Revolutionizing Opioid Recovery: Personalized Aftercare at Domus Retreat

Discover what truly sets Waismann Method and its Domus Retreat aftercare program apart in the realm of opioid detox and recovery. In this insightful podcast episode, Dwight Hurst, LPC, interviews the program’s medical director, Michael H. Lowenstein, MPH, M.D, and David B. Livingston, LMFT, Domus Retreat clinical director.

Tune in as they unveil the meticulous and individualized approach adopted at Domus Retreat, Waismann Method’s exclusive post-detox facility. The conversation highlights the crucial role of individualized aftercare in the post-opioid detoxification process. A deep dive into the lesser-known implications of opioid-induced hyperalgesia reveals how extended opioid use can counterintuitively amplify pain sensitivity.

With a firm belief in crafting tailored treatments and fostering patient empowerment, the experts share insights from their vast experience, painting a vivid picture of the opioid recovery journey. 
For those seeking a deep understanding of medical and therapeutic interventions in opioid addiction and the journey of recovery, this episode is a must-listen. 

Dwight Hurst, LPC: And it looks like we’re on with everybody. It’s so nice to be here with the two of you again so soon. Welcome back everybody who is watching or listening to this, this a video recording, an audio podcast about addiction recovery and mental health. It’s a podcast by Waismann Method opioid treatment specialists. And I am so grateful to be joined by two of those preeminent specialists, not just at the Waismann Clinic, but so throughout the world, literally, as we’re going to get into, I’m your co-host, Dwight Hurst, and I am joined today by Dr. Michael Lowenstein, who is the world’s authority on anesthesia assisted opioid detoxification and rapid detox, and by David Livingston, who is the clinical therapy director in Wiseman as well. So, gentlemen, we want to crack right into this. The purpose of today is to focus a little bit on the aftercare side. Last time we were together, we talked about how important the pre-preparation setup before detoxification can kind of be a make or break for success. And I think we’ll find that just as much on the back end or other end. The aftercare is certainly at least as important. You guys can tell me if it might even be might even be more. And of course, with the the Waismann Method, we have the benefit of having the Domus Retreat, the aftercare option for patients coming through rapid detox. And we’ve shared a little bit about that on the show. But why don’t we get into a little bit of what is some of the design and purpose of that? I know that in some cases people look at it, and unfortunately, some programs might even make these claims that you go through detoxification and you’re essentially cured of your dependence and go out into the world, and so to speak, what are some of the considerations or even the reasons to have an inclusion of aftercare like Domus?

Michael H. Lowenstein, MPH, M.D.: So the Waismann Method that we do, I think that’s really a three-step process, right? We’ve got the patients admitted to the hospital and we pre-evaluate them and we pre-treat them and optimize their their physical or physiology to undergo the rapid opiate detox procedure. And then you have a rapid opiate detox procedure that’s done in the hospital setting where the patients can be carefully monitored and safely, comfortably be detoxed. And what we’re doing in the hospital is we’re treating the opiate dependence. And opiate dependence is the physical aspect of what happens when you take opiates for a period of time and you stop them and you have a withdrawal. And whenever we mention rapid opiate detox, we’re regardless of who’s performing it. It really is detox that’s being performed under sedation with the introduction of an antagonist medicine such as naloxone or naltrexone to accelerate or precipitate the withdrawal. So there are those out there that claim that once you’ve been detoxed rapidly, then you’re cured, which really does a huge disservice to patients, especially you think about young people. They are opiate dependent, they’ve been treated, and then they’re told they’re cured. And nothing could be further from the truth. Their opiate dependence is treated, meaning that they’re not going to withdrawal. And they’ve been transitioned to an opiate antagonist, which will such as naltrexone, which will block the cravings and hopefully significantly reduce the risk of relapse.

