outta control
that you lose your feet or,
Right. Like, I see you're
trending up.
Let's, what are you doing? Right.
Let's talk about that. So it's, it's a lot of that like,
Hey, I don't want you to have a stroke.
Mm-hmm. When you're 60 and with addiction medicine and,
and street medicine both, like, that is flipped
and the interventions you make are having very
immediate life changes.
Mm-hmm. So like, when you get someone started,
and you've probably seen this working
with like buprenorphine and stuff.
Mm-hmm. When you get someone started on treatment,
it's not just like, Hey, I'm feeling better.
It's like, Hey, I got a job.
Hey, I saw my kids for the first time in three years.
Hey, like, I'm not having those legal problems.
So it's just very like, and that's every day. Yeah.
Every day you get to see people
Instant gratification.
Yeah. Yeah. So it's very, yeah.
It's like legit rewarding. So yeah,
It's been great. I just love that
I, I wanted to experience that.
I feel like I was looking for that exact thing,
but when I graduated, I did telemedicine,
and it just, something about it was appealing to me.
I liked that it was access to a doctor
that people wouldn't otherwise have.
Like, Isabella is pretty far from here,
and it's as, you know, a very windy path to get there.
I had a lot of, um, the clinic patients there
driving out there, no doctors, um, go there.
Yeah. And so, um,
but really on the other side of that, seeing
that population, I, I just felt like okay, nobody was like,
I was forgotten about number one because I'm at home.
Yeah, that's fair. But I'm at a standing desk.
I'm actually like, I was, I was so serious about it,
you know, I had like 40 people on my schedule
and I was like, oh God.
They would load me up and then it would be like 10 o'clock,
and then nobody is ready, you know?
Know. Yeah. And,
and in, in our world, readied just, you know,
to anybody listening would be, they have called the patient,
their insurance is there, we have their phone number,
everything's confirmed.
So that, and we have their chief complaints, so we know
that they're not gonna get a surprise bill,
and like we can properly see them.
So, um, I couldn't call them ahead of time anyway.
It was just really, yeah. I don't know.
It was not, it was not instantly rewarding.
It was not fun or, uh,
what I feel like I gave up everything to do
and I just was like kind of standing there
with an empty bucket, so to speak. And I was,
Yeah. That sucks. Yeah.
That's not, that's very,
that's like moral injury and Yeah.
I think like Coming out
of residency we're also motivated and I
Was motivated. Yeah. Like,
let's change the world. Yeah, exactly.
I give up everything to do this, and like,
and then you're there like, oh
My God, I'm so sorry. No
One cares. Yeah. We
had the opposite experience.
It sounds like, like legit out
of residency was like completely
Different. Very
Rejuvenating and like very, like, I feel like I've kind
of woke up again after residency. Oh,
That's what I wanted. Yeah.
I feel like I'm just now
That's wonderful.
Just now feeling that that's Really good.
I feel like I've woken up and I can help people,
and I want to, I have the energy to, and I know how to,
and you just need to call me like,
you know, like, come on over.
Just like, you're, you are so ready
and willing to take on my patient.
Like, that's how, that's how I feel. That's awesome.
Like, if you need something, you just come on
in, like, we've got you. You're gonna feel great.
Yeah. I think it's, it's very easy
to get dragged down into the bureaucracy of a clinic
or the bureaucracy of medicine and billing
and insurance and all that. It
Was shocking. Yeah.
So like, I think that's a very,
that's a very common, um, complaint
or common experience Right.
For a lot of physicians. And legitimately, I feel like all
of that sort of bounces off of me now because,
because of the patients I'm able to interact with
and the, and the relationships.
Like, that's another really critical thing about the way
I I see patients, is that it,
it is all about building relationships, whether it's like
that person in clinic Yeah.
Or that, you know, patient out on the riverbed
or, you know, under the bridge or whatever.
It's just like taking that time
to build a human relationship. They
Know you and, and the patients like they remember you.
They know you. They, they are not worried.
They know that you're gonna be back. Yeah.
You know, if you maybe miss them that day.
Like the, it's just, yeah. It's really cool. Yeah.
So I think that, I think that sort
of relationship building medicine is really
protective towards burnout.
Mm-hmm. So, yeah. Just food for thought, I guess
That's such a good thing.
Yeah. So like for a lot of my colleagues, you know,
as we get together, which is honestly not often, we're not,
doctors are really not that social. Yeah.
How can you be, We're tired.
I found most of the jobs that I've worked,
like since graduation just made me tired.
And so I'm like, why, why don't I love it?
Why am I not like so over the moon to like,
just show up every day?
But then, okay, so fast forward, now
that I'm here, I feel energized.
So it really, it's about like, finding exactly
where you're meant to be, what you're supposed to be,
and just connecting with the field
that you can really do what you're meant to do. Yeah.
That makes, I mean, to me, that makes Yeah, perfect sense.
If you're not, like, if you're not getting something out
of it, sort of that emotional feedback
or something rewarding,
then what the hell is the point of any
Of it? People just take pieces
of you. Yeah.
Oh yeah. And especially in the field of medicine,
and this is not, this is not exclusive to doctors.
Mm-hmm. It's for everybody in the field of medicine. Mm-hmm.
Like, there's always more to be done. Mm-hmm.
And like, there's always a call to be like,
do more, be more, see
More patient. Your list is never done
It ever. Never, ever. Mm-hmm.
So it's very easy to sort
of lose yourself in medicine.
I think you have to be very intentional about like, no,
these are my as, as much as I hate that, I hate
That I'm a yes person. You're, you're
Yes. Person. I'm, I'm
very much a yes person.
