34th AM (2023) - Founder's Award: From “Addiction vs. Psychiatry” to “Addiction Psychiatry”: A Career Journey-Founder's Award: From “Addiction vs. Psychiatry” to “Addiction Psychiatry”: A Career Journey

Founder's Award: From “Addiction vs. Psychiatry” to “Addiction Psychiatry”: A Career Journey
Video Transcription
I think we are almost ready for our next exciting session, our fireside chat with Founders Award winner Dr. Weiss.  He will give us a brief presentation followed by his interview conducted by Dr. Shelly Greenfield who is the winner of last year's Founders Award.  We look forward to a great session and I'm going to hand it over to our AAAP President Dr. Mooney who is going to introduce Dr. Weiss.  Good morning everyone.  I am very excited to have the honor of introducing Dr. Roger Weiss to you all today. Dr. Weiss is a Professor of Psychiatry at Harvard Medical School and Chief of the Division  of Alcohol, Drugs, and Addiction at McLean Hospital. He has been Principal Investigator on numerous NIDA and NIAAA grants and has developed integrated  group therapy and evidence-based treatment for patients with co-occurring bipolar disorder and substance use disorders.  Dr. Weiss led a multi-site national study of the treatment of prescription opioid use disorder as part of the NIDA Clinical Trials Network and is currently a lead investigator  on the multi-site retention, duration, and discontinuation study which is examining optimal treatments for opioid use disorder.  This morning he will be presenting his talk titled From Addiction vs. Psychiatry to Addiction Psychiatry, A Career Journey.  Dr. Weiss, if you'd like to join me on stage to accept our Founders Award in recognition  of your unwavering support of education, treatment, and policies supporting those with substance  use disorders and co-occurring psychiatric disorders, your knowledge, relentless work on behalf of the Academy, and advocacy for the field of addiction psychiatry have had  far-reaching benefits for medical students, fellows, and those in their early careers and the patients that they treat.  Thank you.  Thank you, Larissa, and thank you to the folks who nominated me. This is really a great award because AAAP is my favorite organization, and as someone  in this audience once said, addiction psychiatrists are my favorite people. So getting an award from AAAP really means a great deal to me. So here's my disclosure.  So when I got into the addiction field, it was 1980. People often ask how did I get into it. What led me to be interested in addiction?  And really, I got into it because I was escaping from another job. I had another job, and I didn't like it, didn't like the people I was working with,  and I told myself, the first offer I get, I'm out of here. Turns out, the first offer I got was to run an addiction program at McLean Hospital.  And I didn't know anything about addiction. I had never, at the time, I said I've never treated a patient with addiction.  I should have said I've never knowingly treated a patient with addiction. I probably treated hundreds of patients with addiction, but who asked?  I did have one hour lecture on alcohol in medical school and one hour seminar on opioid withdrawal in residency.  So I was pretty well prepared, and I didn't know anything about research either, and I was told that this unit would be doing research.  And I did have a one hour seminar in medical school on research where we had to read an incomprehensible immunology article and talk about the methods.  So at that time, addiction was really seen as the, there was no interest between psychiatry and addiction. There was only mutual distrust at best.  Social antagonism was really more like it. So I thought I'd really, if you couldn't get a job, you could work in addiction.  And so I thought, here I am, I'm not quite 30 years old, and I've ruined my career because  now I am running a program I don't know anything about, supposedly doing research when I don't know anything about that.  I was asked to pick a research area, and the first three patients that showed up all had cocaine use disorder. It was the beginning of the cocaine epidemic of the 1980s.  So I said, okay, that's my area, which was very fortunate. The one thing I did know about was how to do psychiatric evaluations.  And so a lot of these patients had psychiatric illness. And so I ended up writing up things like, a lot of patients with cocaine use disorder,  called cocaine dependence at the time, have psychiatric illness. And that was news back then. That was news and not welcome news.  It was very controversial, and I remember giving a talk once saying, reporting that and having someone stand up and say, who the F do you think you are telling me I'm crazy?  So that was what it was like back in the day. Back at this time, alcohol and drug programs were completely separate. There was no such thing as addiction psychiatry.  Those two words went together like addiction furniture, addiction bicycle, addiction psychiatry. They had nothing to do with each other. There was no triple AP.  Addiction was the bottom of the barrel career choice for people who couldn't do anything else.  The cocaine epidemic was just starting, and at that time was largely an upper middle class phenomenon.  There were two pharmacotherapies in the world of addiction, methadone and disulfiram. And psychotherapy was never used in the same sentence, unless the word contraindicated  was also in that sentence. So we were supposed to be doing research. So we did, but we didn't have any money or any research staff.  So what we did was the nursing staff would do Hamilton depression rating scales, Beck depression inventories, SEL 90s. The night staff scored them.  Of course, these were all on paper because we didn't have the money to buy a computer. And we had a room that we piled up all of these paper forms.  There was nothing else in the room, but these forms that just piled up, hoping one day somebody  would give us some money to, A, buy a computer and hire somebody to do something with all of this. And at some point, they did, and we bought a computer.  