Last Day Revisited: The Opioid Crisis

6: The Magic Formula

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[01:20] Jessica Cordova Kramer: OK. I’m going to read this note. So this is from Stef on Wednesday, January 29, 2014. It’s around 5 a.m., he writes to me, subject: Livvy’s present.’ ‘Hey, I feel awful about not sending Livvy a card, or talking to her –’


[01:36] Stephanie Wittels Wachs: I was on the phone with Jess recently and we were, among other things, talking about the manic investigative phase. 


[01:46] Jessica Cordova Kramer: On a different subject, I am asking all of you for a second chance to redeem myself so that I might finally have a normal relationship with my family that is positive going forward. 


[01:55] Stephanie Wittels Wachs: If you are not familiar with this very official grief term that I made up, it is the thing that happens after your person dies where you furiously search for clues and evidence in the form of text messages, emails, voicemails, chats, all of it — to try to make sense of something so senseless. And on this call, Jess shared something that she dug up from her own case file. 


[02:16] Jessica Cordova Kramer: So what I’m asking is at some point in the future is for a chance sometime down the road to just be your son, and not the son or brother with the problem. I expect you guys to be skeptical, which I understand, but tried to be as excited for me as you are skeptical and you will see a difference in me without having to talk about it. Anyway. I need to go to work. Love, Stef. 


[02:48] Stephanie Wittels Wachs: Reading an old email from your dead brother out loud is a thing that is definitively awkward. So I asked her how it felt. 


[02:58] Jessica Cordova Kramer: Yeah. I mean, I just feel so in, like — numb to some of the stuff that happened. And this was so many years before he passed away. It’s three years before he passed away. And at this point, he had just left us in Minnesota. And I’d seen him with track marks in his arm, and I begged him not to leave. And so when I got this e-mail, I can assure you, I was not pissed to him for missing Olivia’s birthday so much as I was pissed at him for giving up on what I thought at the time was a chance that he had to stay with my mom, and focus on his sobriety, and not get caught up in like, what do other people think of me? I need to get back to Florida. It’s so cold here. Yeah, like, yeah, it’s cold here. It’s a cold year for a year. And then maybe you’ll be better and then you could go live in Florida without dying. So I don’t — when I read this, I don’t know — it brings me back to that place where I was sort of shell-shocked. It’s like when Harris first told you who’s using heroin. This is, this is my moment of that. 


[04:08] Stephanie Wittels Wachs: I remember my moment of that. It was right after work, around 4 o’clock, and I got this text from my brother. He said, ‘hey, I’m gonna call mom and dad later, but heads up, I’m checking back into rehab tomorrow in Oregon. I started shooting heroin. My sponsor is with me now babysitting. My boss knows I’m fine and alive.’ And that was that. My heart stopped. He was shooting heroin? What the fuck? He had already gone to rehab. He’d already gotten sober. That problem was solved six months ago. Why were we back at the problem, and why had the problem gotten worse? 


[05:01] Stephanie Wittels Wachs: I’m Stephanie Wittels Wachs. This is Last Day. Last episode, we learned that Stefano’s treatment journey began at a facility called Hazelden in Minneapolis, where he lasted for 24 hours. Historically, Hazelden, like most treatment centers in the country, offered an abstinence-based program. Essentially, the model was come here, stop using all drugs, keep not using drugs forever. Which makes sense if you are viewing addiction as a choice. But as we’ve learned, it’s not. 


[05:49] Stephanie Wittels Wachs: Over the years, Stefano tried abstinence-based methods and medically assisted treatment. He tried inpatient and outpatient programs. He tried AA. He tried Florida, Minneapolis, New York and Boston. He tried good old-fashioned therapy. In the 10-year period that he struggled with his disease, Stefano went to a total of six formal rehab programs and none of them worked. He still died. So what does work? Well. Let’s see. I’m a modern girl living in a modern world. And when I need answers, you know what I do? I Google. So let’s do that. Let’s Google. OK, so I am going to my computer now, opening up Google, typing in re — All right. So I see. Ooh. Beach house rehab center, dot com. Inpatient drug and alcohol rehab. Recovery unplugged. Serenity. Oh, this is good. Passages Malibu Center. Unique one-on-one addiction treatment. Rated the number one rehab in the world. Oh, addiction ends here. That is a bold fuckin’ statement. 