So you have to have like, at some point, like a boundary.
I, no. Yeah. And I hate, it's not,
it doesn't come naturally to me.
Same. But having a, like, having four kids
and my wife, it makes that much more doable. Right.
What, you don't live at your clinic. No,
No. But when
I'm in my clinic, I am in, like,
I feel like a piece of my clinic.
Totally. Yes. But then when I'm at
home, that's what I wanna be too.
I wanna be at home and just dad and husband
and not a clinician.
So I love that. And I've been very,
very lucky to do that. So,
Yeah. I think that
really shows too.
I mean, you're always like, so like, my experience
with you is that you, you've always loved it.
You are a piece of the clinic and it's just synchronous
and it's infectious, really. Like, you know, like,
I dunno if that's good or not, but I don't
Know. Infectious in
a good way. Yeah, yeah.
In a way you don't wanna treat.
Yeah. So, no. Yeah. It's been really, really good.
I love the patients. I love this.
I, you know, I've sort of grown more in love
with Kern County over the last
I know. Me too. Five to seven
years. And today was really gross.
Like aesthetically Yeah.
It was very foggy and cold, and everyone sounds congested.
It's so true. Yeah. But it's also, we don't get this type
of weather very often, so I'm kind of embracing it. Yeah.
It's a little moody. Yeah.
Very moody. I embrace it. I totally
Agree. Mm-hmm. This is good. Like,
um, read a good book. Yeah.
Rather. Yeah. Yeah.
But you probably read a lot of good charts today.
No, not too much. I'm not, so, okay.
I saw like 20 patients. I had only morning clinic. Um,
That's like a whole day for a lot of people.
Yeah. But a lot of my visits are, um, follow up.
So they're pretty quick. And honestly, like,
I don't even know if I ever want this out on the air,
but it doesn't feel like I'm working most of the time
because I'm legit.
I'm just having conversations with people
that I genuinely love and care about.
So it really is, it feels like I'm calling
and being like, dude, what's
happening? How's everything? How's,
That's you and your purpose though? That's
What it looks like. I dunno. Whatever it
Yeah. It's really, really,
it doesn't feel like taxing at all.
And that's exactly what it should be.
That's, that's what I'm just now tapping into. Yeah.
Tell me about that, by the way. Yeah.
Tell me about this, the functional medicine.
Okay. So functional medicine I think is such
a interesting new space.
So with primary care, where we all started family medicine,
you can see everybody and you can treat anything.
And it really gets complicated,
especially if somebody has trouble getting into the clinic,
because as a person who struggles to say no, like,
I'm gonna just like maximize the visit
and try to see you for everything.
Mm-hmm. But then the time slot does not allow. Right.
And then insurance doesn't pay you.
So really, it's like, I was just creating this burnout
scenario, like not meeting the goals,
not really helping a patient fully.
Right. Um, you can't fix everything.
It's hard to get people back in timely.
I, there's a lot of things
That's horrible. 'cause then you're
failing everywhere. I felt
You're failing. I failed everywhere.
Your employer or the boss,
you're failing the patient everywhere.
You're failing yourself. You're failing
your friends. That's a horrible
Way to, and then my mom calls
and I'm like, I fail to answer.
And then she's now p****d off. Like, what about me?
And I'm like, oh, well, I just have, I need to find myself.
I need a minute. Yeah. Fair.
I'm so sorry. No, I'm so sorry.
Well, I'm not alone in this, you know, and I, and,
and so sharing this whole like, toxic cycle,
really, this is what led me to where I'm at.
So, um, let's see, 2023, I looked into peptides.
I went to this conference.
Um, I was actually, I was in Grand Cayman where I,
I did med school and um, I, I was just swimming in the ocean
and I happened to meet this, um, er doctor
who is a longevity doctor in functional medicine.
So he's er, and then he specialized into functional.
And, um, I was like, what is that? Just like you said.
And, uh, really in his case, he described it, um, in his
scenario where he had a, um, an aneurysm in his, uh,
in his brain, like around the pituitary.
And he almost died. He was saved just in time.
They put a clip and then he was deficient of a lot
of hormones including growth hormone.
And, um, so, but he didn't know that for a while.
He just was like, I feel horrible.
Like, I would rather be dead than feel like this. Mm-hmm.
And he went to all these different doctors
and including endocrinology.
They're like, oh, okay.
You have, um, you have a low testosterone.
Like really, everything was low, so
low growth hormone, everything.
So he got onto replacement.
He's like, oh my God, I got my life back.
I got my life back.
So from that moment, he just like, I have to do this
for other people, and I don't think I know how to do that.
I'm an ER doctor. Mm-hmm.
So he went into functional medicine from that.
It really is a subcategory.
It's outside of the scope of what, um, anything
that we have learned.
Like we have the primary working knowledge
of the whole body at different ages,
but when you are looking at like, hormones
and like the safety profiles and,
and it's like, yes, the paper,
like we're looking at reference lab ranges,
but then also there's subspecialty labs that you can do.
There's, um, there's, there's spaces that you can, um,
I don't know, I guess go more aggressive,
like do higher doses or lower doses of certain things.
Mm-hmm. Adjustments that you can make
or, uh, supplements that you can do
that really give people their life back. Oh,
Interesting. Yeah. Yeah. So it's,
it's a subset
of endocrinology, or No, it's,
Yeah. I would say everything.
Okay. So, so it's in the space that,
um, that is not the gen general, like health maintenance
and wellness, like, if you went to your regular doctor,
they would likely say everything is fine if you're mostly
fine according to reference range labs.