We had a part-time research assistant, someone to analyze the data. I had a great mentor named Steve Mirren, and when I told him I don't know anything about  addiction, he said, there's not much to know, which was true at the time. And whatever you need to know, I will teach you.  And he said, if you really want to learn about addiction, run a group every day, which I did for about two years. And that's where I really learned about addiction.  And I'm going to talk more about mentoring when I talk with Shelly. One thing that I was very clear about was that I was never going to write a grant.  That was something that researchers did, and I was really a clinician that did a little research on the side.  But we did a lot of research on all these people who were in our inpatient unit, but after about nine years, there was really nothing else we could do.  We got every piece of data we could get from people who were in the hospital for four weeks, which is what it was back in the day.  So I finally wrote a grant in 1989 on predictors of outcome in cocaine-dependent people leaving the hospital.  That was the same year of the first AAAP meeting, which was not called AAAP at the time, it was called APA, American Academy of Psychiatrists in Alcoholism and Addictions.  So then I started sort of slowly but surely shifting more and more toward research. NIDA, National Institute on Drug Abuse, put out a call for a multi-site trial of psychotherapy  and counseling for cocaine dependents. And I knew a lot about cocaine by that time, so I applied for that and got it.  And that's where I really started to learn how to do research on a very different level. With a lot of experts in the area of psychotherapy research and statistics and a variety of  other things, I started to learn how you do these things, including the technology of how to develop a behavioral therapy, how to test it, et cetera.  Soon after that, NIDA started the Behavioral Therapies Development Program, which was a parallel track to the Medication Development Program that they had had for many years.  And psychotherapy was no longer contraindicated, but it was seen as a potentially important tool in the treatment of patients with substance use disorders.  So I decided to put in a grant to develop a new treatment, integrated therapy for patients with co-occurring substance use disorders and bipolar disorder. And I was very fortunate.  I got three grants to test it in a variety of different ways. It turned out pretty successful, and now we use it a lot at McLean Hospital.  And it's actually in use in a variety of other settings and now in several other countries that I know of, Canada, France, Switzerland, Nepal.  So that feels like something I was quite proud of. Meanwhile, back at the ranch, addiction psychiatry had become a real thing.  In 1996, APA became AAAP, the American Academy of Addiction Psychiatry. That was now a term that people used. You could be an addiction psychiatrist.  I served as the program committee co-chair, first with Tom Costin, then with Rick Reese. And these meetings were really different back then.  It was all plenary lectures from luminaries in the field. There were no workshops. There were no papers by members. There were no posters.  It was just more like a board review course. You sat and there was one lecture after another. Our goal was if we could get 200 people to come, then we wouldn't go broke.  And I used to call the executive director every week. How many people do we have? How many people do we have?  And we barely would make it over the 200 mark each year, but it was, the stakes were really pretty high. But these were clearly my favorite meetings, mostly because of the people.  And I made a lot of lifelong friends coming to this meeting. And I, you know, it's really the key reason that I liked coming to this meeting more than anything else.  The next thing I ended up doing was getting, doing my first alcohol study. The National Institute on Alcoholism and Alcohol Abuse combined study.  It was a big multi-site study, 11 sites, 1,300 plus patients. It was the largest study of its kind, testing combinations of medications and behavioral  therapies. So people got either naltrexone or acamprosate or both or neither, all with and without psychotherapy. And naltrexone had a positive outcome, behavioral therapy did.  No combinations did. And acamprosate did not, which was very disappointing to us. We really welcomed the opportunity to bring acamprosate into the U.S.  And it helped to kind of dim enthusiasm for acamprosate and the treatment of alcohol use disorder.  While I was doing that, an envelope dropped into my mailbox with a request for applications for the NIDA clinical network that the head of our department sent that with a little  sticky note that said, Roger, apply for this. So that's what I did. And the Clinical Trials Network, or CTN, is a partnership between addiction researchers  and community treatment providers and general medical settings to develop and conduct multi-site addiction treatment studies.  So I was originally the principal investigator of the Northern New England Node, which consists of a research center and a bunch of treatment programs.  And then we merged with Yale, and it's now the New England Consortium Node. And as part of that, I led the prescription opioid addiction treatment study, which examined  different lengths of buprenorphine treatment and different intensities of behavioral therapy.  And we found that longer buprenorphine treatment, as opposed to just tapering, had much better  outcomes, and adding counseling to medical management and buprenorphine did not improve outcome overall, though some groups benefited from more intensive behavioral therapy.  And one really nice thing about this is it actually changed a lot of policies. One state that had set a cap on buprenorphine treatment at one year lifted the cap.  