Michael H. Lowenstein, MPH, M.D.: But that’s just the beginning of the process. So we’ve treated the opiate dependence, and now we have to address everything else that’s associated with opiate use. It could be underlying psychological issues. It could be environmental issues, family issues. Um, we’ve just completed the very first step of what can be a potentially very long process. So to tell somebody that they’ve been cured is a huge disservice. And it’s actually very dangerous because then they’re not going to get the necessary treatment that they need to be successful long term. And that’s why, you know, the definition of addiction is that revolving door. So we want to stop that and make people successful long term. So the importance of aftercare, many programs will just discharge people to a hotel room with family members or friends, which again, is a disservice because that’s not the job of family member or friends is to take care of these patients after they’ve received a medical procedure and have all this other work to do. So what Domus Retreat aftercare does is it provides medical and psychological support to the patients while their body finds its new normal.

Michael H. Lowenstein, MPH, M.D.: And that’s basically what happens. So physiologically, it has to find its new normal, because we know that opiates affect neurotransmitters and hormones and receptors and the gut and sleep-wake cycles, and there are just so many different body systems that are physically or physiologically affected. And then also a lot of people use opiates as kind of a numbing device. Right. So it’s also numbing all the underlying psychological issues that you take away the opiates. And then you’re now facing all the underlying psychosocial issues that again have to be addressed. So if we can put somebody in a supportive environment and

Domus Retreat is a licensed aftercare facility that’s professionally staffed medical, um, psych, we have a lot of different services to support the patients, um, patients from if we’re just talking from a medical standpoint, their gut has to find its new normal, their sleep-wake cycles have to be restored. The majority of patients I treat have underlying sleep issues. So we’re addressing all of those issues in a very supportive environment. And patients are with us anywhere from 4 to 14 days after the detox, because our goal is when we send them home, they’re in a good place mentally and physically. Um, and they’re ready to go face reality again.

Dwight Hurst, LPC: Yeah, yeah. It’s so important. And when we have something with any mental health or addiction-related disorder, a lot of times it begs the question, do we really treat it as a medical situation with medical treatment? Right. How we approach that? David, I’m curious too, as the clinical director over Domus, what role do you feel like psychotherapy and individual sessions with people? That kind of approach plays in some of the emotional and psychological changes and, and obstacles people go through following detox?

David B. Livingston LMFT: Um, I’d say initially there’s kind of a reorientation. They’re coming into their bodies again. They’re feeling their feelings at a heightened level. Um, so initially it’s just giving some perspective, helping them understand what Dr. Lowenstein is talking about in terms of the physiology, along with how that coincides with their emotional life. And then as that stabilizes, as they get some sleep, as they start to feel better, then then and sometimes this happens very quickly. Sometimes it takes a day or two. They will begin to talk about the things that have led them, to be with us and what their needs are moving forward, and they vary greatly. So I would say, as Dr. Lowenstein does, he’s got a tremendous amount of experience. I do too. I know what to look for as it has to do with opioid use. I know a lot of questions asked, and I can usually do that quickly and begin to get a picture because they’re not really the patients who haven’t with us for a long time. However, you can make progress pretty quickly if you have the right understanding of what to look for. So it varies so greatly. But sometimes there are very often there underlying minor or major psychological issues that are untreated. And if they go untreated for too long, that is part of what creates the revolving door, as Dr. Lowenstein is talking about, because. Um. Opioids are generally used to bring down tension, okay, I would say in a global way. So tensions can come from anything. You don’t sleep well. You’re going to accumulate tension from the effects of not sleeping well. If you’ve got an anxiety disorder and everybody has some anxiety. But if you push yourself too much at work or there’s a lot of loneliness in your life, or there can be many things that are going on and to begin to address those factors and look at how those tensions have accumulated or can be can accumulate again, begins to sort of reorient towards a position of potential success and what’s needed moving forward.

Dwight Hurst, LPC: This is a good question, probably for both of you. When we look at what is treatment like, what is a treatment that is applied? Psychotherapy is one example of that. And obviously detoxification and prescription, post-care prescriptions and medications, those kinds of things are both examples of treatment. Let’s broaden that out a little bit to look at some of the other elements of treatment that happen in Domus Retreat. What kinds of things would people find themselves doing throughout those days that they’re they are there.