Whereas we in functional medicine, might have a different,
uh, summary mm-hmm.
Of your, your labs. Okay.
Like, like, uh, you know, like
how we'll look at hemoglobin on A CBC
and the MCV, we can say macrocytic microcytic anemia.
Right. Um, your platelets, you know, are normal,
but then you just, there's nothing
else that that's on there.
Right. Whereas functional medicine is gonna say, oh,
I see your basophils are really elevated.
Or, um, there's calculations that, you know, would kind
of tell a different story,
or your hormones, um, oh, your estrogen is fine
by reference, but then if it's just a E two,
uh, estradiol mm-hmm.
That's not adequate. So it's just a very, like a expanded
in depth, um, management.
Interesting. Yeah. No, I don't know that I've,
I've heard the term before, so,
Yeah. It's,
so, uh, longevity,
you'll probably hear that, hear that term a lot.
Mm-hmm. So, aging is considered, um, a disease.
It doesn't get that term
because too many people are affected.
Everybody ages. If 100% of people are affected,
then it's no longer considered a disease.
Mm-hmm. You have to have a subset of the population.
So everything that is, um, pathologic mm-hmm.
Is due to aging in a sense. Right.
So it, like, it used to work and then now it doesn't. Okay.
Because something inter intercepted.
So it's kind of just like looking into
different angles of that.
I mean, telomere length, have you heard of anybody talk
About that? Yeah, I remember like that,
like the, the studies
and stuff about that back in
like the early two thousands and stuff.
But I, you know, it's not a thing I follow. So
Yeah. So
you can check the length of your telomeres,
and then you can see, um, based on that,
like if you change your different lifestyles
or supplements, you can extend them.
You can actually have them measured every three months.
That's Wild. Yeah. It is wild.
There's a lot of Harvard studies
that have made, like these labs.
Does. What does that look like in terms of like, practice?
So like, what does your day to day look like as a
functional medicine physician?
Short answer is that it's longer visits. Okay.
Well, that's not a bad thing necessarily.
No, no. It, it actually is very pleasant.
And, um, I look into things like, how,
how, um, are you sleeping?
And I'm gonna hear what you tell me,
but then I'm also gonna ask you, show me
what your wearable data shows you
and me, for example, so my doctor
used to ask me, how do you sleep?
I'm like, good. Like, I think I slept good.
But really when I started using a wearable,
I saw I had a lot of light sleep.
I didn't have enough, uh, deep restorative sleep
and rem so I, you know, made those adjustments.
Um, it was anything from like lifestyle changes,
like stop looking at my phone after six, put it away.
Um, no bright lights, no decisions, no fights.
Like nothing after,
I have no decisions after six.
Oh my God, no decisions Felix. Like totally. I
Make all my decisions For real.
Well, if it, if it's not affecting you. Yeah.
And, and like, your labs look good, you feel good,
and your sleep is is great, then, then carry on.
Right. But for me, it, it was keeping me up apparently from,
it was preventing me from that deep mm-hmm.
Sleep, right? Like, I wasn't unwinding enough. Yeah.
So, and I did that.
And then I also started to exercise in a different way
rather than like, hit interval training.
I would do like heavy lifting and less cardio.
So for me, that,
and also I started to have a lot more carbs. So,
Nice. Me too.
It's Gone Great. I feel
great. Right.
So, so, so like those little changes,
uh, were pretty impactful for me.
That's awesome. Yeah. And that's
When I sleep much better and feel better. Overall.
I do, I feel strong's. Yeah. That's good. Yeah. Yeah.
Sounds great. I feel like after the sleep was corrected,
that corrected like a lot of other things.
But yeah. And I went through hell, like, 2025 was horrible,
but I felt fantastic.
That's good. That's really good.
I feel like it's easy to, uh, really under appreciate
how much sleep can affect your day-to-day life.
Yeah. I mean, there's a lot, I feel like actually there's a
lot of those little things that can really,
really affect just how you interact with the world.
Mm-hmm. Like chronic pain patients, I always think about,
like, if I have a pain that lasts more than, you know,
an hour or so, like it affects my whole day.
Right. It affects my mood. It affects how much I can enjoy.
Mm-hmm. A meal. It affects
how much I can engage with other people.
So then you imagine these people
who have like, pain all day,
All the time, every Day.
And it's just like, how do you, like,
I would be so, well, I, I mean, you'd have
to really check yourself.
Yeah. Because I think I would be irritated.
Yeah. I mean mm-hmm.
I think irritated is like just one of a many potential, um,
emotions to have with that.
Yeah. It's just so awful.
Yeah. So, yeah.
Yeah. So stuff like that. Right.
Like, so, um, so just checking in with people,
like if they do have like a, a irritated like symptom,
and usually it's like the husband and wives come together,
or I do see them separately
and I get to learn like what the real
Oh, the dynamic between them is.
Yeah. 'cause they tell on each other. Yeah.
That's, I like that. Yeah.
But, um, yeah, so it is just looking at data, extended data,
like, uh, I do gut microbiome tests.
Nice. Um, longevity tests.
So you had mentioned like, um, that you had a patient
who was on, uh, a buprenorphine product.
Yes. So how does, uh, functional medicine fit into like,
the addiction space, the, the pathology of addiction?
Yeah. So we are invasive, I would say, you know, a visit,
first visit could be like an hour.
It could be a little bit longer. Just depends.
