Human Up Season 1 Ep 4: 40 Years of Treating HIV/AIDS and Substance Use
This is a transcript of Human Up Podcast Season 1, Episode 4 with Dr. Jerry Cade, which you can watch and listen to here:
Dave Marlon: Welcome to the Human Up Podcast! My name's Dave Marlon, your host, and today I am thrilled and honored to have Dr. Jerry Cade as the guest. Welcome Dr. Cade!
Dr. Jerry Cade: Thank you.
Dave: Alright. Now Dr. Cade is the medical director here at Vegas Strong, and we're so grateful for his service. Now, you've been working since 1984 and you continue to work with harm reduction agencies in an effort to help reduce the incidence of drug overdoses and addiction related morbidity and mortality. But almost more significant since around that time. You and Dr. Mel PO helped start the HIV AIDS program at UMC Hospital. And in many ways, working with people with HIV and AIDS was a logical extension of what you were already doing in your private practice. Although HIV could be transmitted, in many ways, sharing needles is one of the common reasons of HIV transmission. Furthermore, data shows that the sexual transmission of HIV and aids, this is associated with the use of alcohol and other drugs. In 1995 to 1998, Dr. Cade served on President Clinton's Presidential Advisory Council of HIV and AIDS, where he helped author in past national HIV recommendations and policies. Dr. Cade was also the author of some of their strategies with supporting syringe exchange programs. Did I miss anything else big on your bio, Dr. Cade?
Jerry: That's actually more than enough, but thank you very much.
Dave: Alright. Now could you kick things off by starting this, by telling us how this work for you came to be?
Jerry: The initial work with addiction medicine was just coincidental. That was Dr. Paul, who was an addictionologist back before it became popular, and he had a family practice that I joined. And at that moment in time, I had to learn everything. I didn't know much about addiction medicine. We don't learn a lot in medical school, unfortunately, about addiction medicine. It's a couple of hours course and that's it. But that's what he did. And I thought that was really exciting and interesting and important and it made me, it inspired me, and that's what I work better if I'm inspired. Little did we know how crucial it would be, as you said in the AIDS epidemic. I mean, the data is, as you said, there's a certain percentage that get AIDS directly from intravenous drug use and sharing needles, but the estimates are that 80 to 90% of the sexual transmission is from disinhibition with alcohol and drugs is that everybody goes out on Friday night and says, I'm going to use my condom and I'm going to do this. And after a couple of drinks, that doesn't become as important or a little more of other kind of chemicals. So alcohol and drugs are been an unfortunate co-factor in the HIV epidemic, at least in our country.
Dave: That makes a lot of sense, and thank you. Now, can you tell me why and how you got involved with, as a doc specializing in HIV treatment?
Jerry: Basically because no one else was doing it. I mean, this was 1985 and the HIV epidemic started in our country in June 5th, 1981. Fortunately in Las Vegas, the coasts New York, LA, San Francisco saw the initial cases. So we didn't have a lot of cases until 19 84, 19 85. But I started with Dr. Poll. We were doing an outpatient addiction medicine program, and that's what we were doing. And then all of a sudden, it was like 14 months after I started with Dr. Poll that this patient came in and I'd read enough about the HIV epidemic. In fact, I had been on an A MA panel. I was the resident member of the Amma's Council on Scientific Affairs panel on HIV if we produced the second article ever in JAMA on HIV. So I didn't know anything, I just knew all of that information. And this patient came in on a Friday afternoon, I remember, and I knew he had aids.
And at that time, that was when hospitals did all this gown and glove and masking. I knew enough by then to realize that probably wasn't really what you needed to do. But I called UMC where I kept most of my patients and who ultimately created a dedicated HIV unit and said, this patient's really sick. We need to get 'em in. And they were very good about, okay, whatever you need, we're here, we'll do it. I admitted him to a unit five North UMC, and I knew enough not to, and I'm a doctor so I could get by with it. We're supposed to gown, glove masks and do all that kind of stuff. I said, I don't need to do that. So I didn't. And to their credit, my nurses on that unit said they were young. They just graduated from UNLV Nursing School. They said, we want to help.
