Maybe someone you love is starting treatment for opioid use disorder and their doctor mentioned buprenorphine, or a monthly shot, and you're thinking, Wait... isn't that swapping one opioid for another? Or maybe you're the one struggling, and the idea of withdrawal feels so terrifying that treatment doesn't feel possible. Those fears make so much sense. And a lot of what we've been told about these medications is confusing, outdated or wrapped up in stigma. In this episode I sit down with Nick Casale, a pharmacist who has spent the last 15 years in addiction medicine, focused on opioid use disorder. Nick started out in a Pennsylvania Medicaid health plan in the early 2010s, right as the opioid crisis was exploding, and watched firsthand how inconsistent, and sometimes punishing, treatment coverage was. Today he works in medical affairs for a pharmaceutical company, talking with clinicians, researchers, and even sheriffs and jail medical directors about what the evidence shows. Nick breaks down how buprenorphine works in the brain (there's a great musical-chairs metaphor in here), why fentanyl has made opioid use disorder so much harder to treat, and what long-acting injections are changing, especially for people leaving jail. And we talk about the part medication can't do alone: counseling, support, peers who've been there. It's a hard topic. The numbers are heavy. But there's real hope here. Treatment works, access is better than it's ever been, and reaching out is a brave first step. In This Episode Nick's path from retail pharmacy to a Medicaid health plan to addiction medicine, and why he fell in love with this workWhy insurance coverage for opioid use disorder treatment was "all over the board," and how kicking people off treatment for a failed drug screen made things worseWhat buprenorphine is, in plain language: a partial opioid agonist that holds the receptor, eases withdrawal and cravings, and blocks other opioidsThe three waves of the opioid crisis: prescription opioids, then heroin, then fentanyl and other synthetic opioidsHow fentanyl changes the brain by creating more opioid receptors, and why that makes withdrawal so brutalTablets and films vs. long-acting weekly and monthly injections, and why steady levels matter nowMedication for opioid use disorder in jails and prisons, and why the days after release are so dangerousHow buprenorphine can be misused, and why naloxone was added to some formsWhat real-world research is showing beyond clinical trials: fewer non-fatal overdoses, fewer serious infections, people getting their lives backAccess and cost today, and why so many people still aren't getting treatment. Key Takeaways Most people who need treatment aren't getting it. Nick shares that roughly 4.8 million U.S. adults live with opioid use disorder, and only about 1 in 5 receive medication for it. He describes the overdose toll as the equivalent of a Boeing 737 crashing every day.Buprenorphine works differently from other opioids. Nick's metaphor: heroin plays musical chairs, jumping on and off the receptor. Buprenorphine sits down and stays. That steadiness helps keep people out of withdrawal and blocks other opioids from taking the seat.Fentanyl has changed the game. According to Nick, the street supply is now dominated by fentanyl and other synthetic opioids. They're so potent the brain grows more opioid receptors, which makes withdrawal harder and treatment more complex.There's no set timeline for treatment. ASAM (the American Society of Addiction Medicine) recommends at least three months, and longer treatment is linked to better outcomes. How long to stay on medication is a decision between you and your provider, much like blood pressure medication.Relapse isn't a reason to be punished. Nick and I agree that setbacks are part of many people's recovery journeys, and treatment should keep the door open.Medication is one piece, not the whole picture. Buprenorphine works "exponentially better," as Nick puts it, alongside counseling, behavioral support and peer mentors."Just be brave, seek out the treatment... just make that first step." — Nick Casale TIME STAMPS 00:15 Nick introduces himself and his work in addiction medicine01:40 From retail pharmacy to a Medicaid health plan in the middle of the opioid crisis08:06 What "transmucosal" means and how buprenorphine treatment has evolved10:47 How buprenorphine works in the brain, and the musical-chairs metaphor16:05 The numbers: 4.8 million adults with opioid use disorder, and 1 in 5 treated17:01 The three waves of the opioid crisis20:02 How fentanyl "upregulates" opioid receptors21:58 How long should treatment last?25:42 Long-acting injections and steady protection28:57 What the research shows, and why abstinence isn't the only measure30:52 Treatment in jails and prisons, and the risk after release33:40 Stigma and pushback in correctional settings36:40 Can buprenorphine be misused?39:36 Why medication works best with therapy and support44:29 Access, insurance and cost47:48 Nick's one message for anyone struggling About Nick Casale, PharmD Nick Casale is a pharmacist who has worked in addiction medicine for about 15 years, with a focus on opioid use disorder. He began his career in retail pharmacy before joining a Pennsylvania Medicaid health plan as a clinical pharmacist, where he led the plan's opioid overutilization program and its addiction medicine benefit during the height of the opioid crisis. He then moved into the pharmaceutical industry, first working with Medicaid programs across the country and now leading a medical affairs team. His team shares scientific information with physicians, nurse practitioners and physician assistants, works with leaders in addiction research, and helps jails and prisons understand the evidence for treating opioid use disorder. Connect with Nick LinkedIn: search Nick Casale, PharmD Resources Mentioned Buprenorphine and buprenorphine/naloxone (tablets and films taken under the tongue)Long-acting injectable buprenorphine (weekly and monthly)Methadone and naltrexone, other medications for opioid use disorderAmerican Society of Addiction Medicine (ASAM)National Commission on Correctional Health Care (NCCHC)SAMHSA National Helpline: 1-800-662-4357, free and confidential, 24/7FindTreatment.gov: find treatment providers near you, including medication for opioid use disorderSupporting Resources Looking for a therapist? Medication works best with support around it. Novus Mindful Life offers therapy for addiction, betrayal trauma, anxiety and depression, in person in Garden Grove, CA, and by telehealth in California, Idaho, Virginia, Florida and Texas. → NovusMindfulLife.comHealing after betrayal? Addiction can break trust in a relationship. Shame to Resilience is a guided program for both the betrayed partner and the person who caused the harm. → ShameToResilience.comStay close to the work. Get new episodes, tools you can actually use, and a little hope for the hard days in your inbox. → Subscribe at TheAddictedMind.comListen, Follow and Review If this conversation helped you, or helped you understand someone you love a little better, please follow The Addicted Mind and leave a rating or review. It helps someone else who's struggling find the show. Apple PodcastsSpotifyInstagram: @addictedmindpodcastFacebook: The Addicted Mind Podcast community groupYouTubeLeave Duane a voice messageIf you're struggling with opioids, or loving someone who is, keep reaching out. Help is out there, and you're not alone. Find more episodes and resources at TheAddictedMind.com. Follow and Review: We’d love it even more if you could drop a review or 5-star rating over on Apple Podcasts. 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