[07:30] Stephanie Wittels Wachs: That is a lot of things. I mean, how do I know which one to go to? Is there a Yelp or TripAdvisor for treatment? I can’t pick a place to eat dinner without reviews. And none of these results feel particularly trustworthy. I mean, I know that they say it’s the world’s best, but the design is mostly terrible. So. What is the move here? Like, what’s the right option, if and when I’m ready to get help?


[08:06] David Sheff: When I found out that my son was in trouble, that he was addicted, that he was going to die if we didn’t figure out what to do, I was thrown into this — this morass of confusion of what we call a drug treatment system. 


[08:22] Stephanie Wittels Wachs: I totally agree, David Sheff, New York Times best-selling author. I just Googled it and you are correct about the confusing morass. David wrote a book called ‘Beautiful Boy: A Father’s Journey Through His Son’s Addiction’ that was made into a movie starring Steve Carell and Timothee Chalamet. I actually watched this movie on a plane recently and quickly became the crying person on a plane, which is always a fun role to play. The book is based on David’s own experiences with his son, Nick, who is currently in remission. He joined us from his home on a good old-fashioned landline. 


[09:02] David Sheff: I mean, if the person that we love had any other diseases, we know what to do. You go to the doctor. But here we don’t even know where to start. And so I was desperate. Nick had almost overdosed. He’d been missing for a few days. And I finally got him and needed to find something. And I called counselors, I called our pediatrician, I called the therapist. I mean, nobody knew what to tell me. And I finally found a referral just from a friend of a friend of a friend whose kid had gone through something similar. And she told me the name of a rehab in San Francisco that I called and they had a spare bed and they took our insurance. And so I sent Nick there, really not knowing what I was doing, not knowing if he was going to get the treatment he needed. As unsure as I was, I still was naive to think that I would pick him up in 28 days and he would be cured. And of course, I learned since then that’s not the way it works. But the treatment that he got in about seven or ten programs over the course of ten years — a couple of times he got good treatment, but most of the treatment that he got was terrible and that’s unfortunately what most people get when they enter the treatment system in our country. 


[10:14] Stephanie Wittels Wachs: David’s done extensive research on all sorts of treatment facilities in America. If you haven’t read his book ‘Clean: Overcoming Addiction and Ending America’s Greatest Tragedy,’ you should. It is eye-opening and maddening and highly informative. 


[10:31] David Sheff: There really is no definition of what rehab is. I mean, there are programs right now that cost a fortune, and some that are free, that are appalling. They do things like walks in nature, you know, I mean stuff that is not how you treat a disease. And so rehabs are unregulated. And in many places, anybody can open a rehab without any credentials. I could go open a rehab and then take people’s money and offer treatments that include, you know, I mean, in some places you go out and — there’s one that where they give patients Nerf noodles, I guess they call them and, you know, you confront a horse with them. I mean —

[11:10] Stephanie Wittels Wachs: What?

[11:11] David Sheff: There’s plenty of crazy stuff like that. And then some of the treatment programs that, again, are supposedly rehabs trying to help people that have serious illnesses will do things like — you know, Nick was kicked out of a treatment program because he didn’t make his bed well enough. Like he was in the Marines or something like that. I mean, as if that is relevant at all. I mean, most rehabs are terrible and there are good ones, but it’s really hard to find ones that are good. And the difference is in a program that is good and one that is terrible is that, you know, the terrible ones obviously are not just a waste of time and money, but it also can be lethal. I mean, people can die. So once we understand that people are ill, we follow the research that tells us what works for people with this particular illness. When Nick was breaking into our house, when he was stealing from me, when he was stealing even from his little brother, who, you know, who he adored. I was so baffled. It’s like what has happened to this person that I thought I knew — this moral, lovely child. And it didn’t make any sense. 