This is our mission. This is what we think we should do. And they first said, we don't think we need to do all the gown and gloves. I said, you guys work for the hospital, you better follow the rules. I can get by. I'm on the medical staff. I can get by without it. But we changed them after a short period of time. And that group of nurses became the inspiration for what was the HIV program. In fact, it was all their idea. I am wrongly given credit for what has been their very good idea for having an HIV program. But they were awesome. We actually still go out from time to time. Most of them are retired. We go out from time to time and reminisce about those days. But it really was the ultimate healthcare team working together, helping each other and making sure things happened. The epidemic made that a necessity. Unfortunately, the staff responded,
Dave: Wow, that's an amazing story. It's a very Vegas story. This is such a small town. Just thank you for sharing that to me, getting to work closely with you. I've seen more and more similarities between addressing substance use disorders and addressing sexually transmitted illnesses. I had heard in, and I know in the eighties and nineties, there was a terrible amount of stigma associated with HIV. I read an interview you did previously where you talked about how despite doctors taking a Hippocratic oath that some doctors even refused to work with your patients. And I wanted to ask you, how did you navigate that and what pushed you to work through that?
Jerry: And you're right, and that was true, say in the late, well, in the eighties and early nineties, and you've got this dilemma here when a doctor says, I don't want to see your patient. You've got the dilemma of, okay, do I force him or her to do what they said they're going to do? On the other hand, do I want my patient being taken care of by somebody who doesn't want them? And anytime I get confused about an issue, patients trumpet. I mean, if I'm worried, and in the early days of HIV, there were all of these things going on, and I would say, well, what if I were the patient? And that seems to have always led me to the best answer. If I'm the patient, I want a doctor who wants to take care of me. I don't want somebody who's going to blow me off or not really care about me. And fortunately for all the, I used to say for every bad story you hear, there was an unexpected angel on the other side that came along. So we worked through it because ultimately I think people are pretty good. We just have a little moments where we're not our best.
Dave: I agree. And I've treated substance use disorder clients for 20 years now. And now I've really in the last, I don't know, 10 years moved to treating folks who were unhoused. And to me, I'm noticing there's some providers that don't want to treat homeless clients. There's some providers who don't want to treat people with substance use disorder. And that very similar stigma that's associated with sexually transmitted diseases also occurs with people with substance use disorders. And I found the same thing. Fortunately, the folks who do want to work with them, there's so many success stories where people dramatically turn around their lives and productive and end up giving back themselves. And those stories are really the ones that keep me on fire for doing this work.
Jerry: Yeah, no, you're completely correct. I mean, ultimately, there's a lot of good stuff and it's the good stuff you focus on and to just neglect, forget the bad stuff. But you're right, people are amazingly inspiring at some point at moments in their life when they have to be.
Dave: Yeah, fortunately. Could you tell me a story from your work on the President's Advisory Council? I think that's badass.
Jerry: Well, I can tell you what about, I did write our policy on needle exchange. This was in 19 95, 96, something like that. And this is how politics works. It's just an interesting story as how politics works. So the president Clinton's 30 members, we are all on board for needle exchange because we also were on board for more dollars for substance use and for treatment. But you got to be alive for us to treat you. So our first priority was to try to make sure people didn't get HIV and didn't die from HIV. So we voted to do that. Secretary Chalo was the Secretary of Health and Human Services at the time. She met with us and said, president Clinton's on board. He agrees with you completely. And at the time, we had six major studies. I mean, the question was, would needle exchange programs is do they promote substance use? And we had six major studies from the NIH three of which were neutral, but three of which suggested that a needle exchange program might be the beginning of recovery. The beginning of
Dave: Recovery.
Jerry: So the needle exchange program might be is the first step that some people take. So actually people in needle exchange programs were more likely to eventually get into recovery than people who didn't because for whatever reason, maybe because they've took care of themselves because they were more concerned, nobody knew the answer. So Clinton said, okay, I'm on board. But the drug czar at the time was Barry McCaffrey, who was a four star general. And so Clinton and McCaffrey, this was on Friday. Clinton and McCaffrey spent the weekend in Columbia looking at cocaine fields and with an idea of what can the United States do to help stop the flow of cocaine into the us. So Clinton came back on Monday and refused to sign off on our needle exchange program over the weekend with a trip with Barry McCafferty at Columbia, the world changed. But that's how politics is.
