Alcohol & Drug Recovery: Learnings from 40 Years of Care

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: August 1, 2025
Expiration Date: July 31, 2026

Estimated Time of Completion: 30 minutes

Alcohol & Drug Recovery: Learnings from 40 Years of Care
David Streem, MD

Description
Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience
Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director
Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer
Cindy Willis, DNP

Faculty
David Streem, MD
Psychiatry and Psychology

Host
Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Alcohol & Drug Recovery: Learnings from 40 Years of Care
David Streem, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast August 1, 2025 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neurorehab, and psychiatry.

Glen Stevens, DO, PhD: In 2023, the national survey on drug use and health estimated that 48.5 million Americans age 12 and older have a substance use disorder. This includes 28.9 million people with alcohol use disorder and 27.2 million with drug use disorder. In today's episode, we're discussing how a tripartite approach in leveraging clinical care, education and research has allowed Cleveland Clinic to provide 40 years of care for those pursuing alcohol and drug recovery. I'm your host, Glen Stevens, neurologist neuro-oncologist in Cleveland Clinic's Neurological Institute. And joining me for today's conversation is Dr. David Streem. Dr. Streem is director of Cleveland Clinic's Alcohol and Drug Recovery Center, part of the Department of Psychiatry and Psychology and the Neurological Institute. David, welcome to Neuro Pathways.

David Streem, MD: Thanks for having me, Glen.

Glen Stevens, DO, PhD: David, to get things started, why don't you just introduce yourself to our listeners, where you did your training and what you do here at the Cleveland Clinic.

David Streem, MD: Well, I'm a lifelong Clevelander. I had the privilege to attend med school at The Ohio State University, and I did my psychiatry training at Cleveland Clinic, followed by a fellowship in consultation psychiatry here as well. I do wear a lot of hats at this point in my career, but my primary focus is serving as the Gregory Collins Endowed Chair in alcohol and drug rehabilitation. And that entails leading the alcohol and drug recovery center operation. I also work in electronic health recovery programming and documentation, and I'm the compliance officer for the Neuro Institute.

Glen Stevens, DO, PhD: Well, thank you for all you do. It sounds like you do have a lot of hats. If we look at addiction, and you can correct me if I'm wrong, but it's a chronic condition characterized by a compulsion or compulsive need to engage in a behavior or in what we're talking about today, a substance despite harmful consequences. What happens to the brain with substance abuse? Why has it become a problem?

David Streem, MD: Well, one of the fascinating things to me about addiction and what happens in the brain is that the structures that are primarily involved in addiction and become dysfunctional are subconscious. They're primitive parts of the brain, parts of the brain that are present in lower mammals and even lizards and other things. And these don't generate conscious thought, but they connect through those connections to the frontal lobe and other areas of the brain that do, they very insidiously corrupt the thinking that sounds like our own thinking, so that little voice in your head that directs you and gives you judgment and leads other people to rely on your wisdom, all of that gets corrupted by addiction. And helping people to understand what parts of their mind they can trust and what parts they can't has been a very enriching and interesting part of my work.

Glen Stevens, DO, PhD: If we look at substance, you take a substance, whether it's alcohol or some other type of drug, it stimulates neurotransmitters in the brain. Can you talk about that a little bit?

David Streem, MD: The big factor is that these drugs that are associated with use disorders cause releases primarily of dopamine, but of other neurotransmitters in sometimes one and a half, sometimes two, sometimes three or more times the concentrations that you'll see in more quote unquote "natural" reinforcers like food, water, and sex. That causes desensitization in those addiction parts of the brain, primarily the nucleus accumbens, so then what that leads to is that the things that are normally reinforcing, again, food, water, sex, and other reinforcers associated with those inputs become less interesting. They attract our attention less. And so what the person with addiction develops is their sole interest becomes obtaining the drug, using the drug, recovering from the effects.

Glen Stevens, DO, PhD: I do hear people talk about a runner's high, do they get increased dopamine from that? Is that a true thing or not?