[12:13] David Sheff: But now when I look back, I realize that it did make sense because he was sick. And that’s why people who are addicted are judged and blamed and vilified and made to feel worse about themselves than they already do. And it’s why people who love them are also made to feel, you know, to be also shamed, embarrassed. I mean, people have said this, you know, if you have a child in your family who has, you know, another disease, you know, they come down with cancer or something. The doors are open. Your neighbors are going to come by. They’re going to bring your casseroles. You know, you’re gonna get support everywhere you go. Everybody’s going to just reach out. But when somebody that you love is sick with addiction, you oftentimes you don’t even talk about it because you’re embarrassed. You have shame. People are going to judge you. 


[13:04] Stephanie Wittels Wachs: And then there’s the issue of accessibility, or put in simpler terms, the fucking insurance companies. 


[13:12] David Sheff: Sometimes I’ll hear from people who had to fight their way to get an insurance company to pay for their own or a child’s treatment. And then after five days, the insurance company is ready to kick them out of treatment, as if you can cure this disease in five days. So, you know, on one hand, we have a lot of good therapies that work, but on the other hand, you know, people just can’t have access to it. You know, even in the best of all possible worlds — even people with unlimited resources have a really hard time getting good treatment. And I hear about it all the time. People who’ve spent — you cannot imagine how much money, hundreds of thousands of dollars to try to get treatment. There are places in many of the big cities, but they’re really hard to access. I mean, there’s a program in San Francisco that’s amazing. But there is a three- to six-month long waiting list. So you’ve got somebody who’s dying on the streets because they’re addicted to heroin. Until then, they have to wait three or six months to be treated. And there’s a good chance they’re gonna die. It’s appalling. And as hard as it is to get treatment, you know, anybody who has anything if you don’t have money, if you don’t have good insurance, you know, if you have cancer, it’s hard to get help. But it’s harder with mental illness and it’s harder even still with addiction. 


[14:25] Stephanie Wittels Wachs: So. OK, I have to be honest. Some — it’s just — a lot of it’s really depressing. 


[14:33] David Sheff: Yeah, sorry.


[14:34] Stephanie Wittels Wachs: It’s so depressing! No, I mean, listen, I’m already depressed about it. You didn’t do this. So how do people who are struggling with substance abuse find the energy to keep getting up off the mat after relapsing and keep coming back and trying and trying again? And similarly, how do families sustain that energy and that hope? And that will to keep trying. 


[15:00] David Sheff: Well, it’s really hard, as you’ve identified. I mean, it is really hard because it is so frustrating and it can take such a long time and it’s so scary. But, what choice do you have? I guess that’s sort of where I go, is that, yeah, you can give up. But, you know, I was never going to give up on my son, you know? Are you going to give up on yourself? I mean, the good, positive news — and people have to understand that is that even though it’s hard to get good treatment, good treatment exists and you cannot give up. You just have to keep trying. And sometimes it takes two times a treatment. Sometimes it takes three. Sometimes it can take ten. Yeah, it can be exhausting. It can be debilitating and it can be really scary, as I said, because, you know, people die every day. We just have to keep trying. And sometimes this is a chronic illness. But the big message is don’t give up. 


[15:48] Stephanie Wittels Wachs: Yes. Don’t give up. I get that. But also, like he said, it’s really fucking frustrating to love someone who is actively destroying themselves. And that frustration turns into anger and that anger is toxic. And I’m not trying to sugarcoat any of that. That stuff is real and that stuff needs to be dealt with. But like David said, what choice do you have? We are going to offer you some better choices than Google when we come back. 


[18:43] Stephanie Wittels Wachs: We’re back. You’re listening to my new show, Treatment is a Fucking Nightmare, formally titled Last Day. This summer at my mom’s support group, one of the dads described this recurring process of finding a seemingly good rehab facility online, calling the hotline listed on the website and then discovering that the person answering the phone would actually get a commission if they got you to commit. A commission! I gotta say, it’s hard to keep the hope flowing when you feel like your person’s chronic illness is someone else’s commission. Just sort of leaves a bad taste in your mouth about the whole industry. But like David said, good treatment does exist. It may be harder to find, but there are really good people in this field who are doing really good work. They are, as they say, on The Bachelor, in it for the right reasons. Last week, we met Dr. Nzinga A.Harrison. She is a physician who specializes in adult psychiatry and addiction medicine. 