Um, but when we're looking into every category of like,
your sleep, your performance,
because it's really about, like, you're optimizing a lot
of people, they show up their, they're healthy,
they're high performers.
They're already doing, they look
like they're killing it in life.
Mm-hmm. So, but they're like, I just know that I used
to be stronger, or I used to not have these episodes
of like, uh, anger or I used to.
Right. It's, it's, I used to.
And then, so that changes the space
that somebody would see me for.
Okay. Because you're fine until you're not.
And it's really, um, so for this, uh, particular patient,
um, he, I mean, now that I've learned a lot about the,
the personal life, there's like a lot of social,
I would say triggers going on, like with his family dynamic.
And then, um, he had a performance issue at his work.
He's a self-employed. Mm-hmm. So focus was a problem.
Um, uh, he just felt tired all the time.
Uh, just, um, he, he worked out, he could lift heavy.
He was like doing as much as he could to really stay on,
um, a schedule.
Mm-hmm. But his sleep was poor.
And then I tried different, like sleep aids just to temper
or behavioral changes.
Mm-hmm. We checked all the labs. Um, testosterone was low.
We replaced it. There were just a few things,
but like finally we realized it was kratom.
Yeah. But,
but I, I started out, I would say like
two years prior to him. I didn't know what that was.
Yeah. It's sort of, um,
really taken off in the last It's crazy couple.
Yeah. So it was, you know, it's been around for a while,
but it really, honestly, in like the last,
I would even say the last 12 months,
we've seen a huge explosion of, um, patients
who are struggling with Kratom.
And it's a very strange chemical on its own.
And it acts like at low doses, it sort
of acts like a stimulant,
but then at high doses it acts like an opioid to the point
where it's like, you can overdose on it,
and then you can just go buy it.
Like, you can go at
A gas station. Yeah. Totally.
Legally, no restrictions. It's, yeah.
It's, it's really, really wild.
So yeah, we've had a lot of great impatience
and it's really, it's really tragic. So
I had to learn like c you know,
whenever you're going over like a medication list, like
what stands out, right?
Like, you're kind of listening for certain things,
like which ones are impactful for this patient?
So for him, I had to just ask him directly.
It was not brought up, and I was like, nothing else.
Makes sense. Yeah.
And so just, you know, so I have to go, like,
that's the part where I'm no longer like, primary.
I'm like, let's go functional medicine right now.
Let's go a little bit rogue. Tell me
your supplements and herbs.
Tell me which teas we're drinking.
Tell me, like all that stuff. Wow.
So I had to like learn like all of like the, the language,
like ashwagandha, rhodiola, like, oh yeah, remember those?
Let's talk plants and herbs right now.
So there's a whole like, repertoire of things
that people dive into.
And I, I know, I know them all now and that's good. Yeah.
There's a lot of 'em. There's so many.
And they're not regulated the same way
as not at all regular meds.
So if someone's like, Hey, I'm on this dose, it's like,
yeah, well, what does that actually mean?
Because it doesn't, you know, 25 milligrams
of amlodipine is different from 25 milligrams of, um, uh,
you know, thistle or whatever it is.
Yeah. Because it's just not,
it doesn't have the same
regulation. Yes. So, yeah. It's a tough one.
That's a tough one. Yeah.
So, so like, really learning how
to speak to that type of patient.
I mean, I would say that's really the
type of patient that I would treat.
Yeah. And, and a lot of them, they're like, well,
I know I have diabetes, but I don't wanna take this.
And, and so like, we really, I feel like it's a, a gap
that I can bridge because it's like, look, here's
what you're doing by not,
so we talk like regular medicine first always nice,
but then the rest it would be like, okay, so go ahead
and take your, your statin,
but then let's also add on cozy Q
because it's gonna give you an extra benefit.
Maybe they'll, they'll reach like a lower dose statin.
Mm-hmm. You know, there's, I don't know, it's just,
it's a language, it's a reframing.
Yeah. Like somebody, like, they reject, uh, depression.
I don't have depression. I don't have anxiety.
That's for other people. And, and I get it. Right.
Because they, I mean, they're intelligent
like professionals.
They, yeah. Doctors, lawyers, a lot of, you know, that type
of patient, like, don't, don't diagnose me with that.
That's for other people. Right.
Well, I don't know if it works that way
with any other Right.
Illness, like no profession has spared pancreatic
cancer or Yeah.
High Blood pressure. So I know,
But yeah. Well, well, okay. But it's
happening. Right?
So like, a lot of this type of, these types of patients,
they, I feel like we do a lot of reframing.
Mm-hmm. Like, okay, this is a nervous system issue, so
let's, you're too much in sympathetic overdrive,
so let's get you back over to parasympathetic.
And so, I don't know, it's just interesting. Yeah. Yeah.
It's a language. Yeah.
It's, I mean, what a, again, I, I,
this is my first step into the conversation
of functional medicine, but what, what one part I,
I love this I'm hearing is, um,
that there's shared decision making
and patient-centered care.
Yeah. And so that very much overlap
And overlaps and a Whiteboard overlap.
And a whiteboard. Oh, yeah. It makes sense. Yeah.
A lot of education. So,
but that, that very much overlaps with addiction medicine
and street medicine as well,
because it's not about like, Hey, I'm coming in
with my agenda for your health.
Mm-hmm. It's like, Hey, I'm just a conduit to like Exactly.
Treatment. And what is your plan?
Like, what is your, what are your goals exactly.
And how can I help you reach those goals,
specifically? Not my goals, but
100%. That's
the same way I see myself completely.
Yeah. That's good. Yeah. That sounds fun. Yeah.