Whoever has the last ear of the president or the political person gets their way. So we actually pushed it and it worked out. All things work out. It had a dual good purpose. It inspired some needle exchange programs, and it actually inspired drug dollars. So to help treat people with, I mean, as you well know, drug and alcohol dependency have always been way underfunded and certainly are not looked at as they should be simply a medical problem that needs treatment, which is the other challenge we have, although that has improved somewhat dramatically over the few years we've been doing this. But yeah, politics is just, it's capricious.
Dave: And I'm sure that flight to Columbia was orchestrated by somebody,
Jerry: Probably General McCaffrey, general McCaffrey, this is pure speculation, but we think General McCaffrey heard that we were going to do needle exchanges said, oh, the other cute thing about needle exchange programs, we were going to suggest it in prisons. Well, we were going to start with condoms. We thought condoms in prisons. And the head of the Bureau of Prisons stood up in front of our 30 member council with a straight face and said, we don't need condoms. There is no sex in prison. And so we didn't even try the needle exchange thing since we didn't get condoms.
Dave: Wow. That's more insightful than I expected.
Jerry:
Yeah, politics is very interesting. A touch frustrating, but very interesting. It
Dave: Is. And I've worked with politicians here in our state for 30 plus years now. It's interesting talking about harm reduction though. I've always been in treatment and I sometimes worry that the needle exchange programs in Vegas are too robust. And when I hear they're giving out a million needles a year, I wonder, is there a tipping point?
Jerry: Let me tell you about the one here, which I'm proud of for a lot of reasons. And again, harm reduction is a way post for us. We're hoping what everybody hopes is that we reduce the harm. But you get into recovery. I mean, that's the goal. The goal is the endpoint. It's not a destination. Ultimately, harm reduction models, harm reduction models are, let's try to get there, but we actually track this. What is supposed to happen. It is supposed to be a needle exchange program. Lots of communities do exactly what you said. They just give out needles. In fact, I have been told without any personal proof that in Reno where they do have a needle exchange program, one of the problems is they just give out needles. And they're places where there's a lot of drug use and there's just tons of needles. Ours is indeed a needle exchange program. You bring in your syringes, which we destroy to get new needles. Now of course, there's a net outflow, but the net outflow here, last time I looked at the data we had last, the last month, and it's been several months, but we had 150,000 needles out, but 140,000 needles in.
So we destroyed 140,000 dirty needles, even though there was a net outflow of 10,000. But you are right. One of the challenges with needle exchange programs is there, they don't exchange. They just give. And that was not the idea behind the programs.
Dave: If I have one message to you, it's I'm just so grateful that you're helping us at Vegas stronger and helping me with my passion of having evidence-based substance use disorder treatment available for the most underserved. I'm curious, do you see similarities in the population that you treat on the HIV side as well as the population that we're treating here at Vegas stronger?
Jerry: Yeah, absolutely. And it's what makes both of us passionate about doing this. I mean, you take care of, I have patients I take care of who have zero problems in life. They have good jobs, they have cars, they have things. And those were the patients that I was bored with. I love talking to 'em. And gossiping, don't get me wrong, but I quit my private practice the same time I quit UMC because I was just seeing HIV positive patients, and they all had private insurance, and they all had cars, jobs, and insurance. And they had good T-cells, which is a marker for HIV. And they were non-detectable, which means the virus is suppressed. That's wonderful because it didn't start that way. But as I closed my private practice, I told my patients, I said, HIV care has become wonderfully boring and I need something. And our populations bring up all of the, what can we do?