[19:52] Dr. Nzinga A.Harrison: I operate within a multidisciplinary team to provide the biological medication management that goes along with treating a substance use disorder, as well as identifying any other psychiatric disorder — depression and anxiety, experiences with trauma, schizophrenia, bipolar disorder. So what we know is that 80 percent of individuals with a substance use disorder also have another psychiatric disorder. But then also psychotherapy services — so individual therapy, group therapy, education about the illness. Kind of really experiencing my patients as the entire individuals they are outside of the diagnoses they carry, and figuring out how we can kind of help them develop that magic formula that helps them get their symptoms in remission and live the lives that they want to live. 


[20:47] Stephanie Wittels Wachs: I am very into this. Her approach is not prescriptive. It’s more nuanced. She believes strongly in treating the whole person. The funny thing about her magical formula is that it’s less about magic and more about being really methodical. She’s picking up on every data point about her patients and she’s extremely deliberate about her language. 


[21:15] Dr. Nzinga A.Harrison: There’s absolutely a vocabulary — and you’ll find even throughout this interview I call myself language-militant. And not just around substance use disorders, but in life in general. We under-appreciate how much stigma and marginalization we unintentionally convey in the words that we use. And so you will always hear me say ‘a person with addiction’ or ‘a person with depression’ or ‘a person with schizophrenia,’ because whatever that illness is not the defining feature of that person, right? So you won’t hear me say ‘an addict’ because the substance use disorder is not the most important thing, nor the only thing about that person. It’s not defining. So I try to be very intentional about making sure I am conveying compassion and just an appreciation for the equal value that each of us holds as a human being, regardless of what medical illness we may be experiencing. 


[22:16] Stephanie Wittels Wachs: I love that. That is so sweet and wonderful. My person is not an addict. They are so much more than that. They are a person with addiction. Yes. Yes. Yes. But I’m still not thrilled about that? I mean, I still want to help them to not be a person with addiction, and we know from last week that detox is just the beginning. So what do I do? 


[22:57] Dr. Nzinga A.Harrison: So if we think — and this is one of the problems with our system — that we can just give a person a detox for three to five days and then quote unquote, your substance use disorder is treated. That would be the same as getting a person in diabetic coma out of the ICU, stopping their insulin, discharging them from the hospital and saying, ‘good luck keeping their diabetes away.’ Right? We would never do that because it just doesn’t make sense. And so when you have a person in front of you who has completed their detox, the answer to what kind of treatment they need is extraordinarily individualized. And so the other concept I’ll give is that part of the issue with our system is that we don’t have enough options at each step of the way so that the intensity of treatment can match the severity of illness. And so it’s like if you break your leg, we don’t put you in the ICU. If you have a stroke, we don’t give you a pair of crutches and say, good luck living. But because the access to the different levels of substance abuse treatment is so spotty, there are communities where literally there’s only an ICU or like a 12-month residential treatment program. 


[24:10] Stephanie Wittels Wachs: Dr. Harrison sees all these communities around the country that lack the appropriate resources to meet the actual needs of the people in them who are dealing with addiction. Some places are essentially treating cancer with band-aids, while others are offering chemotherapy for paper cuts. To better tailor treatment options, she suggests looking at the consequences of drug use in five specific areas. 


[24:37] Dr. Nzinga A.Harrison: And so we’re figuring out the biological, the psychological, the social, cultural and value set of that person and then hopefully being able to craft a treatment program that can intervene on all of those. Because we know if you leave one of those unaddressed, you’re leaving a pathway to relapse of symptoms. 


[24:58] Stephanie Wittels Wachs: The magic formula. The biological, psychological, social, cultural and value set of the individual. Got it. Tell me more. 