And that honestly, like, it makes sense
that you're feeling more rewarded Yeah.
Now, professionally because like, finally, yeah. Mm-hmm.
Because it, it feels really good to like, I don't know,
let someone else drive.
Mm-hmm. And you are just participating and,
and helping in, in a meaningful way.
And as opposed to you are dictating
and composing and finger wagging. Yes. Um,
Like, you are going to die of this.
Like, I mean, I, we talk risk, like your risk of Yeah.
Mortality is high if you don't change anything.
You know, it's so funny. It's like, that is straight up.
So when I first started doing street medicine, I thought,
okay, I'm gonna take like the high quality evidence-based
medicine that I perform in clinic,
and I'm gonna take it to the streets.
And then I got out to the streets
and the patient was like, what the hell?
Like, this is what I want. This is what we're talking about.
This is, this is what I need. Mm-hmm.
And I, and I had to become, I was sort of forced
to become patient centered.
And so then I took that philosophy back into my,
this is when I was still doing primary care.
I took that back to like my diabetic patients
and was like, Hey, here's like your A one C'S 14.
The guidelines say you should be this, this,
we should start doing this
medicine, this medicine, this medicine.
Maybe some insulin. But really, what do you want?
Yeah. Let's start there.
Because that's like a fail, right?
That's like a hundred percent. That's, that's overwhelming.
Like, oh my God.
Like, I just wanna crash
and like, I'm gonna go to sleep. And,
And what'll happen is if you do prescriptive medicine in
that way, Hey, you need to be on these meds.
I'll send the meds for you. They'll say, okay, thank you.
And I'll never see 'em again. Yep.
Because they're not gonna take all those meds.
It's too much. But they're gonna be too embarrassed
to come back and not have done what the doc Exactly.
Yeah. So then I found out, I was like, all right,
like if the first step you want do is let's talk about
cutting a tortilla outta your diet.
Like, cool, let's do that and we'll just follow up.
And I feel like when you let the patients,
when you really do all that hokey mm-hmm.
Patient centered mm-hmm.
Care, it really has better health outcomes. It
Does, does, I know I used to laugh at, right.
It's like the, I don't know the way we're talking really.
Yeah. Because I'd be like, okay, like marketing. Yeah,
Yeah. Oh, I remember being
taught in med school, like,
all these tenets of good medicine, patient centered care.
Right. And it's like, yeah, okay. Yeah.
Like, like I know what to answer on the test,
but then it's like, no, when you actually
apply it in a real world experience, it's like, like,
Let the patients decide.
Yeah. It's life changing. Yeah. Yeah. Yeah.
So I'm actually doing that.
That's, yeah, it sounds like it. So, yeah. That's awesome.
Yeah. It's pretty cool. Or like diets, I mean, there's
so many weird diets, and like a lot
of people like bring out these like very restrictive things.
I'm like, yeah, you're gonna lose some weight.
Like, oh, okay, you think I'm going to?
I'm like, no, I know you're going to, you're going to,
but like, can you sustain that?
Right. Like, is that, yeah. Is that good for your longevity?
No. Yeah. So then that maybe would be,
when we talk about their telomeres,
Lots of lots of telomere talk.
No, we don't talk about it that much, but that's good.
Yeah. No, I think it is patient-centered.
That's awesome. Yeah. I think that's, I think
that's the way to, I think that's what's missing honestly,
in a lot of, um, uh, uh, medicine as a whole.
Yeah. It's just like, it's very, we sort
of get taught to be prescriptive.
Mm-hmm. We get taught to like, Hey,
here's the algorithms, here's what you do.
And it's never like, well, okay, well how do you present
that to a patient, but then don't do that.
Mm-hmm. How do you present that to a patient
and a patient tell you no,
and you still come up with a plan mm-hmm.
That's going to have, that is
Right. So there's
an action.
Yeah. Right. So how do you do that? Yeah.
And I don't feel like that's really focused on,
it wasn't in my medical, medical education,
So it wasn't in mine either.
It's like, I'm the doctor because I said so.
Yeah. I hate that. I hate that. I hate that. Yeah.
I don't, I don't like that. I don't like
that power dynamic at all to begin with. But
Yeah, it's kinda like parent child, like,
because I said so Yeah. And Yep.
No, so we see that. So, and that un legitimately like,
that does not work in addiction medicine.
They just, they're like none of that.
So it's nice because it is, like, it gives me the ability
to not have to like, I don't know, pretend
to be someone's parent
or to pretend to be this force that I'm not.
So it's really, yeah. It's really wonderful.
More people should do addiction medicine.
Well, okay. So on that, like, is there any,
was there any like moment that you felt like hopeless about
or hopeful that you're like, I know I can help this person,
or this one I can't help?
Yeah. I mean, it's, um, so, you know, we see
the field itself is sort of crazy
because you have like these moments
and they're, they're very routine.
They're very regular all the time of just like overjoyed,
uh, experiences where just pa like I said, patients are
re involving themselves in their lives
and reconnecting with their family, and they feel alive.
But then because of the nature of the disease of addiction,
like we also have a lot of death.
Mm-hmm. And so we do see a lot of patients where it's like,
we can start treatment and then we lose them,
and we start treatment and lose them,
and then we don't hear from 'em for a while,
and then we find out like, yeah, they passed.
And that, that really speaks to the mortality of the,
the chronic disease of addiction.
Yeah. Um, but I've never felt hopeless. Yeah. Um, like, so
Professional. So you believe that there's
always like, hope for anybody
that steps into the clinic?