David Streem, MD: That's part of it, yes.

Glen Stevens, DO, PhD: We'll just shift gears here a little bit, and we all know that substance abuse disorders are not a new phenomenon clearly, but the Cleveland Clinic's been at the forefront of this for many, many years. Can you take us through a little bit of history about the different epidemics? We hear a lot on TV, about certain types of things that we faced as a society from an addiction standpoint over time?

David Streem, MD: Well, in the 1980s the primary drug use that was seen was cocaine, either in powder form or as crack. And then in the 1990s that started what we now know as the opioid epidemic, which started as a prescription drug problem and has since morphed into a heroin problem. Then fentanyl and carfentanil. Most recently, the pendulum has shifted back to cocaine, but with the new twist that cocaine is increasingly laced with fentanyl and also powders that are sold as fentanyl increasingly are laced with xylazine. And that's led to a huge increase in the lethality of the general illicit drug supply. And then underneath that, all of this has been the damage that alcoholism has wrought all over the country, that's a constant.

Glen Stevens, DO, PhD: You had mentioned at the start that the clinic has had a program for a long period of time. Take us through the evolution of that going back probably 40 years or so, and probably we'll talk a little bit about Dr. Collins and his involvement with the program.

David Streem, MD: Just by way of context, so Rene Favaloro pioneered the field of coronary artery bypass grafting in the late 1960s. And in 1961 the psychiatry department was created under Dixon Weatherhead. Fast-forward about 20 years after the creation of the department, and in 1980, Richard Steinhilber was the psychiatry chair who recruited Dr. Collins to come from Metro to start a program here. He later brought his colleague and addiction counselor, Dr. Joseph Janis, and they got right to work creating the Inner Circle program with Coach Sam Rutigliano and the Cleveland Browns, which quickly became the model for addiction treatment for pro athletes. By 1985, they really had just started getting going and they opened a dedicated hospital unit the same month that the iconic Crile building opened.

It was the same month in September, Dr. Collins partnered the professional psychiatric care with an active AA volunteer group and an alumni association that supported people in recovery. Hospital treatment added then to our outpatient treatment and the department's historical strength in hospital consultation, so all of that merged together, and that was really the start of the program and the foundations that Dr. Collins and the team at that time laid. And it's really a remarkable story because at the time, again, you're talking about the Cleveland Clinic having maybe 200 doctors at that time, and so they really accomplished a lot early on in the history of the center.

Glen Stevens, DO, PhD: And comorbidities, psychiatric comorbidities, I imagine pretty high with the substance use disorders. Can you comment on that?

David Streem, MD: The importance of this underscores the importance of universal screening. When people into our program, they get screened for a variety of psychiatric conditions in particular, depression, bipolar disorder, social anxiety, and the number one is trauma and post-traumatic stress disorder. It's my firm belief that if we don't adequately screen and identify people with these disorders and then effectively treat them not just with medications, but with the best evidence-based psychotherapy that is out there, if we don't do that, then we're setting ourselves and our patients up for failure, so it's really important that we address all of that right from the start.

Glen Stevens, DO, PhD: I've always looked at substance use disorders in some ways like cancer, that these are very serious medical problems. Do we have an idea of the life expectancy of individuals that develop a substance use disorder? I'm sure it's a little variable depending on the substance, but is it different than the average population? Is it similar?

David Streem, MD: The presence of a substance use disorder is definitely going to reduce the average lifespan of that population. But one thing that I think is a cause for great hope is we've been studying the long-term health and safety of people in recovery, particularly physicians in addiction recovery. And one thing we've learned from all of that research is that people in recovery who are appropriately monitored and don't have a return to use in the first five years of their treatment are less likely to have a return to use than the incidence of substance use disorder in the general population.

Someone who's been in recovery for five years and has done well and has not had a return to use, who's working a good program, they're less likely to go back to using than a random person off the street, is to develop a new addiction problem. It's really hard to ask a treatment program or a service line to do better than that, so I think that's a tremendously hopeful thing that these are folks that we don't have the luxury of wasting them in our society. And if we can give them that even five years of sobriety and support their growth and recovery during that time, then they're going to be important productive members of our society very likely for the rest of their lives.