[25:10] Dr. Nzinga A.Harrison: So the biological consequences — are there lasting physical symptoms? Are there co-occurring psychiatric symptoms? Usually depression, anxiety, trauma. You look at the psychological effects of the illness. So is there relationship problems? Is there a view on the world this person has been marginalized and has no support system? You look at the social aspects — is housing stable. Are there meaningful connections in the community? Is there a source of income? Do they have health insurance? And so you add all of that up and ideally match them to a program that fits their severity of need. 


[25:52] Dr. Nzinga A.Harrison: And so there will be, for example, a person who gets detoxed that this is the first time they have had a detox from an opioid. They are stably in a relationship. They have a good support system. They have a stable job. Their housing is stable. They have a, you know, had it a childhood that was supportive and stable and they have good coping skills. That person probably can go straight from detox into an outpatient substance use disorder treatment. Right? Another person who was homeless as a child, who experienced trauma, who started using drugs at twelve and has had four overdoses and has been in residential treatment three times and has now just had a near-fatal overdose, who was just detoxed, needs a different level of care. 


[26:47] Stephanie Wittels Wachs: So there’s just not one-size-fits-all.

[26:50] Dr. Nzinga A.Harrison: That’s correct. Like anything.

[26:52] Stephanie Wittels Wachs: Like clothes, for example, think about clothes. One-size-fits-all isn’t doing anyone any favors. It doesn’t work. You’ve got to have specific measurements in order to find a good fit. And in this case, the measurements are the five components of that magic formula. More on this when we come back. 


[29:17] Stephanie Wittels Wachs: We’re back. This is Last Day. So we know that this magic formula has to do with assessing the needs of the whole person. But it’s also about the kind of care that can best meet those needs. 


[29:32] Dr. Nzinga A.Harrison: So if you look at the American Society of Addiction Medicine, they have mapped out levels of care, so ASAM Level 1 is outpatient. And the intent is to benchmark these to the needs of the person. So Level 1 is outpatient. That’s less than nine hours a week of treatment. Level 2 is intensive outpatient. So that’s between nine and 20 hours of treatment. And then there’s day hospitalization, which is basically five days of treatment, 20 hours or more. And then there’s Level 3, which is residential, where you actually live where you are receiving the treatment. And then there’s Level 4, which is in the hospital. So a medically staffed treatment. On the heels of all of that is that it has to be a longitudinal relationship. 


[30:21] Stephanie Wittels Wachs: A longitudinal relationship. Such a poetic way to say that this is going to be a long, long ride. 


[30:32] Dr. Nzinga A.Harrison: Just because we, you know, get you in residential, and you get 28 days abstinent from opioids, the treatment is not done. We get you intensive outpatient. You get six months abstinence. The treatment is not done. What we know is that relapse risk for substance use disorder does not fall to that of the general public until five years in recovery. And recovery is not only drug-free. Recovery is meaningful connections, stability of those other psycho social determinants, relationships, psychiatric illnesses treated, physical illnesses treated and cessation of drug use. 


[31:12] Stephanie Wittels Wachs: And here I’ve been trying to weigh the pros and cons of 30- vs. 60- vs. 90-day programs, maybe six months. It never occurred to me to consider treatment on a five-year timeline. 


[31:29] Dr. Nzinga A.Harrison: So the closer they are to their last use, the higher the risk of relapse. Over time, the risk of relapse reduces, reduces, reduces, reduces. It does not meet the lower risk of a person who never had an opiate use disorder until five years later. 


[31:46] Stephanie Wittels Wachs: Oh, wow. OK.