David B. Livingston LMFT: Or the first part is, I think, just really coming back to themselves. People take opioids because life is too much. There’s too much going on, and a lot of other places either don’t give enough or they just load you up with session after session after session. So, you know, we’re really put together to try to find a good balance to that where there’s they can have time to themselves. There’s some intensive psychotherapy where we get to get down to some of the deeper issues as they feel up to it and ready. And in terms of what a treatment is, in essence, it’s understanding what needs the person is having that are not getting met. Well, so if your need is to sleep okay, well, we have to figure out what that is. If you are pushing yourself at work and your life, maybe you have a really good life. We see people have really developed lives. They’re pushing themselves so much at work that there’s a discrepancy between their outside life, which is going very well, and how they feel internally. So the opioid is taken off and to fill that gap. So I feel better, at least temporarily. And then, you know, now you’re into a cycle that doesn’t work. But so you look for what are the needs that aren’t being dealt with well or need to be met.

Dwight Hurst, LPC: That’s one thing I appreciate about the philosophy. A lot of times myself as a therapist, a lot of times I’ll see people who they feel like immersing themselves into the ins and outs of addiction and even the therapy world, that so much so that people can like all they do is they listen to obviously, podcasts like this, obviously we’re in favor of that books. Obviously, we’re in favor of that, right? Therapy, obviously all these things. But sometimes there’s also a need to say you need to do some other stuff. Don’t just immerse yourself 100% in the addiction part and instead look at the health part, you know, things like physical exercise, other types of, I don’t know, supplemental, supplemental type of healthy behaviors. And it sounds like that’s part of the goal is to get people on that road as well.

Dwight Hurst, LPC: Certainly.

Michael H. Lowenstein, MPH, M.D.: Yeah, I think it’s important. I always talked about patients trying to establish and find balance. Right. And pills just are not the answer or drugs to finding balance. And so you’re right. So you need therapy. You need at Domus there’s massage. There’s or there’s um yoga. Um, we you know, I think part of it is just patient people learning to be comfortable with just being with, by themselves, um, not always relying on other things. So we do use some medications at Domus to transition, um, and help to reestablish good sleep. But exercise, nutrition, sleep, therapy, um, you know, just finding that balance in their lives because a lot of patients or people just go, go, go, go, go. And I think that’s kind of what, you know, David was referring to as well. The other thing I’d like to mention is that we’re not just treating opiates anymore. So if you look at the drug supply, a significant percentage of the patients that show up to be treated are positive for methamphetamine, they’re positive for cocaine. We know that there is xylazine and animal anesthetic in in the medications. Now there’s people that are also drinking. So we’re not just stopping opiates when we detox them. We’re stopping all of these other medications. And while there may not be a specific detox for these other, their body still is recovering, um, or detoxing from these. So it’s another reason why an aftercare like Domus Retreat is so important because we are they are detoxing from the opiates, which, you know, we’ve successfully treated that dependence, but their body’s got to find a new balance from not only psychological balance but now physiologic balance after having all of these substances discontinued. So aftercare is just so essential.

Dwight Hurst, LPC: What are some of the importances that you think of having? I mean, as we’re talking here? We have a minute. Excuse me, medical director, clinical director. We’ve got those things that are there. We’ve touched on this already a bit, but let’s draw that out a little bit more. What’s the important contrast there between that and being in a program that maybe I mean, let’s go from like as you said, leave it all the aftercare in the hands of friends and family. I think you can go up a bit and say, sometimes there’s even volunteers in some organizations, and then you go up another level and maybe it’s done by paraprofessionals, mostly things like that. What are some of the benefits of having a highly trained staff surrounding these, these individuals?

David B. Livingston LMFT: Um, I think in general the overall experience reinforces well-being, period reinforces sobriety. When expectations are met, largely you feel you calm down, you feel a sense of um, trust gets, gets, gets better. And so the better. Everybody’s doing their job, the more that your expectations are getting met, the more that it solidifies your recovery. I really think that. And so that’s one of the things that we try to do is really give them a good experience. Here is Dr. Lowenstein was suggesting, you know, one of the things is we try to find a balance between not too much stimulation, but enough, because one of the things is you have to begin to bear your own self in order to stay sober. You’ve got to be able to bear how you feel and so forth. And I think if you’re overloaded with meetings or not giving any support or help, either way you’ve got to find the right balance, because ultimately balance really is, you know, what’s needed for all of us, for health. And everybody is a little different about what that means to them.