Glen Stevens, DO, PhD: Let's dive into the tripartite pillars of the program, how has clinical care for these patients evolved over that 40-year period of time?

David Streem, MD: Well, there have been huge changes over that time, but the two changes that I would focus on most would be the length of stay in the hospital has shortened dramatically. When I started at the clinic in 1995, the average length of stay on the ADRC unit was probably two, two and a half weeks. Now it's three and a half days, so we have to do a lot of work in a short time for each patient if they're going to be successful. And then the second is the development of medication treatment for addiction, particularly buprenorphine for opiate use disorder and also naltrexone for opiate and alcohol use disorder.

Glen Stevens, DO, PhD: And the ADRC, can you remind me what that stands for?

David Streem, MD: Alcohol and Drug Recovery Center.

Glen Stevens, DO, PhD: And all this is being done on campus at Lutheran now, is that correct or no?

David Streem, MD: We have a location at Lutheran, and then we also have a location as part of Cleveland Clinic Akron, that's based in Fairhill.

Glen Stevens, DO, PhD: And research into the field, so what's new in the field? Maybe even touch on genetics a little bit because I assume there must be individuals who must have a predisposition.

David Streem, MD: Genetics accounts for about 60% of the variants in who develops a use disorder and who doesn't, so genetics are a very important part of the research in the field in general as opposed to oncology where research and clinical practice are so intermeshed and intertwined. In addiction medicine in my experience, the two areas are often very difficult to mesh. Research is often just very separated from clinical practice and organizations very rarely do both well, so our focus has always been on the clinical practice side, but we're actively increasing our research participation, particularly in the area of alcoholic liver disease. These are in very close partnership with our colleagues in hepatology. We've also had the opportunity to collaborate with cardiac surgeons and the infectious disease group here to develop an innovative approach for people who inject drugs and experience endocarditis. That's been very exciting, and we were honored with the CEO award for that work in 2021, and we contributed a chapter in the latest Cleveland Clinic textbook on the treatment of endocarditis.

Glen Stevens, DO, PhD: I just want to get back to genetics just to try and understand a little bit. Can we test anything, do a blood test or check anything to determine what someone's risk might be? Or is there a profile that we can tell or not at this point?

David Streem, MD: There are genetic markers and genes that we know are associated with particularly alcoholism. There has been some research looking at whether, for example, naltrexone is more effective in people who have that gene as opposed to people who don't. And there was one very exciting study that showed a huge improvement in the outcomes in that situation, but unfortunately it couldn't be validated. We do, I would say the most basic, but arguably most cost-effective genetic testing available, which is asking patients about family history.

Glen Stevens, DO, PhD: And the outcomes over the forty-year period of time, do you track that? Relapse rates, I'm sure it varies depending on which generation and which substance you're looking at, but comments on that?

David Streem, MD: I think the biggest challenge has been in the years from about 1995 until maybe 2007 or 2010, where the opiate epidemic was simply running rampant all over the community, all over the US. And availability of medication treatment was still very thin, and the relapse rate without medication assistance in treatment was and still is about 90, 95%. That was a very, very difficult time, and it was very challenging for us. That was, at that point, buprenorphine prescribing was limited by federal law to 30 patients per organization, per practice. Dr. Collins and myself, and there was one other wonderful provider, Dr. Covington, we had to share between the three of us, 30 patients, which was really, really tough. Now there's essentially no limit. And so we're able to be much more aggressive about treating patients in an evidence-based manner. And when you look at that compared to non-medication treatment, medication treatment the return to use rate is somewhere on the order of 50% or so, 40 to 50% in three months to a year, so much more effective. We can still do a lot better though.

Glen Stevens, DO, PhD: And the importance of a social program like AA involved with this treatment and long-term benefits?