I mean, I think about it all the time. How can I deliver healthcare to somebody who's unhoused? I mean, I've told you we need to get a van and go do it. Everybody deserves access to healthcare. And some populations are more challenging than others. In the early days, you're completely correct. In the early days of HIV, that was a population in which it was challenging to provide healthcare for a host of reasons. You didn't have help, you didn't have people, you didn't have this. You didn't have that stigma very much. And the stigma, I feel very much that what we're doing with the unhoused and the chemically dependent population is the same. And I think we can do as much. I mean, I think these are not insurmountable obstacles. I just think we haven't spent the time and energy and creativity to make things happen. And I think we can
Dave: Agreed. Agreed. And I'm grateful. We're still scaling. Let me pivot for a second. I'm fascinated by terminology. And in my career, I've watched this evolution of terminology where we used to call, they used to be called addicts who I treat, or people with abuse disorders. And then it just became just substance use disorders. And then we talked about relapses and we talked about dirty uas, and then we changed it to, not relapses, but a recurrence. A recurrence, and a positive UA indicating a recurrence. What's your sense on the evolution of terminology?
Jerry: I just try to keep up. I'm like, okay, if that's how I'm supposed to say it today, nothing has changed in my head, but I do my best to try to keep up.
Dave: So do you think changing the terms ends up helping?
Jerry: I don't. Who knows? Ultimately it doesn't hurt. So that's kind of always been my criteria is okay. I don't know if it helps or not, but if it doesn't hurt, it's not a big deal. Let me just do it. So I mean, obviously I understand the psychology behind it is supposed to be. It's a less pejorative, less judgmental way to look at it. And if that helps. So I am for anything that helps, don't get me wrong, same. I hardly support absolutely anything that will help us. So if this is it, I'll do it.
Dave: Same. Although being an older guy, I have to consciously work at it.
Jerry:
Me too.
Dave:
I remember 10 years ago if we heard someone had committed suicide that wasn't a sin, and now it's completed that we wouldn't say somebody committed it. So I certainly don't want to hurt anyone. And if there's a way for me to frame something in less pejorative, more supportive as a counselor, it is important to me. So I'm glad folks are helping change our culture, even within our industry, to be more sensitive to everyone.
Jerry: I mean, of course, when you think there's nothing new that we finally reached the end. So there's another nuance. I thought, okay, we e established this, but then a few years later we didn't. So
Dave: How long has prep been out?
Jerry: So actually, I can tell you the article in the annual England Journal of Medicine, which is the Bible in medicine, is the New England Journal of Medicine. The article in the New England Journal came out in 2012. It was written by a very good friend of mine. It did not hit the public consciousness though for a while. And I was surprised. I mean, as a doctor, I was well aware of prep and well aware of what good it could do to keep you from getting HIV. But people didn't ask about it. It took about two or three years and there's actually some data or some thoughts about this, like diffusion theory. It takes a while for things to diffuse. Roberts, I think, is the guy, the author of the diffusion theory, but it took about two or three years for people to pick up on it. Now it's very common. In fact, it's one of those questions that my patients tell me they ask when they see somebody, are you on prep before they even consider going any further?
Dave: Oh, wow. Makes sense.
Jerry: Yeah. And it does make sense.
Dave: Yeah. Alright. Wow. It seems new to me. And now you're telling me it's been around for 12 years. That's certainly, yeah, 12 years.
Jerry: But in the consciousness, and obviously the gay community picked the gay male community picked up on it first because that's where that's still unfortunately, the most incidence of HIV is worldwide. It's a very heterosexual disease. But in our country, I think, and I may be wrong, don't let anybody believe my statistics, but I think 55% of HIV transmission in this country is still among men who have sex with men. I think. So that
Dave: 55, that's certainly not everyone.
Jerry:
It's certainly not everyone, but it's a big percentage. So that's where it diffused first and then kind. And same with women. The data's done on men, but of course it should work just as well in women. And it was probably two years before the first woman asked me, can I get prep? But certainly at one of their two center sites, we really focus on STIs. And Saturday I started 1, 2, 3, 4 people on prep on this past Saturday morning. And that wasn't including all the people who came in for discontinuation of their prep. These were new starts.
Dave: Okay. Well good. And boy, we're lucky to have you so active. I'm curious, I was going to ask you, how old were you when you were growing up? How old were you? You when you recognized that you were smarter and wired tighter than the average bear?