Dwight Hurst, LPC: Yeah. And so kind of giving people a sense also of empowerment to say in a way, here’s the guidance and here’s we’re treating this as a problem that requires a professional intervention, but also at the same time empowering people to find that balance instead of I know we’re always careful not to send that message that, oh, you got into trouble with this and you don’t know what you’re doing and you can’t take care of yourself. So there’s an important balance there of empowerment versus also saying this is serious enough that you do need professionals that are with you.

Michael H. Lowenstein, MPH, M.D.: Yeah, I think it’s also important that we have the ability to not take a cookbook approach to treating people. So from the medical procedure, it’s individualized to each person. Right. Because everyone has different underlying issues. What they use and why is different. So starting in the hospital the treatment is individualized. And then I think at Domus Retreat it’s the same thing, is that we’re able to really specifically address each patient’s underlying issues and tailor the treatment specifically to what their needs are. And David’s phenomenal at making sure that happens at Domus Retreat.

Dwight Hurst, LPC: How do you approach that, David?

David B. Livingston LMFT: And say that again. I’m sorry.

Dwight Hurst, LPC: How do you approach that?

David B. Livingston LMFT: Um. You mean the individual part of tree? Yeah, I mean, I listen, and I get to know the person. And because we do individual therapy and we and I take time to, sit and get to know them, I they’ll tell you what they’re needing. They’ll tell you what the problems are and. Uh, and as they tell you, they begin to understand themselves better. I mean, we really kind of speak ourselves into existence. So once you start to tell your story, you actually start to see who you are, who you’ve been, where you want to go. Um, if you if the hardest question I ask people is often, what do you want for yourself? Because one of the terrible things about addiction and is that it limits imagination. If you used to love music, people stop listening to music. If you used to see your friends or like traveling, all of that tends to halt over time. And so there’s this expansiveness again, where there’s a new sense of agency. And in order to stay sober and build a good life, you have to begin to reignite that sense of your own agency, your own imagination, your own feeling of what it is you’re looking forward to because that culminates in why you’re here.

David B. Livingston LMFT: So as those things begin to take hold, there begins to be a feeling of a course forward again. And that’s critical. Uh, our dopamine system is an anticipatory system. Dr. Lowenstein can speak on this better than I can, but it’s an anticipatory system. What happens is, when someone’s on opioids, the only thing they anticipate over time is the opioid to regulate their system. If it deadens pain, it’s also going to deaden everything else. So as that happens, they’re not getting any dopamine hits. And all of a sudden if you begin to reestablish some sense of what it is they want to do moving forward, you reignite that, um, that anticipatory system, they actually start to get dopamine hits, usually when people call and they decide to come in to see us, they already start to feel better for that reason. So that’s a that’s a big component.

Dwight Hurst, LPC: Yeah… As before we wrap up for today, I wanted to ask you guys if there are experiences or stories. Obviously, we have confidentiality completely. But any kind of general experience or stories you’d like to share with people about working through this aftercare process with people.

David B. Livingston LMFT: Um. Oh, there’s so many different ones. So there’s a fair amount of people who will come in who have. So you could say there’s nature and there’s nurture. Okay. Dr. Lowenstein and the medical profession deals more with nature. I tend to deal more with nurture, but they both go together. So I will see people who come in who basically are on opioids because they don’t sleep well. You might say they’re just like an engine that revs high. Okay. So it’s hard for them to slow down. They tend to be high achievers often. And so, you know, I saw I saw a man once who was running 8 to 10 miles, waking up every day, waking up at 4 a.m. and we started talking and I’m like, okay. So I diagnosed him. I said, I’ve seen many people do well on this medication. Do you have a doctor or psychiatrist? Yes. Go and ask him and see if this is… he thinks this would be right for you. He did. You know, I asked him, have you ever taken a nap? No, I haven’t taken a nap ever, you know. And so he got on a medication. He followed through on the treatment and I talked to him a couple of weeks later. He said, I just took my first nap in 30 years. And so that doesn’t happen if you just it doesn’t happen. And a lot of people we see are resistant to getting treatment and care. Maybe they haven’t had good experiences, which is why I’m saying one of the foremost things we need to do is give them a good experience so that what we’re doing and the work they’re getting done with us moves forward.