Like, I'm not gonna give up on this one yet. Yeah.
Oh, yeah. Yeah. So a lot of, you know, a lot of that, like
what do we do with, um,
when when someone is still actively struggling
and they're not, they're not gonna reach, uh,
necessarily some goal of, of complete remission, right?
Mm-hmm. So that's where harm reduction comes in.
And that's where it's like, all right, well if you're still
like, I like that term using illicitly.
Mm-hmm. Like, what can we do so
that you're using safely, right?
Absolutely. So then there's a lot of,
a lot of what we do mm-hmm.
Isn't necessarily medical.
It's like, Hey, how can we educate the patient on like safer
injection injection practices mm-hmm.
Or safer used practice, right?
If you're gonna use fentanyl,
like you should probably use with a partner.
And if you can't use with a partner, here's a phone number
where you can call and just have someone
on the line while you're using.
So if you overdose, like someone can call 9 1 1.
And we talk about Narcan and things like that.
So even if someone is in the throes of active addiction,
like we still want them to be safe.
Right? So even if it's like, Hey, I'm not ready to stop, um,
using, and a lot of people
Are not. 'cause they, the future of
them would want
to live a hundred percent.
Like they, the person wants to live hundred.
It's such a chemical, like demon, like
a dopamine deficiency. Yeah,
Absolutely. Yeah. So,
and again, like our goal isn't
to have everyone come in and, and be like, Nope.
Like the way we want is we want you to be a hundred percent,
um, in remission, or else it's a failure.
That's nonsense. We don't do that for other diseases, right?
Mm-hmm. Like my patients who have high blood pressure, many,
many of them will have great blood pressure for months
to weeks to years, all of a sudden
to like lose that control.
Mm-hmm. And that happens in addiction.
And no one like gives the blood pressure patient a bunch
of s**t for like, dude, this, it's like,
oh my God, no one's in tears.
Or it's like, yeah, that's how this disease works.
That's how all chronic disease works. Yeah. It's just there.
Yeah. Waiting for a moment to pop its head up again. Yeah.
Fine. Until it's not. Yeah. Yeah.
It's the same with addiction. It's just like, um, you know,
it's, it's kind of always
there for the vast majority of people.
It's just always kind of there in the background.
If you can get it into that state of remission, hallelujah.
But if, if you lose, right.
If you have an episode of use
or you kind of have a return to use it,
It doesn't mean, or some, some trigger
Right. It doesn't mean it's
over. It doesn't mean
like you lost anything.
It's like, yeah, that's the disease
Man's like, yeah. Like a speed bump.
That's it. That's all it has to be. Yeah. And so,
Yeah. So you get right back on
it. Yeah.
And then there are other patients who are like,
look, I don't wanna stop.
Mm-hmm. I want to use less. Mm-hmm. Or I wanna use safe.
It's like, great, let's, let me help you as best can, let's
Do that. That's interesting. Okay.
Yeah. Oh, no. We have plenty of patients who are like,
still actively using.
And so it's like all, well, what can we do to like,
prescribe in a way that keeps you safe?
And what, what are other harm reduction principles
that we need to help you utilize so
that even though you're still actively using
illicit substances, like mm-hmm.
Oh, you're gonna be here mm-hmm. Right.
Next week or the week after, so
that we can continue this battle together. So,
So like all of that stuff is just really, it's good
to, I don't know.
I guess it's good for me to hear loud
because like, imagine so fast forward a decade, I all
of those patients that were yours,
like now they're mine in the nursing homes, right?
So like, if you're 65 plus, you can't, uh,
you're not, you're still some like enough dysfunction
or weakness or whatever.
So you can't live on your own.
You have to be a skilled place.
There's they at this facility now
where every single thing is controlled
and there there's just, there's nobody
who knows really how to handle it.
There's no guidelines for it. And that's interesting.
And, and like a Norco five every, you know, say four hours,
maybe a max of Norco 10,
that's really all that they're gonna get.
Yeah. And so if they're, if they're going straight cold,
they're, they end up cold Turkey.
Right. Like straight from the hospital
where they're getting like IV morphine, you know,
from the street to the hospital for whatever reason.
And then to the, the sn f like, there's no, there's no
Bridging, there's no like taper.
That's awful. No.
And I had so many, um, pharmacies,
like say somebody's on a suboxone program.
Mm-hmm. They, they would, you know,
they have their usual dose,
but then they're not gonna get that
because the pharmacy, the, they would tell me,
I don't feel comfortable with this many MMAs.
I'm like, I'm sorry, what is your
Name? Yeah, no,
it's, it's really unfortunate.
And I don't, you know, we have, we have issues
with pharmacies and physicians sort of have their, um,
concepts of opioids and
It's Horrible. It is
horrible. And I get it.
Um, the problem is, a lot of pharmacies, they have to answer
to the DA and if they're prescribing a certain amount
of controlled substances versus
non-controlled, they can get hits.
People also have their own inherent biases
and they can treat patients a certain way.
I will say like, just sort of, kind
of touching back in on the,
the patient who's exiting the hospital on opioids
and having zero, um, like tapering nothing.
Right. So that's horrible. Yeah.
Like opioid withdrawal is
the way we're taught it is like, oh, it's a bad flu.
Like, you get the sniffles and you get like body aches
and goosebumps and you're gonna feel a little anxious.
That's b******t. Like every patient I've ever had,
describe me opioid withdrawals is it feels that you, like,
you cannot survive it.
It's, so, it feels like you're going to die.
And imagine having that feeling,
but also being post-op from a femur, right?