One of the Scandinavian countries that did not allow maintenance, opioid agonist treatment maintenance for prescription opioid use disorder changed that policy.  And Hazelden, which had never had maintenance treatment, actually awarded that paper. Their most important paper of the year, and changed their policy and started doing maintenance  treatment. So that ended up being a really impactful study. The current study that I am co-leading with Drs. Nunez and Ratrosen is the retention duration discontinuation study.  It's a large study, part of the CTN and the NIH HEAL initiative. It's two studies in one. The retention phase of it is to try to improve retention in medication for opioid disorder,  and the discontinuation stage is the first prospective study to examine patients who are stable on buprenorphine, and have decided to discontinue their medications.  So this is 18 sites, well over 1,000 patients.  We should have results in early 25, I think, for retention, and about a year and a half later for discontinuation. So just a couple of closing themes.  Keep your eye out for unexpected opportunities. Grab them when you can. Find a good mentor. Most importantly, work with people you like, and you'll like coming to work.  Work with people that you don't like, and you'll be miserable every day. And go to AAAP and get involved, and you'll be glad you did. So I will stop there. Thank you.  So thank you, Roger, for that great talk. Thank you, Shelly. And great overview, and I just want to say what an incredibly great honor and pleasure  it is for me to be up here to have this, what we're calling a fireside chat with Dr. Roger Weiss. For those of you who don't know, I really did start my career working with Roger at  McLean Hospital when I was a resident. We did two months of addiction psychiatry as an intern, as a PGY1, and that's where  I did my addiction psychiatry rotation, and it was with Roger. And ultimately, when I completed my training and came back as a junior faculty member,  Roger became my first research mentor as I began my career as a physician scientist. And so it's an incredible pleasure to have an opportunity to be here to talk more with  Roger about his career and some words of wisdom he might have for others who are in our field.  So to start, as a very accomplished individual and a national leader, what advice would you give to more junior colleagues who wish to follow a similar path to the one that you've  carved out for yourself today? So the first thing I would say is follow your own path, not my path, because you may want  to do some of the things I did, but you may want to do something else. So try to figure out what you want to do. As I think about that, you have a long career.  Most people finish their training when they're in their early 30s. So they're going to have 30, 40, 50 years to practice, and there's going to be a lot of twists and turns involved.  There's a great saying that is attributed to John Lennon, which is, life is what happens when you're busy making other plans. So things will come up.  You'll be doing something, and they may be good or they may be bad. You may get recruited to something that never occurred to you but sounds really cool, and  you'll go in that direction. You may be working in a hospital, and they decide to open or expand an addiction treatment program, and they'll ask you to run it.  Or you may be working in an addiction treatment program, and the hospital decides to close it. You may get sick. Someone in your family may get sick.  All sorts of things happen that will affect what you're doing. You may be doing research that NIDA, N-I-A-A-A isn't interested in, and they get a new director,  and this becomes their top priority, or vice versa. So I think a big part of it is if you've got an idea of what you really want to do, and  it's something you would really love, go for it. You've got a long time to try things, make mistakes, succeed, fail, go back and forth.  I think if what you want to do is research, if you want to be involved in the research world, there's more than one way to be involved in research.  You can be someone that likes writing grants, or you may be somebody that doesn't want to write grants.  You know, it just doesn't fit whatever other interests and priorities that you have. And you can have a great academic life involved in research. You can be a study doctor.  You can be a co-investigator.  I mean, there's all sorts of ways people can be involved in research without writing grants, doing a lot of teaching, and have a very academic job.  Research is a high-risk, high-reward. I mean, grant writing is high-risk, high-reward. Writing a grant that you get is highly rewarding.  Writing a grant that you don't get is not rewarding in the least. It's a kind of miserable experience. Oh, no. You know? Like, nothing. And there's no partial credit.  so what that means is for people who are writing grants, I always ask people, what's your plan B? And whenever I wrote a grant, I always  thought to myself, if I get this, that's great. If I don't get it, I'll see more patients, which is fine. I like seeing patients, which leads me to to say,  regardless of whether you're doing, you know, all clinical work, if you're mostly research, don't give up your clinical practice for a couple reasons. One, you  may need it, but even if you don't need it, even if you're funded really well, if you stop seeing patients, your research is not going to be as impactful  or interesting. Where are you going to get your ideas? I mean, you get your ideas by seeing patients and realizing, huh, I'm not sure what we should do here, and this  is actually a pretty common situation. We should study this, and I know how to study it, and I know what patients, how patients will respond to a study of it.  