Michael H. Lowenstein, MPH, M.D.: Let me add to that question from… So my background is.

Anesthesiologist, pain management and opiate detox for the past 30 years. So there’s a phenomenon that’s called opioid-induced hyperalgesia, which people take opiates for a long period of time, causes changes in their brain that makes them more sensitive to pain and less tolerant. And oftentimes the dose of opiates escalates for that reason. And in the days of prescription medicines like OxyContin, then that the prescription meds would just increase, increase, increase. But now that those are harder to get Ahold of on the street, those patients will then switch to fentanyl, heroin, things like that, and becomes a whole different animal.So we tell patients who have taken large amounts of opiates for years, they’ve had multiple surgeries, that their pain will probably be better off the opiates. That can be a hard sell.

Michael H. Lowenstein, MPH, M.D.: So part of the reward of doing this is explaining to people the concept of opioid-induced hyperalgesia, telling them that it may take 4 to 6 weeks for their brain to find its rebalance and find its new normal, and to tell them that for the next 4 to 6 weeks, you just got to give it time. And then let’s see where your pain is at that point. And it’s interesting, many of these patients, the day after they’ve been detoxed, you know, they come in and they say, oh, my pain is at nine over ten on all these meds. And the day after they’re not even mentioning their pain anymore. So it’s a very real phenomenon. And it’s very rewarding because these patients on an outpatient basis, they’ve tried to wean, they’ve tried to get off their pain meds, but it’s so, um, it’s been such a part of their existence for so many years that to see them get off the opiates and have significantly less pain and their pain, they still will have pain. But I tell them at the end of 4 to 6 weeks, whatever, there is real pain versus opioid-related pain, and the majority of patients have significantly less pain off their opiates. So that’s one of the from a medical or physiologic standpoint, it’s a very rewarding thing to be able to take these patients from very large doses of opiates to being opiate free, and to see their pain actually get better.

Dwight Hurst, LPC: And that’s one of the big obstacles, oftentimes, not only the pain of not only the fear of pain that the opioids were were at first maybe addressing, but also then the fear of withdrawals, which obviously the detoxification can help with both of those, those obstacles, as can the aftercare. And I find that it’s interesting, as you said, David, sometimes even knowledge knowing and taking a couple steps already feels better. And that knowledge that you guys just have shared with us today definitely, definitely could make me feel better approaching. So hopefully it’s something that people need as well.

Dwight Hurst, LPC: I’ll just say one thing and Doctor Lowenstein is right, the number of people who afterward report to me and so surprised that their pain level is so much lower, um, it’s they’re shocked because they get on an opioid and it probably helps. Pain for a while, so they’re not anticipating. It doesn’t really make sense to them that the opioids they’re still taking after all these years could actually be exacerbating their pain. And then they get offered and they’re like, why is my pain lower? And you know, and so hyperalgesia is a real thing.

Dwight Hurst, LPC: Well, thank you for this opportunity to share and to talk about this. As always, everyone out there, thank you for listening and watching. If you are just listening to audio only, please go over to opiates.com or go to any of the social medias @opiates in order to find some links to this or see our videos and how that is put together. Or if you’re listening right here on the podcast, please share and give us a high rating if you would on these podcasts. It helps algorithms to share us apparently with other places and things. So as you are looking for information which you obviously must be, you’re an information seeker if you’re here with us. So remember to keep asking questions, because when you ask questions, you can find answers. When you find answers, you can find hope. We’ll be with you guys again soon. Thank you so much.

David B. Livingston LMFT: Thank you!

Michael H. Lowenstein, MPH, M.D.: Thank you.