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A Conversation with Dr. Rey Ximenes | Driftwood Interviews

"In some ways, a person who comes through a program like ours has an unfair advantage over the general population. Because people don't ordinarily get that education in coping with life. We're not born with a manual.

"Every Time I Teach, I Learn"

This is the sixth in a series of posts introducing the people who make up Driftwood Recovery’s community of caregivers.

Through these conversations, you’ll get a chance to meet the people on Driftwood’s team—from its executives to its care coordinators. You’ll learn about the programs they facilitate, and about how their work serves Driftwood’s overall treatment philosophy. You’ll learn about the various paths that brought them here. And you might pick up a book or Austin restaurant recommendation.

In this post, Kuraĝo editor Matt Williamson talks with Driftwood’s Medical Director, Rey Ximenes, MD.


Matt Williamson: You have several board certifications, correct?

Ray Ximenes: Well, I have a board certification in anesthesiology, which is where I started. And then I got board certifications in pain medicine and interventional pain medicine. And then I got board-certified in acupuncture and in naturopathy. My last board certification is in addiction medicine.

MW: Could you explain the difference between pain medicine and interventional pain medicine?

RX: Pain medicine is what we all started out doing. It was basically using what we had—mostly opioids—to treat pain. We've since gotten into different drugs and medications: gabapentin and muscle relaxers and antidepressants and things like that.

In interventional pain medicine, we use nerve blocks. That means, for example, using a local anesthetic to dull a nerve’s ability to transmit information. We also use steroids to calm inflammation. And we use spinal cord stimulators and intrathecal pumps, pain pumps. We’ll perform what I guess is called “minor surgery,” although that term—“minor surgery”—I'm never sure quite what it means.

MW: Kind of an oxymoron.

RX: Exactly.

MW: So in interventional pain—correct me if I'm wrong—it sounds like one distinction is that you're not using drugs as often?

RX: Not as often, no.

MW: And the approach sounds much more localized, or targeted. I can see the connection to acupuncture.

RX: Acupuncture is, for me, just another tool. For years, I saw people doing epidurals and facet blocks and radiofrequency thermocoagulation. And I thought: no one's doing acupuncture. I realized that if I did that, I’d be ahead of the crowd.

MW: Why do you think that this treatment, which is so mainstream in half of the world, has been so slowly adopted in the West?

RX: It's hard to really know. Back in the day, the Emperor of China wanted to trade with the West. And at a certain point, he actually said: “No more acupuncture. No more Tai Chi. No more Chi Gong. It's all this magical stuff that makes people think we're country bumpkins.” They started adopting a lot of Western medicine at that time, and really put down and shunned traditional Chinese medicine. When Mao took over, I think he kind of went, “This Western stuff’s pretty expensive. We’ve got to figure something else out.” He wanted to go back to some the old ways, including acupuncture and herbs.

In the Western world, we think acupuncture is this thing unto itself. We address it as acupuncture, and we have licensed acupuncturists. In the East, they're kind of scratching their head about that, because traditional Chinese medicine has always included ten or eleven different disciplines. Diet is very important. Exercise is very important. Herbs are of paramount importance. Acupuncture is important, but it’s part of the fine tuning, not the primary thing. Somehow we got fascinated with the art of needles. An acupuncturist here is kind of like a mechanic who’s licensed to use one specific type of socket wrench.

I use acupuncture as a tool. I also use herbs as a tool. I use a lot of exercise. I use Tai Chi and Qi Gong. And I use a lot of lifestyle advice: telling people what to eat, how to eat. It's truly a holistic approach.

MW: Do you ever teach Tai Chi to residents here at Driftwood?

RX: Yeah.

MW: I assume that most people who stay here don't have any experience with it. How do they usually take to it?

RX: Honestly, it’s tricky. Nobody's here long enough to really learn it very well. So what I finally did was to set up weekly lessons at Bull Creek Park. I said: “Look, everybody's invited, every Saturday morning.” It's very much the Eastern way of teaching Tai Chi: “just show up at the park and do it with us.” And eventually you will learn.