So people, I think it's always important to stay in touch with patients. Last thing would be, lots of people say, you know, I want to do half clinical and half  research. What you're really saying is, I want to do 80% clinical and 80% research, because you can't do, you can't do it that way. First of all, you're competing  with people who are doing all research, and if you're not, you're at a disadvantage, and the other thing is that unless you're doing shift work, your  Monday patient is going to take up your entire Thursday when you're not seeing patients, because your patient is unstable and needs, you know, who knows  what. So everything leaks into everything else, and so you have to be very careful. If you want to do research, you should be doing 75-80% research. Not  that you should be doing 80%. I mean, not, I'm not telling anyone you should do research, but if you're going to do it, you got to commit to it. So thank you. So  I think that this is just a lot of words of wisdom around how you think about carving your own path through your career, and also how you think about the  fact that there are many things that occur that you don't plan for, and how you accommodate those as you move forward in your career. So it leads me to  another question, which is, and you alluded to it during your talk, which is the role of mentorship and mentors, and I'm wondering if you could comment on  the role of mentors and mentorship, and also comment on any significant mentors you had that you thought were really pivotal in your own career, and how  were they helpful to you? In what way? So my mentor was Steve Mirren. So when  McLean decided to open an addiction unit, he was the only person that knew anything about addiction, and he knew a lot about addiction. And he was asked to  open this unit, and he said he would oversee it, but he didn't want to run it day-to-day, so he asked me to do it. Even though I told him I thought I was the  wrong person for the job because I didn't know anything. What made him, how was he helpful? He was helpful in a number of ways. First of all, when I was  trying to figure out, should I do this? I talked to the chief of the hospital at the time, because there was another offer I had to do to work with somebody else.  Not this first person I worked with that I was trying to get out of, but there was another possible offer. And he said, and I think this was like the key thing  about mentoring, is he said, Steve will support you and will help you to grow. And this other person, if you look at the people who have worked with that  person, they're stuck. They're not, they, they're always working with that, for that person, and it's clear what the pecking order is. So I think what, what  Steve did, and what I think good mentors do, is a little bit like what a good coach of a team, of a sports team does. Before this year, the New England Patriots  were actually a good football team, and Bill Belichick, one of the most popular men in America, was the coach. And they always talked about what made him so  good, and they would always say, he put his players in a position to succeed. So he would take people, you know, from other teams that were not doing that well, and  he said, you know, if I put this person here, and have them play this position, they'll do better. And I think that's what a good mentor does. They put you in  a position to succeed, then it's up to you to do it. So how did he do that? I mean, first of all, just telling me run a group every day, if you want to learn  about addiction, like, that was brilliant advice. That's where I really learned, you know, what goes on in these patients' heads, and in their lives. And the next  thing he did is he said, pick a research topic, that will be yours. And it was, that was mine. If there was a paper to be written about cocaine, I was the first  author, period. The next thing he did was, a few months into my starting to work on this unit, he had written this long book chapter on all of the major substances,  and the publisher asked him for the next edition. And he said, sure. And then he said, Roger, you do it. You may be familiar with this, Shelley, because when the  third edition came up, I said, Shelley, do you want to do it? So when you have to write essentially a hundred-page book chapter, you really learn a lot about the  field. And so once I did that, and of course this is before computers, so like, you know, longhand, it was like the dark ages, and I really felt like, I know a lot  now. And I was six months in, and I went from feeling like, I don't know anything, to, ask me anything. And, you know, and I loved it. I mean, I loved this job, even  though I had no, you know, went into it completely bewildered. I loved it from day one, and I think a reason I loved it is, I loved the patients. They were great.  But I also loved the staff, and, you know, Steve helped create a great atmosphere. And it was fun. We laughed a lot. You know, I always feel like if you laugh a lot,  you're doing good work. And we laughed a lot. So he then, other things that he did, he, we'd go to a meeting, like the APA meeting, because there were no triple AP  meetings back then, but we'd go to the APA meeting, and he'd be going out to dinner with people who were, you know, above me. Herb Kleber, Chuck O'Brien,  people who were sort of eminences, and say, Roger, why don't you come along? So I would get to meet these people. And, you know, did they, Herb Kleber, you know, said,  if you want to work with me at Yale, I guarantee you we can pay you less than they're paying you at McLean. So I got a job offer. So it was, that's, that's how  he sort of opened things up for me. He got offered the American Psychiatric APA Publishing, contacted him, and said, we'd like you to write a book on cocaine.  