David Streem, MD: Well, one of the advantages of being in Northeast Ohio, of course, is we're not far from Akron, which is the founding location of AA, so there's tremendously deep AA routes in Northeast Ohio, and we've always been very open to accepting and encouraging of twelve-step-based recovery work. That's not the only possible answer, but in an environment, in a community like ours, to not take advantage of 100 years of recovery wisdom from Alcoholics Anonymous would be not taking maximum advantage of all of our strengths in the area, so we do do that, but that's not the end of the story, certainly.

Glen Stevens, DO, PhD: One of the things I did in medical school many, many, many years ago was they had the medical students attend AA meetings, but they did it to really help you understand what's going on and the flavor. I found it fascinating. I'm not sure if they're doing that in medical school programs now. You could probably answer that, but I thought it was really impactful and really helpful.

David Streem, MD: That is absolutely a requirement in the Cleveland Clinic Learner College of Medicine. It's a requirement that I insisted on when we developed the curriculum and the fact that at Ohio State, that was a requirement in my medical school career and that then inspired me because I had no contact in addiction treatment before that, no experience with that at all, that really fueled my fascination with this whole part of medicine. And that's the point that turned my career, I would guess, so to me, it's really important.

Students who attend at least one AA meeting, sooner or later, they're going to confront someone, whether it be a colleague or a patient, and they're going to encourage them, or they should, "You should try to go to an Alcoholics Anonymous meeting." And the understandable response from patients a lot of times or colleagues is going to be, "Hey, you're telling me to go to an AA meeting, have you ever done it?" And for each and every one of those students that's been to one AA meeting for the rest of their career, they can quickly answer that question and say, "Yeah, I did," so it's a very, very important thing.

Glen Stevens, DO, PhD: Well, congratulations. I do think it's great. It was certainly impactful for me. I remember it all these years later. One thing we never like to talk about, that's insurance. Any comments about coverage for these programs? I'm assuming they can become quite costly.

David Streem, MD: It's always a struggle. It's a battle that we fight on behalf of our patients. Just like every caregiver in all of our healthcare organizations, it's a battle that we fight every day. It's as frustrating as it's ever been. But I think there's also reasons for hope in terms of the development and the tools that we have available and what we're doing to try to control the costs, particularly of the pharmaceuticals.

Glen Stevens, DO, PhD: You mentioned a little bit the next generation, and we did discuss that briefly that all the medical students are doing it, but what are we doing for the next generation or where's this going to go from here?

David Streem, MD: Our approach has always been that we'll teach anyone who's interested in learning, so we're currently teaching faculty for psychiatry residencies all over the city. There's four psychiatry residencies in the city, and we're a teaching site for all of them. We're a teaching site for an addiction medicine fellowship and for other fellowships. My colleague, Akhil Anand, stepped up to lead a city-wide addiction psychiatry fellowship in partnership with the other major health systems in Cleveland, which is a huge accomplishment. Our latest teaching partnership is with Mayo Clinic, and that's been very exciting.

Glen Stevens, DO, PhD: Well, I'm very glad to hear that. It certainly does give hope, no question about it. Final takeaways for our listeners or things we haven't discussed that you feel are important?

David Streem, MD: Well, as a former engineer, I'd be remiss in not pointing out the importance of leveraging technology to be able to help patients when they need help, in the manner they would like to receive that help, virtually or in person, in hospital or ambulatory, today or tomorrow. And making sure we always have access to state-of-the-art, evidence-based medications and other therapies that help people recover. If we have these tools we're in an organization at the Cleveland Clinic where amazing things happen all the time.

Glen Stevens, DO, PhD: Well, David, thank you so much for joining me today. The field has changed a lot over time. I heard some very hopeful things for you. Congratulations for 40 years of work. I have the privilege of knowing Sam Rutigliano, so a wonderful man, no question about that. And I was unaware of his involvement with this, but it makes sense with the type of person that he is, so kudos for that. And we hope it only gets better and clearer days ahead for all those that suffer from this very difficult disorder. Appreciate it. Thank you.

David Streem, MD: Thank you, Glen.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.