Mm-hmm. Like a, a femur surgery or something. Yep.
And you're 70 years old and you just got kicked out.
And, and that's my patients. Yeah. That's so sad. Mm-hmm.
It's so, so sad. Mm-hmm.
So that feels like bad medicine to me. So
It is so bad, and I don't know who can fix it.
'cause I feel like, yeah, I, I, I don't know.
I I'm one person. Yeah.
Oh yeah. Yeah. No, it's a systemic thing and mm-hmm.
Um, yeah.
I think, I think there just, I mean,
more conversations about what about opioids in general.
We kind of all, you know, we had this,
the huge opioid epidemic, which we're still sort
of on the tail end of a whole other one. I feel
Like it's not over at all.
No. I don't know that it ever, we're in a whole other one
now, like with the fentanyl era and all that.
Mm-hmm. But like, you know, the pharmaceutical company,
the medical community played this huge role in the
opioid epidemic.
And I honestly feel like we sw swung
too far in the other correction.
Totally. And too many doctors got very scared of the d
So now they're like, pa neglectful.
Right? They're like, sorry, I
can't, you just have to look away. I can't do that. There
Are many, many practitioners, doctors mm-hmm.
Um, NPS PAs who just draw a line in the sand
and say, I do not prescribe these medications.
Yep. Again, that's crazy. 'cause we don't do that.
Imagine any physician who's like, Hey,
I don't prescribe metformin.
I don't prescribe stat. Like, period. That's like,
It feels so unethical your job.
Yeah, it does. Yeah. But what is it that you do?
Yeah. So, yeah. Yep.
It's like, and, and I think it's good for all of us
to have a healthy appreciation for the risk associated
with opioids, but it doesn't mean that
They're often, you can't just abandon. Right?
No, absolutely not. I think that's bad. Yeah.
That's bad medicine. Every, every medicine we prescribe,
every intervention we enact, like has risk and benefits.
Mm-hmm. And like, you have to weigh those
and have those conversations with the patients.
But like, taking something off the table completely just
feels like a bad idea.
So Yeah. I feel like PMR doctors do pretty good. Yeah.
I actually got to work with them at, um, acute rehab. Yeah.
Palliative hospital also do palliative
docs are where it's at. Those guys
Are so good. Yeah. Yeah.
I got to work with one of, um, one of our, uh,
um, attendings as well.
Really? Yeah. Yeah. Learned a lot of good little tricks.
You should, uh, at some point, if you ever get the chance,
you should have a conversation with, uh,
Rishi Patel, Dr. Patel. Oh, I
Would love to. Yeah. He's
a palliative doc.
Street medicine. I wanna be better at it.
He's so good. He's, he's a good dude, good human,
and like really good advocate for his patients.
I would love that. I mean, I feel like, um,
I don't know if it was, uh, PMR or palliative,
but I learned, you know, like four fentanyl patches.
Mm-hmm. You know, 'cause it does get kind
of like crazy if you're chasing pain
and you've got like the short acting
and the long acting pain control
and then, you know, your pain's still not under control
and you can't do IV based on the setting.
Um, and then so fentanyl patches were pretty good option
for a lot of people, but you have to have a little,
you know, chubbiness to you.
Yeah. Yeah. Oh, that's a problem. Yeah.
One of the problem with fentanyl, um, yeah.
Chronic pain's a difficult one.
And the problem, you know, opioids in chronic pain, again,
they are necessary for many patients.
And I think, uh, many patients
need to be treated with opioids.
And I'm, I'm very happy that we have those as an option.
Again, it's not to say they don't have their downside.
One of the ones that sort of I always butt heads
with in the pain world is the hyperalgesia.
Mm. The patients who have been on opioids for a long time
and now they're like hypersensitive to pain stimuli.
And it's really unfortunate.
'cause that's a very difficult thing to combat.
You can't just take 'em,
It's like a sensory Yeah. Increased sensory
Like hypersensitive.
Yeah. So then things
that would normally like not hurt them become mm-hmm.
Very like, you know, like a nice little like mm-hmm.
Someone just kind of socking, Hey man,
how you been becomes exquisitely painful.
Mm-hmm. And so, and then every, like,
every pain stimuli just becomes sort of amplified.
They're more sensitive to it when they've
been on opiates for a long time.
It's like, yeah, well, you can't just stop opioids.
So then you have to, that's one
of the nice things about buprenorphine as a whole, is
that you don't typically get that hyperalgesia effect.
So if someone's on long-term buprenorphine, oh, that's good
to know for pain, then you don't get that effect typically.
Okay. The downside is like, buprenorphine
as a pain medicine hasn't proven
amazing, you know what I mean? It hasn't been like this.
Is it like a bandaid or like
No, I mean, bandaids are great overall,
but I mean, no, just like umaid, it's just not as powerful.
Right? Yeah. It's just not as like, um,
you're not gonna get the same level of, of, uh,
pain relief mm-hmm.
With, with say like a Suboxone mm-hmm.
Or belbuca as you would with like a Percocet or something.
Mm-hmm. But that, that being said, there are plenty
of patients who are on buprenorphine for pain mm-hmm.
Long term. And it, you know,
that they're doing really, really well.
And, and I think in Europe, they're much more likely
to start patients on buprenorphine than they will on other
full agonist opioids.
So there's just room in the US for us
to be a little bit better about it.
Oh, I know. And really, I think that's like a,
along the lines of the podcast, um, you know,
what, what are we doing well?
Where is the space to improve?
Because I mean, I just can't accept that.
Like, we've nailed it in every category.
Which category did we nail?