And he said, he told me to do it, and I was the first author. So, which was a big deal, you know, to write a book. So, really opened doors, very critically edited what  I wrote, like really critically. So, I tell people this, and people who are young enough, it sort of blows them away. Back when the words cut and paste meant that  you took, you cut the page, and then would paste it onto the page. And so I would write a first draft of a paper, and it would come back unrecognizable. I'd say,  where's, where's page two? No, that's page four now. And it was sort of, it would come back much more red than black and white. So, he didn't just, you know, no lazy  revisions. It was really learning how to write a scientific paper. You know, I wrote good college papers, but, you know, he taught me, throw that out the window. You know,  this, you're writing a very different way, and nobody's born knowing that. And he really taught me how to do that. So, there were all sorts of, everything from just  encouragement, to introductions, to very technical knowledge. He just helped me in all those ways. Yeah, thank you. And I was thinking that, I think I did write that third  one. Yeah, you did. The third round. And also, it made me reflect that when I was writing all of my first papers, and also my first grant, at that point, there were computers, I was  typing them, but I was printing them out, and they came back from you, absolutely, just completely red inked in every possible sentence. There was nothing recognizable. So, it's a  kind of see one, do one, teach one in a way, in a different kind of a way, in terms of mentorship. You know, having a mentor, and who does those things, to becoming a mentor, to do  those for your next generation of your mentees. And, you know, I wonder if you could reflect  on how you've overcome obstacles, because we all, you mentioned this, when you were talking about things that come up that are not anticipated, and everybody in their course of  their lifetime, their personal life, and their professional life, will have obstacles, will  have setbacks. And I'm just wondering, through your journey, how you've overcome obstacles, and what lessons you've drawn from those things, and what you can share with others.  So before I answer that, I want to go back to one other thing about mentorship, which is being a mentor, as opposed to having a mentor. Because that's so much fun. Being  a mentor is great, and at some point, you become the mentee of the person that you were the mentor to. Because if you're doing your job, they're developing their own thing, that  they now know much more about than you do. And they're teaching you about things that you don't know so much about. And it goes from mentor, to colleague, to sometimes mentee  about other things. And that's part of the fun of all of that.  Obstacles, challenges, setbacks. So there have been some bumps along the road. So about a year into opening this drug addiction unit, I got a call from the person that was the  director of Bridgewater State Hospital, at that time called the Bridgewater State Hospital  for the criminally insane. Not the most desirable place for anyone to work. And he said, I hear  you're looking for a job. And I said, no, actually, I'm working on this addiction unit. He said, oh, I've heard it's closing. I said, really? That's how I heard that our unit was  supposed to close. Because of some politicking that was going on at McLean, and we were losing  money because we were a small unit. And even when we're full, we lose money. And so that felt like a bit of a setback. And I thought, well, what am I going to do now? I really  liked what I was doing. And so I had a little bit of a crisis for about a month. And then  everything changed. And they said, essentially, never mind. We're not going to close the unit.  We're going to expand the unit. And then it won't lose money anymore. But that felt like a setback. That just flashed into my mind. I hadn't even thought of that in 40 years or  something. But when I thought about setbacks, that kind of came to mind. But there were a couple of things. So when I was the program chair, one of the symposia that we put on  was one entitled, The Other Addictions? Gambling, Sex Addiction, and Eating Disorders. Are These  Addictions? And I thought it was kind of an interesting symposium. I was chewed out publicly,  told, you are going to sink this field by sort of cheapening it. You know, these aren't real addictions. We're trying to gain some sort of recognition here. And you are undercutting  everything we're doing. That felt a little like a setback. Another setback, I was trying to go from  assistant professor to associate professor. And I thought pretty sure I was going to get it. And I  met with Steve Nearing, who said that he had sought letters of recommendation. And one person  that he sought recommendation said, no, I'm not going to write him a letter. He hasn't accomplished  enough. That really felt like a blow. And sort of a wake up call, like, huh, I thought I was doing well. I guess I  need to write more papers. I guess I got to get another grant. I guess I've got to do, you know, whatever it  was that I had to do, I had to step it up. And that was a bit of a crisis. Like, I was, I wanted to murder the guy. So  that was, I decided not to. But that was my first thought. Then I could have gotten promoted because other people would  have written good letters. But I really, it would, at that time, I was thinking, do I even want to keep doing this? You know, I sort of  said to myself, I'm doing my best, aren't I? Or am I? You know, it was like one of those questions. And I said, okay, I guess I got  to do more. You know, I would like to keep this thing going. But that was a big part of Steve's being a mentor. He said, you know,  you'll get to professor if you keep going. You can do this. So that was another, you know, it was a sort of a big mentor role, which is  when you have fallen down to help pick you up. But he didn't pick me up. He just said, I'll help you up, but you got to get up. And so I did. But that,  that really, that one sticks in my mind more than, more than any of them, because it was a real career turning point.  