By Niki D’Andrea
Dr. Laura Stewart takes an integrated approach to battling opioid addiction
On a Tuesday afternoon in mid-August, Dr. Laura Stewart stands in the hallway of her clinic with a remote control in her hand. She aims it at a black horizontal bar atop a stand – designed to be at eye-level for someone sitting in a chair – and a sequence of blue dots lights up across the bar, with some blinking on the periphery.
The machine, called a light bar, is frequently used in a therapy called EMDR (Eye Movement Desensitization and Reprocessing). Dr. Stewart utilizes EMDR as part of the treatment program at Recovia, the 10,000-square-foot, fully integrated clinic in the Airpark for which she serves as executive director. EMDR was developed in the 1990s and has shown to be effective in treating people who have experienced trauma – particularly people who have PTSD (Post-Traumatic Stress Disorder) – by helping them properly process traumatic memories.
It really works, Stewart says, but nobody is exactly sure just how it works yet. On a subconscious level, the blinking lights and tapping sounds of EMDR somehow replicate the REM (Rapid Eye Movement) stage of sleep in the brain, she explains. That’s considered the “deepest” stage of sleep, associated with vivid dreams and when all sorts of electrical and chemical activities take place.
The modality is also highly effective in treating patients with chronic pain and addiction, Stewart says. EMDR is just one of many things she and her clinical staff use to treat people who are detoxifying from opioids and recovering from opioid addiction. Behavioral health, medical management, physical therapy, functional medicine and occupational/life skills assistance are also important parts of the program.
An Arizona State University graduate with a trio of degrees (Bachelor of Arts in Sociology, Master of Science in Counseling Psychology and Doctorate in Clinical Psychology), Stewart focused her clinical training on the neurobiology of PTSD and addiction at the Veterans Affairs Medical Center in Phoenix from February 2009 to June 2011. Following that, she worked as a clinical psychologist at Southwest Behavorial & Health Sciences for nearly three years. She founded Recovia in February 2015. Stewart says in all her years of research and practice, opioids “are probably the most unique substance I have ever worked with. It’s a beast to get over opioid misuse and abuse and addiction.”
In March, the National Institute on Drug Abuse reported that more than 115 people die every day in the United States after overdosing on opioids, and that roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them. Much has been made of the opioid crisis in media, with former Centers for Disease Control director Thomas Frieden describing America as “awash in opioids” and President Donald Trump declaring the country’s opioid crisis “a public health emergency.”
“When I speak about the epidemic and what we do in programs and in treatment, one of the first things I say is, ‘We have to change the way we look at addiction. Every single person in this room knows somebody who is addicted to opioids,’” Stewart says. “And I can confidently say that, whether they know who the person is or not. They know somebody who is struggling with it, because the numbers are that high.”
“This is not addiction like how we used to think about and label and stigmatize addiction,” she continues. “This is completely different, and it can hit anyone: any race, any ethnicity, any socio-economic class – it knows no boundaries.”
Opioids, Pain and the Brain
Though Stewart stresses Recovia is a recovery program and not a detox clinic, medication-assisted treatment is a key component of her multi-disciplinary approach. There’s a pharmacy onsite that fills Recovia patient prescriptions for Suboxone, a medication that helps ease the symptoms of withdrawal. That’s the first step in weaning patients off opioids.
But the biggest step, Stewart explains, is helping chronic pain patients understand and manage their pain. “Nobody’s super excited about getting off their medication when they start, so getting them to understand the program, what we do, and how we manage pain is a huge part of program success and program buy-in,” she says. “So, a lot of the first week is really psycho-education: ‘This is what opioids did within your body, within your central nervous system. And this is what it did within the receptors in your brain, and this is how it impacts your mood, and ongoing use creates this.’”
Opioids create something called opioid-induced hyperalgesia, “when the nerves are hyper- and over-sensitized because of the pain medication,” Stewart continues. “Usually, (patients) will say, ‘OK, so if I understand you, not only am I physically dependent on this, but my nerves have literally adapted to where they create more pain now because of it?’ And we say, ‘Yep, that’s exactly true.’”
“‘And the reason I feel so hopeless and get so anxious and irritable in between my dosages is because my brain no longer has natural neuro-chemicals to make me feel balanced and content, happy and joyful?’ And we say ‘yes.’”
Many chronic pain patients are afraid to move or exercise because they think they’ll hurt themselves, Stewart says, “and that’s a big mental construct that we have to work on.”