Jerry: I don't know if you really recognize that, except in retrospect. Right? I don't know about the smarter, but I do know about the wired tighter. I'll agree with the wired tighter. I didn't perceive myself as particularly smarter than anyone else. I just thought I was more manic than everybody else around me.
Dave: So at what age, now granted, you've noticed it retrospectively. How old were you when you started noticing We're on the edge of the bell curve.
Jerry: One of the things that surprised me, and I swear I didn't recognize this until I was probably in my mid forties. It was a long time, but I remember talking to all of my colleagues who talked about having to apply for med school two or three times or worried about getting in medical school. And I thought back, it never crossed my mind. I wouldn't get in the first time I had finished college in three years, knew I was going to go and I had a list and I was pretty sure I was going to get into my number one school, which I did. And it never crossed my mind that wouldn't happen. And then I have all these friends that tell me these stories about what they did. And I'm wondering, I like instant rewards, you and eyeballs. Yeah. That's what produced some of the drug and alcohol things. We like the instant rewards. So I've often thought if I hadn't gotten in medical school the first time around, would I have done it? Would I have put up with that? I might've gone some other path. This was not an overwhelming mission for me at first. I mean, it became one of the best things I ever did. But it wasn't like I have to go to med school. I have to be a doctor to feel complete.
I was older when I said, well, I guess everybody didn't think because we all just see the world through our eyes basically. We're all pretty egocentric unless we pause to think about other things. So I just presumed everybody was like me because that's what we presumed
Dave: For me. I got sober at 40 and getting sober at 40. It helped me do so much reflecting and looking back and seeing patterns that I had just been oblivious to.
Jerry: That may be true for me. I had to think about it. I got sober 35, so maybe that's why it was my forties maybe during the alcohol and drug phase. Well, I do know I was much more narcissistic during the alcohol drug phase that egocentrism that I just
Dave: Self-absorbed.
Jerry: Yeah. I didn't have time for anybody but me. So you may be right. That may be when you started paying attention. I never even thought about that to be honest with you. But it's a really good thought that sobriety produced insight.
Dave: Yeah, no doubt. No doubt. To me, there's so many things about sobriety beyond just separate, not taking drugs and alcohol,
Jerry: Right? Oh gosh, yes. That's something I try to instill is sobriety has very little to do with stopping drugs and alcohol. I mean, that's day one. And then you go from there
Dave: And each of us, so much of our life has become service to others. And to me, that's all a byproduct of recovery.
Jerry:
Yeah. Maybe we're making up for that egocentrism of the first 35 to 40 years. I don't know what the deal is, but you're right. I mean, it's probably because we finally noticed others and finally could see that the things around us that needed to be done while we were too busy at the first part of our lives, just making sure we had what we thought we had to have,
Dave: Getting the immediate gratification, which takes me to, we named it or I named the podcast Human Up, and I wanted to ask you what you think that meant to you. And I wanted to talk about human up for a moment.
Jerry: Okay. Obviously I like the name mean. This is way, I think that for me it implies the other parts of being a person besides the physical, it's the psychological, spiritual, social parts of being a person, which we don't focus on. I mean, we focus on your job, what you make look like. And those are not the human parts of us. And they're certainly not the best parts of any of us, I think. So that's what it implied is, oh, this is the mental health stuff, the psychological health, the spiritual health that we need to try to achieve. So I thought it was a great name.
Dave:
Well, good. Thank you. I also, to me growing up, the oldest son in an Italian family, the answer to anything, if you were crying, if you were sad, if you were anxious, it was man up. And to me, having that evolve, talking about the terminology, you know what human up is to me, being clean and sober became part of that. Becoming aware of my family, my community, and that just helping other people is so much better than you talked about having a good car or wearing fancy brands or money or anything personal. But that really, the answer to life lies in being of service to others.