Yeah. Well, I think it's really good to have the chance to hear about that type of experience, because I think everybody has that type of  experience. And, and I think I'm guessing everybody here can relate to that in some way, or another. And I think when one thing that I take from  that, is that, you know, in the face of these things, thinking, having someone, as you said, to help you get up is critical. But also, it seems to me  that figuring out what you want and deciding to persevere, in spite of that, is also really critical. And I take that also from what your  comments are. Yeah. So I just, I was thinking, another question, maybe you've sort of answered this, but maybe you have other thoughts about it is, what do  you think was, I know, it's hard to, I know, it's hard to think about it this way, but like one of the most pivotal, if not the most pivotal moment or  experience that you had, that led you, you think, to where you are today? And you know, you've described some of the most early things, but are there  other things that you think of as really pivotal experiences that have, you know, led you to this point in your career?  Well, clearly, the most pivotal one was this job offer to get into the addiction field. I mean, if I had liked my first job, I don't know what I'd be doing, but it  wouldn't be this. I wouldn't know any of you people. And it's, you know, I never would have gotten into addiction, it just never would have occurred to me. So  that, that's like the number one. But I think along the way that, you know, some things that, that were big events, you know, that sort of turbo  charged my career in a sense, like getting into the clinical trials network was a huge shoot. So opening up this envelope, you know, with the request for grant with a  little yellow sticky note, apply for this, when I really didn't want to. Because it, you know, at the time was a 45 page grant, and you had this, like this huge  section on data management, you know, which I didn't know, like even a thimble full about data management, and you had to write like 15 pages on it. And it, you know, the  idea of writing this grant just seemed so impossible. But I managed to sort of, you know, scramble and I was told by a colleague of mine, don't do this, they'll never give it to  you. Because, you know, we already, there's already, you know, one in New York and one in New Haven, they don't want to, they don't want, you know, too many too  close. But I did it, and I got it. And then I think what sort of shifted the, my career, I mean, in the last 10-15 years, it's been on opioid use  disorder. And that happened through just sort of luck. And so when I was sort of early in the clinical trials network, we were asked, all of the principal investigators were asked to write a little three-page proposal of what they think the CTM should do.  I wrote one on integrated group therapy, do a multi-site trial. Which people liked the idea, but Dr. Volkow, who ran NIDA, didn't like the idea.  She thought it had already been shown to work and didn't need any more. But what she thought was a really important study was a study of prescription opioid dependence.  Which had been proposed by someone else, Walter Ling, who's a big opioid researcher. He proposed it, and  she announced at a steering committee meeting that that was her top priority.  However, Walter Ling was already leading another study, and you weren't allowed to lead more than one study. So I was in some small meeting, and  Dr. Betty Tai, who runs Clinical Trials Network, said, well, we need to do a study on prescription opioid dependence. Walter Ling was the one that proposed it, but he can't do it.  Roger, you're new, you're not doing anything, why don't you run it?  And that turned out to be just a fabulous thing.  I'd never done a study on opioid addiction.  I'd never led a multi-site study. I'd been in multi-site studies. So this whole thing was really quite daunting. But this is what I mean, opportunities are there, grab them.  It's one of these things where there's only one answer, yes. It's like, I remember my daughter took fifth grade dancing class, and the teacher said, if someone asks you to dance,  there's only one answer, which is yes. So when the person running the program asks you to run a study, there's only one answer, yes. And then that just turned into a whole,  that has been the biggest part of my career ever since. And now I'm doing this other opioid use disorder study.  So I think one other thing, this sort of reminds me that  one of the things that makes a job interesting is if you get to do different things.  Whether it's doing research on, it's not like I'm gonna go do research on cell lines or something like that. But something I don't know anything about.  It's always gonna be something in the substance use disorder, but I've done some cocaine research and alcohol research.  They're very similar, but a little bit different. And it keeps things interesting.  So in that regard, you do do a lot of things. You are a researcher, but you also run a big program. You're a fellowship director.  You ran a treatment program for a long time. So in that regard, this is a little bit of a different question than where we've been, what we've been discussing.  But it's really important when you're doing those things to have a way that you can foster teams, foster collaborations within teams.  And I'm just kind of wondering how you go about fostering a sense of camaraderie, a supportive group. And how do you foster collaboration and  create a supportive environment for the groups that you're running and supervising and leading? Cuz I think that's a very important question for everybody,  no matter what they're doing in our field or any field for that matter. So I'm just curious about the way you think about that.  Think about the ways, so going back to the beginning of my career with this addiction unit, So we were doing sort of research.  Everybody was sort of pitching in doing this research, but I thought it was really important for them to have a stake in it. So, We had a teaching conference every week.  Lord knows what I was teaching them, I didn't know that much. But I was, every week we did teaching, and then whatever data we had that we'd gotten from these things,  we shared, as opposed to, hey, collect this data so I can write a paper.  