MW: It strikes me that Driftwood is a small, intimate place. The resident-to-staff ratio is 1-to-2.8; by design, there are almost three people on staff for a single resident. And at the same time, people are coming in with a wide variety of substance abuse and pain problems, and their recovery programs are highly customized. I would imagine that, for the medical staff here, this would present a challenge. You see a little bit of everything, right?

RX: Sure. People come in here and need something very specialized. For example, if someone is withdrawing from alcohol, we’ve got to be careful. We’ve got to really monitor them, and make sure that we have every medication on hand that we could ever need, because one of the problems people have with alcohol detox is they can get into seizures. At the other extreme, when someone has been dependent on hallucinogens, most of the withdrawal is psychological; there's no full-blown physiologic detox, although symptoms can recur for a long time. You have to look at each person and know what you're doing with each one.

Anyway: once you're in the clear, out of your early withdrawal, the approach to treating addiction is similar for everybody. Obviously, there are nuances that are different for each individual. But in the end, the goal of an addiction specialist is to make sure the person is healthy.

MW: When you’re speaking to somebody who has never had a problem with substance dependency—is there some sort of analogy you typically use to help them understand what an addicted person is experiencing? Why is it so hard to “just quit?”

RX: I do have a favorite analogy, actually.

First off, know that addiction takes over the survival center of the brain. I don’t call it the “pleasure center”; it’s the survival center.

There’s a cup of coffee on the table here. Let's imagine that I told you to take a sip of that coffee, and you didn’t want to. If you felt strongly about it, you’d refuse.

Now: what if I took a .45 out and pointed it at your head and said: “take a sip of the coffee?” What are you going to do?

MW: Take a drink.

RX: That's what the addict is experiencing in the brain. “If I don't drink that, if I don't snort that, if I don't shoot that, I'm going to die.” The addict might know that they don’t have to. But they feel that they do. And that's the trap.

MW: Listening to you, I was just reminded of a documentary I saw recently about a treatment center in Alberta. It’s a public, free, seemingly high-quality residential treatment program. In one scene, this guy comes in who seems, genuinely and desperately, to want help. A staffer is explaining to him what he has to do to get into the program. “It’s free, we’ve got a place for you, we'll just sign you up. The only thing is, you have to abstain from drugs for five days before you enter treatment here.” And the guy seeking treatment says, basically, “forget it. I'll never be able to do that.”

RX: That's pretty rough.

MW: You can see that he isn’t even contemplating it. He’s just listening politely after he hears that “five days” is a hard requirement. In the next scene, a different guy is explaining that he would rather die than go through the agony of fentanyl withdrawal.

RX: That five-day period is going to feel like five days of re-enacting The Deer Hunter. Click. Click. Click. Five days of that? You can't do it. That's where residential treatment becomes crucial.

Once you get through early withdrawal, though, you’ve come to the most important part of recovery. When you reach that point, what often matters more than anything else is community. You need a group of like-minded people around you, who know something about what you’ve gone through and are going through. Every time you want to go back and use, there are people who are right there, ready to say: “Nah, man. Don't do that. I did that. Here’s what happens.”

At Driftwood, we keep people busy, and we educate people. I tell people that this is an educational program. Using cognitive behavioral therapy or motivational interviewing, or various other techniques, we're teaching you how to cope with life events. Because in the end, addiction is about what you’re hiding from. What is it you fear? If we can get people to cope with that fear in a healthy way, then we've made it.

In some ways, a person who comes through a program like ours has an unfair advantage over the general population. Because people don't ordinarily get that education in coping with life. We're not born with a manual.

MW: You’re talking about skills that everyone needs. But we don't develop them, because we're not in crisis situations that force us to develop them.

RX: Why don't we have seventh-grade AA? Some kind of cognitive behavioral class: Life 101? We pretend like it's not necessary until it is, and by that time it's almost too late.

MW: Most people either have incoherent value systems, or they simply haven't thought about what their values are. We’re nose-deep in this culture that trains us to laugh at the idea of ever getting reflective, philosophical.

RX: Yes, and getting into recovery presents opportunities to inquire, to grow. I've learned so much doing addiction medicine. I've learned so much about myself. I’ve started paying more attention to the ways I deal with things.

The original meaning of “doctor,” you know, is “teacher.” And so I come out here every week, and I teach. And every time I teach, I learn.