Hence, physical therapy is incorporated into each patient’s personalized treatment program at Recovia, sometimes along with modalities like acupuncture and yoga. “The buy-in comes when they understand why we’re having physical therapy every day as part of our program. It’s a way to get the brain to stop guarding with pain and understanding that pain can actually be a protective mechanism of the brain. It’s real pain, but the brain uses it to guard – kind of a survival mechanism. So there’s a huge neuroscience component to it, and to physical therapy, so they’re not afraid to move,” Stewart explains.
Bill Reese is a retiree from Florida who came to Recovia late last year at the urging of his children, who live in the Valley. Reese had a series of back injuries and failed surgeries that left him in constant pain and sometimes barely able to move. He’d taken high doses of prescription painkillers off and on for almost a decade, and says he still found himself in constant pain and didn’t like taking the pills.
He empathizes with people struggling with addiction. “It overtakes your life as far as the everyday, but you can’t let it take its toll, to where you’re taking more than you need or you’re seeking out additional illegally,” he says. “Sure, there’s a struggle – all you want to do is catch your breath, just breathe without pain for a minute. If you go through a program like hers (Dr. Stewart’s), they teach you how to do that. Is it for everybody? Yes, but it doesn’t work for everybody. I would say probably not everybody, but everyone needs to try it in this situation because whether it helps you 100 percent or a little bit, anything is better.”
Since completing the Recovia program, Reese has traveled a bit around the states and looks forward to spending more time with his family. He calls Recovia “an excellent program.”
“Dr. Stewart understands what you’re going through because that’s what she studies, even though I didn’t understand what I was going through at the time,” Reese says. “She saw huge changes in me as I went. I learned to deal with the pain physically and mentally.”
The Recovia facility includes a physical therapy area full of treatment tables and exercise equipment. That comes as a surprise to anyone who is expecting a traditional group-meeting rehab setting (though there are group sessions at Recovia, as well).
Phoenix firefighter Ernesto Altamirano, who completed the six-week Recovia program in June, didn’t know what to expect when he first came to the clinic. “My thought of how a program is supposed to be is, you go into a group and sing ‘Kumbaya’ with a bunch of people. I didn’t know,” he says. “But going to Recovia has been great, from the first day I walked in, as a matter of fact.”
“Dr. Stewart is amazing,” Altamirano continues. “The way they run things there is pretty incredible, from the counseling individuals to group, from the physical therapy that you have to go through and the heart map, the acupuncture that they do, the yoga. There’s so many different things, and these people aren’t judging me. They’re genuinely there to help.”
And people need help in all sorts of areas. Stewart emphasizes that an integrated, multidisciplinary approach is the most successful for treatment of opioid addiction. “In the state of Arizona, a lot of the ways that we’re providing treatment is not necessarily evidence-based for opioid addiction,” she says. “So you can go and get treatment and you might be inpatient for five or six days, and then you come out and say, ‘OK, I did treatment and I detoxed and now I should be better,’ and the mechanism of opioids don’t work that way. Opioids have a one-two punch. They impact psychological function, they impact physical function, and it takes a while for the brain and body to get back to even close to baseline. And if there’s no treatment wraparound with that, people aren’t getting better.”
“There’s a lot of good treatment facilities in the state of Arizona, and there’s also some not-so-good ones,” Stewart continues. “So I’m always thankful when people make their way to one that gets it, and they do understand it, and they’re providing evidence-based treatment programs.”
For Altamirano, Recovia wasn’t anything like he expected it to be, and it turned out to be one of the best things in his life. He remains opioid-free and has resumed going to the gym with his sons and spending quality time with his wife. “(Dr. Stewart) even reached out to my wife, just to make sure my wife was OK,” he says. “She asked me, ‘How’s your wife? Who’s her support system? She needs to have a support system through this, too.’”
During the last week of his recovery, Altamirano had expressed how supported he felt at Recovia. “I’m looking forward to going there. Like, my weekend goes by and I’m excited to go there. I can almost say that most people that have addictions aren’t excited to go to rehab,” he said over the phone, on his way home from one of his final treatment sessions. “But you do your yoga and your stretching and it’s all tied in.
“So when you come out, you’re like, ‘Oh man, I’m good. I’m so good,” he continued. “And then you feel good about yourself, you feel good about what you’re doing. You just feel good about everything.”
Dr. Laura Stewart