Jerry: Yeah. No, and as I said, and working on all the other aspects, I get up every morning. I've never told you this, so I guess we can tell you it publicly, huh? I get up every morning and I have a little casita that's private with a little fountain, and I read stoic philosophers. And a lot of what stoic philosophers say are just what we've been talking about. Things like what you need to do is learn to interact with other human beings, and you need to learn how to respect what they do. It's all about being a good member of society and whatever. Not being a good you necessarily, but just doing your place and your purpose in society. And I do that every morning. I'd go crazy if I didn't, and I might, but that's what I really like. And Human Up reminds me of what they say. I mean, this is Marcus Alio, Seneca. People like that, who kind of began the idea of mankind is more than this physical being. Let's explore that.
Dave: That's awesome. And I have daily disciplines picked up in recovery and a little meditation, some quiet time in the morning. You said, oh, it stops me from going crazy. No, I agree. But it also has me just walking around as a more confident, I'm more at peace, human and able to be of service because I'm less caught up in my head.
Jerry: Yeah, no, it makes a big difference. It does. And obviously it was from years of recovery that I got the idea. I mean, I kind of branched out into other things, but it's the same thought. And I don't know I would've ever thought of that if I didn't have to. When I got sober at 35, I mean, I had to get up and do something or I really was going to be crazy.
Dave: I'm glad you have a fountain there too. The water. It sounds peaceful.
Jerry: It's so cool. Water is peaceful in the overall scheme of things.
Dave: Now we're on a podcast that other people are going to see. But I'm going to ask you anyway. I believe our whole country is becoming bifurcated by politics, by the press. And my sense is that if we human up and we talk to each other as individuals, we actually don't have major strife amongst us that the political process is sort of bifurcating us. I get the sense that you're a little left of center. I'm a little right of center, but I get the feeling you and I work together very well and don't hold grudges despite the fact that it seems to be fashionable to do so right now. What's your sense?
Jerry: No, I actually completely agree with all of that. Left of center. Right of center. But I thought that's cool. My best friend's Republican and for many years, my sisters are Republican. But you know what I have always thought, and this is still philosophers too, to give them credit, if you stop and think about it, we are so much more alike as human beings than different. And for us to focus on these petty differences really betrays what we should be doing. So that's my philosophy about that is I really, truly don't care what your beliefs are one way or another. I know I've got 99% of me is a lot more like you than different. And those things in which we are alike are the more important things. They're the human up things. I mean, it's a great title. The Human Up things are the things that we all struggle with. How do I do this? How do I be a better person? How do I prove that I care about my family? How do I support? Everybody struggles with the exact same issues. And you're right, this craziness that we get into in politics, it's just, it's craziness. It's okay to disagree, but it shouldn't be rebelliously vehemently disagreeing with anybody
Dave: Or put a chasm between us as humans.
Jerry: Yeah.
Dave: Yeah. I like there's a 12 step saying, it's like if you go to a meeting and you look for the differences, you're going to find them. If you go to a meeting and you look for the similarities, you're going to find those two. So really the question is what are you looking for?
Jerry:
Yeah. I think it may have been in a 12 step meeting. I learned what I just said to you. Oh really? That we are much more alike than we are different. I think we all started saying, we all started going to meetings going, I am not like that. I can't be an alcoholic or an addict. I think that's a normal initial response, but it doesn't take long to go, well, I am a lot like that and I didn't quite do that, but I did this. And you all of a sudden realize you're not that different.
Dave: Right. I just want to say that the few times we've had lunch, the time we went to see a speaker, the times we get to work together and each time you've come by the building and it just so happens we're having a major county meeting talking about our funding. It's so serendipitous and I appreciate working with you so much and your passion. So I really just want to say thank you. Thank you for your friendship. Thank you for being our medical director and thanks for being on the Human Up Podcast.
Jerry: Yeah, well likewise. I mean obviously I love what we're doing. It keeps me inspired and I work better if I'm inspired.
Dave: Yeah, me too. Anything else we should say before we close?
Jerry: No. Can we say give us money?
Dave: Oh, absolutely. That's a good one. We're both the Center and Vegas Stronger, our 5 0 1 C3 nonprofit organizations and each one of us have a website. And if you could make a tax deductible contribution to us, it would help us so much, please support both of these critical agencies that are helping address a social problem in our community.
Jerry: Good.
Dave: Thanks for being here, Jerry.
Jerry: Alright?
Dave: Have a good day!
Jerry: Too.