So, they were really interested in our patients. Our patients, if you look at their depression scores, they go down from here to two weeks by this much,  except the people with major depression, they don't go down as much, etc. But it became, that gave them all a stake in what they were doing.  And I think when you have a team sort of giving people a stake,  involving them in something, in sort of educational activities, etc.  One little thing we do, we have, as you know very well, we hold a conference every year that,  for people in the audience, it's a really good conference every May. And so, we pay for anyone in our entire swath, all of our treatment programs, to come to the conference.  And when it was all in person, we'd get tons of people coming, and it was like a big team building thing.  People loved coming to this conference and hanging out with each other, etc. So, sort of trying to keep people involved in  the bigger picture of what you're doing, I think is always important. And I keep coming back to this thing, if you like the people you work with.  When you hire nice people, it's really easy for everybody to be collaborative, because by definition, they are collaborative.  When you make a mistake, as I have, and you hire somebody that's not collaborative, it puts a chill on the whole operation.  And you usually don't know that that's gonna be the case until you see it.  But it's a poison, and it just, that's why I say, if you work with people you like, they'll always like coming to work, and when you don't, it's really different.  Yeah, well, thanks for those reflections. And I would say, I'd go back to one other thing you said earlier on, and  it goes along with having a group of people who enjoy working together, is that you said, when you're laughing a lot with the people you work with, you know something's going right.  And I can attest to that, because I have been a participant in those groups, and there is a lot of shared humor, and it is really very important and very helpful.  I wanted to have an opportunity now, I have many more questions that I could ask, but I'm also wondering about the audience. We have about ten minutes or  so where I'd really like to open it up to audience questions, is that okay? Yeah, sure. So, I don't know if people have questions, but  if you do, I think please come to the mic, and that would be great. And I see, and if you can, could you just say your name and where you're from, too, when you get to the mic, so  everybody knows who's asking the question, so go ahead, Tom.  Is it on? Is it on? Yes. Okay, well, I'm Tom Costin, and I come from the place that was willing to pay Roger less than he got at Harvard.  And the two questions I had, one is the collaboration that I'm probably more than 100% research and 80% clinical, and  collaboration has become extremely important outside of not just addiction psychiatry, outside of psychiatry. I mean, a lot of my collaborations are immunology, neuroimaging,  a bunch of other stuff, and if you're not doing that, it's, in fact, increasingly hard to get grants.  The other question is one that you don't have to answer if you don't feel like it, because I know it's like asking about what's your sex life like, but it's money.  A big impediment, I think, for academic positions for people coming out of their residency, at least that I hear, was I'm in debt already,  and I'm in a lot of debt, and I can't afford academia. Now, my wife had a very good solution to that, because at my institution,  becoming a psychoanalyst was something that, if you really were a psychiatrist, you'd become a psychoanalyst, and I wasn't a real psychiatrist, and  I didn't think I'd be a psychoanalyst, but I did my training analysis for about a year and a half anyway, at the end of which my wife said,  you can either continue your psychoanalysis, or we can buy a house. One of those choices comes with you potentially trying to find a new wife.  And that kind of, I wonder if you had similar experiences to that. Yeah, actually, my plan, when I finished my residency,  was to work on this general psychiatry unit and go into the psychoanalytic institute. I had a training analyst lined up, who had a one-year waiting list.  And during that year, this whole addiction thing came up. And I said, I'll postpone it for another year just to see how this goes.  And it went pretty well, so I stuck with it. But we were around the same time, right on the cusp of when psychiatrists, leading people in leadership positions,  it was sort of required that you were an analyst or not. It was just around that time that some people were doing it and some people weren't.  And so we both ended up on the other side of that. But the cost of that, I mean, yeah.  Ridiculous, yeah, yes? Hi, my name is Jay, can everyone hear me? I'm a medical student, a fourth year at St. Louis University in St. Louis.  And thank you so much for the discussion so far, I love hearing about mentorship. I've been really lucky as a fourth year medical student to mentor M1s, M2s,  M3s, so it's been really fun to be on that journey and continue to mentor people. But I was wondering, for you, how do you balance research and clinical work?  I'm gonna be going to residency, I know during residency it's gonna be harder to do research, I'm gonna try and keep up with it. But how do you keep a balanced life with that?  As a psychiatrist, I think it's really important, wellness and self-care. So how do you balance the research without digging too much into your weekends?  I love going to the mountains, I love going to the beach. I also like doing psychiatry, of course, but how do you keep that balance?  So you asked about balancing research and clinical work, but then you went on to how do you balance work with the rest of your life?  I mean, those are really two different questions. So why don't I start with the first one, and then answer the second one.  So the first one, I certainly do less clinical work than I used to. I mean, I started out as a full-time clinician. And the research was just around the edges.  