See? Yeah, you reacted, right? Yeah.
No, so like, I feel like I, we should be able to say that.
Like, where can we improve and like, let's try to do better.
And it's, it's more than just like academia.
It needs to be like, on our side too,
like in real life for real time.
Yeah. There's not all this evidence to support it,
but we know that we can do better
and it's like we have to try, like where's the time
and space to make that shift? Yeah,
I agree with that wholeheartedly.
Yeah. There's tons and tons of room for improvement.
I think the numbers would show it, uh, as well,
But Oh, yeah. Yeah.
Because I mean, I, I see suffering every day.
And so like, uh, I don't know.
I just, it getting old looks horrible.
I'm so sorry. You feel that? I don't feel
that way at all. I mean, feel Well 'cause you're not,
You're not old yet.
I'm, I think I'm older than you by
Pretty good. You're
older than well, I don't know.
Yeah. I'm 46. Okay. I'm 42. Yeah.
I'm older than you, but I'm talking like eighties.
Yeah, I mean, that's fair.
Like, you know, I, I sort of watching my, um,
my grandparents sort of in the, you know, the last decade
or so I would imagine of their lives.
Mm-hmm. And it is really, really, really tragic.
It's to sort see the amount of suffering Yeah.
Day to day, especially with like cognitive decline
and that that's huge.
Not having insight into your own, like,
what's going on, right.
It's like things are happening in my body and in my mind,
but my mind is not capable of understanding those things
and how frustrating that is and how
Yeah. So, so inflammation
is said to be behind a lot of that,
like Alzheimer's dementia.
So that's a lot of what I'm really Oh, interesting.
Diving into, um, I can,
so there's a skin test that you can do.
I haven't done any yet, but I just learned about it.
You can, um, really profile Alzheimer's by a bunch
of the different proteins.
Oh, interesting. Um, there's blood tests that I, you know,
that I do currently order to look
for different proteins in the blood for Alzheimer markers.
Um, you know, like the A p oe
and there's, uh, a bunch of other things.
Um, we don't go as wild as like getting CSF fluid, but Yeah.
That's pretty Invasive. Yeah. We don't go. Yeah.
I mean, I'm sure some patients would, but like we, we Right.
We wouldn't. Um,
but still there there's profiles that you can, um,
biomarkers that you can look for in the cash pay world,
where it's like, if money is not the issue,
then let's look for it.
So, so now we know that like the science is there to find
and diagnose anything.
Mm-hmm. Can you treat it well? It depends on the cause.
Yeah. So, um, you know, like it's just, it's, there's
so much that, um, I'm obsessed with it.
That's kinda the direction. That's good.
You know, that I want to be like, like, uh,
Alzheimer's dementia, it tends to start in the forties.
You're, you're in your forties
and they're just kind of trending it, you know,
and all these studies and it's so preventable.
So That's crazy. It is. They're finding, yeah.
This is news to me. Yeah.
All of these like, uh, neurofibrillary tingles,
they're just found in the brains
and they're finding these on these scans in the studies, so
That's wild. Yeah.
Well, at least we're doing that, right.
At least we're still like for now, um, doing, um,
pretty good research out there. So,
Quick question. Yeah. Because
I know we're almost outta time, um,
on the premise of, uh, like addiction medicine and,
and everything like addiction related, that area
of the brain that registers addiction.
Um, even something as simple as like food
or, um, or smoking.
Like, do you think it's okay
and do you agree with the principle that you can,
you're just, you're substituting a lesser evil
for, for something else?
Like the addiction part of the brain is still active mm-hmm.
But you have to take away something
that creates a dysfunction in the personal
or professional life, so you're substituting
Yeah. I mean, I,
Is it still an active sight?
So I think the way I view addiction, I think,
I think the most accurate view to take on addiction is
that it is a very nuanced, complicated multifocal, um,
neuro biological, uh, illness, chronic disease that's so
Proper Re relapsing and remitting disease.
The, the simple way I like
to think about is the way we've sort
of always been taught is, you know, environment plus
or minus bad choices equals addiction.
And the real reality is like having a better understanding
of the neurology, neurobiology of the genetics is
that it's actually incredibly complicated.
And that, that equation is really like genetics
and, uh, environment and socioeconomic status
and childhood trauma and like a myriad of things.
Choices are a part of that. Mm-hmm. Whole equation.
But it's one part of many, many, many,
and that's what equals addiction.
We like to focus on like, hey, the choices need to
Be, we wanna simplify it into one bucket.
Right. We like, what we like to do is say like,
this is your fault because you made choices.
Yeah. But that's not accurate.
And it's, I think it's the world could benefit from seeing
addiction as a more nuanced does.
And it's the same with like thing about diabetes.
It's like, yes, your dietary choices play a role in that,
but so do your gen genetic like massively.
Yeah. Your genetics play a role in that. Yep.
And your, your your where how you were raised as a child.
Like it's not just as simple as one thing. Yeah.
And so that's how I view, um, that's very helpful.
Addiction as a whole. I don't know if that sort of fits No.
Answer that question. No, it's complex and,
and I think we need to do a lot more work to,
to address it from multiple different points.
Yeah, I agree. Angles. Yeah. Yeah. You gotta attack
All those things. Well, thank you
so much Dr. Bear. No, thank you.
You're such a champion. Enjoyed, I
enjoyed, I was so impressed.
Yeah. You are an example of success
and I just am so like, I'm grateful.
Yeah. Thank to have you on. I'm so fun to be here.
Thank you. Until next time. Yeah. Thanks. Ah.