When my kids were, when they went to bed at 7 o'clock, so they were pretty little, I would work after they went to bed. That's when I wrote and stuff.  Once they went to bed at 8 o'clock, I couldn't do that anymore, cuz I was too tired at that point. But, and I had a very,  This gets more to the work versus the rest of your life.  I love my job, but I love my family more. And that was, so back when I was running this inpatient unit,  I was home every night for dinner at 6.15, except for Thursdays. Thursdays I stayed home in the morning with the kids. And then went to work at noon, and  worked as late as I needed to do to get all my paperwork done for the week. So that was just like the routine.  And it was a lot easier then, cuz there was no email, there was mail. People actually got mail, and there were phone calls, and that was it.  But nothing else, so the only phone calls I ever got were clinical emergencies on the inpatient unit. Somebody fell down, was going to the emergency room, something like that.  That didn't happen very much. When you were home, you were home. You're not always looking down, going, ugh. So it is much harder now,  cuz it just sort of goes all through your life. And I don't have any magic answers on that.  It's harder to set those boundaries.  And I try my best, I think, when, but I've always prioritized stuff with my family. And cuz that's always come first. And there's all sorts of ups and downs that occur.  But you have to have the priority. The research versus clinical thing, I think,  in writing grants and that sort of thing, it's always been this issue of, I'll see more patients if I don't get this grant.  And I've been kind of fortunate that I haven't had sort of  fallow periods for a while. So my clinical work has become less, I've just done less clinical work. But I get involved, I hear about a lot more cases than  people that I'm actually treating.  So we have less than three minutes, and I'd love to be able to squeeze in both these questions if possible. So come on up and ask your question, and  we're gonna try to get to the next one, too, before we have to stop. Hi, I'm Jacob Gutierrez. I'm an addiction psychiatrist working for the Altamed Health System.  My question was because you brought up this idea of having a collaborative team and how that makes work-life a lot easier.  What type of traits would you consider in people would be good team members in a collaborative team, and what would you call a collaborative team?  What do you consider to be collaborative? That's my question. So what kind of traits do you look for in people who would be part of a collaborative team?  Good question. It's a great question.  It's a great question.  And I'll give you an answer that I'm not sure, really.  When I interview people, whether it's for a job or any sort of position, it's, do I wanna spend time with this person?  Week after week, month after month, year after year.  Do I like this person? I mean, obviously, I look at their CV and see, they've published and they've done this. That's the screening. The screening is on paper.  Once you get to, okay, this person looks okay on paper. Now, what are they like?  That's, it's a pretty soft kind of thing. But if you hire somebody, you're gonna spend a lot of time with them. Is that what you want? And if it is, I hire them.  And if I don't really feel comfortable with them, I don't.  I don't know if that's a good answer, but that's, at this point, and it's worked out pretty well.  So, that's it. So, Nita, do we have, can we fit in this one more question? One last question. Okay, last question.  Thanks, Dave Condiff.  Love that, and I would add that since we all have implicit bias somewhere, you need something that informs your choices as to who you wanna spend time with  in a way that is also just and fair in the big picture. I had a question, though. Obviously, your mentors and those you valued and who had power over you  applied the right amount of stress to help you grow without ever applying so much stress that it broke you.  In retrospect, that's wonderful. How do you feel in retrospect, in prospectively, how do you feel before you've said it, before you've done it?  What's the right amount of stress to help your people grow without breaking any of them?  That's another good question. It's like the three bears, not too much and not too little. I don't think when I'm mentoring somebody that I'm really  thinking about, I wanna stress them a certain amount or not. It's really, here's what I think you should, it's again, trying to put them in a position to succeed.  I'll say, you need to do this, you need to do that, you need to do that. I don't do it for them, but I say you need to do these three things.  And if you can do it, now you're on to the next thing. If you can't do it, then I have to make a decision.  Do I think there's something that I can do to help them get to a point where they can do it?  And if the same thing comes up repeatedly, then we have to have a conversation of this isn't working. And a lot of times people say, I can't do that.  I remember working with somebody, they were writing a paper and I said, this paragraph doesn't follow from that paragraph. And they gave it back to me and  I said, this paragraph doesn't follow this paragraph. And this happened three times and he finally said to me,  I don't know what you're talking about, this is the best I can do.  So we've tried to work on it, but it was like that's not just sort of a technical thing to teach. It's just that person was a fabulous clinician  who was trying a little more academic and said,  this isn't really for me, if this is what is involved. This writing, it's just not my thing. And then we reached a good agreement, I tried it,  it really wasn't my thing, and I'm gonna stick with clinical work and teaching, I mean, this person was terrific, except not at that.  So I just want to thank you for wonderful answers to these questions. And congratulate you. Thank you.  Thank you. Thank you. Thanks, Roger. Great. That was really great. That was great.
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