[31:47] Dr. Nzinga A.Harrison: Right? And so the thought that we can do a three to five day detox, or a 28-day rehab, or a six-month outpatient program, it’s all fallacy. Think about breast cancer. Breast cancer, after a person gets into remission, surveillance continues either twice a year, or once a year, depending on the condition, until the risk falls to meet that at the general public. We should be having that same strategy for substance use disorders. And so I’ll take it back to the woman with breast cancer. She’s not every single day living her entire life around breast cancer once she gets a remission, unless she chooses to do that, you know, like as an advocate or beacon of hope. But she does have that relationship with her physician. She is doing her monthly breast exams, right? So if she finds something, she can get back in quickly to someone she already trusts. She has that doctor’s office reaching out to her, saying it’s time for your three-month checkup. Make sure you schedule it. And so that same concept needs to be applied to substance use disorders. And then the other thing is residential treatment absolutely is sometimes necessary, just like hospitalization is for any medical illness. But when you are in a pristine bubble that does not assault you with your life stressors, when you come out of that bubble and you’re thrust back into those trigger drivers for relapse, then sometimes that creates a vulnerability point. 


[33:21] Stephanie Wittels Wachs: This makes so much sense. Think about all the stressors that exist in your daily life that routinely threaten to throw you off track. You got a flat tire. Your kid has a fever again. The baby is screaming bloody murder while you’re trying to have a conference call. Now imagine you’re dealing with all of these normal, everyday triggers, but you’re also white-knuckling your way through the early days of sobriety. So the stakes are not just, ‘will I make it to carpool in time today?’ They’re literally, ‘will I make it through today?’


[33:59] Dr. Nzinga A.Harrison: And so the reason we absolutely want people in outpatient treatment, which is where they are living in their own environment and having to deal with those triggers but with the support of a treatment team wrapped around them, then you learn to deal with those triggers in a way that you just can’t learn to deal with them in real time if you’re isolated in a residential treatment outside of your regular life. 


[34:24] Stephanie Wittels Wachs: You’re saying that what really makes a difference is that there’s a long-term strategy in place, whether that be that you’re going in for 30 days, whether you’re going in for hospitalization, whether you’re doing outpatient, that you just have a plan to constantly keep maintaining and monitoring the disease. 


[34:42] Dr. Nzinga A.Harrison: That’s exactly right. No matter how long the residential treatment is — you can stay at a residential treatment for an entire year fully away. When you come back to your real life, it will be your real life. And you will need additional support to maintain the foundation that that residential treatment program helped you build. 


[35:02] Stephanie Wittels Wachs: Some treatment centers, offer standalone outpatient resources. Others provide free outpatient programs pending completion of the residential program. It varies, but whenever it comes into the process, the key isn’t just getting sober. It’s figuring out how to maintain sobriety. And for more and more people, that means medication assisted treatment, or MAT. 


[35:28] Dr. Nzinga A.Harrison: Yes, MAT increases the chances that a person will be in recovery one year from now by two to three fold. Two to three chances higher that this person will still be in recovery in one year. And so speaking specifically about opioid use disorders, the very first MAT that was ever developed is methadone. 


[35:52] Stephanie Wittels Wachs: If you’re listening to the show, you’ve probably heard of methadone. It’s like the O.G. MAT. It’s very polarizing depending on where you’ve heard of it, you either know it as a godsend or a crutch, but actually it’s neither. It’s just one form of medication used to treat a chronic illness. Some naysayers will have you believe that MAT isn’t valid because it’s just substituting one drug for another. But according to the surgeon general and a bunch of other fancy smart science people, it works. It works. Here’s how it works. Buckle up. It is about to get technical. 


[36:36] Stephanie Wittels Wachs: Remember those opioid receptors we have in our brains? They are key players in how we experience pain and develop dependencies. Essentially, the receptors receive messages. Duh. That’s why they’re called receptors. And the way they receive messages is kind of like a lock waiting for a key. So depending on what kind of key you put into that lock, you activate different responses. So let’s take heroin, for example. Heroin is known as a full opioid agonist, meaning that key fits right into the lock and swings the door wide open, fully activating that opioid receptor and triggering euphoria along with dependency. 


[37:24] Stephanie Wittels Wachs: Methadone is also a full opioid agonist, so it can help replace the craving for other substances. But the risk is that it can also send an intoxication message. This leads us to a newer MAT, buprenorphine. Remember Sam Snodgrass from Episode 3? This is what he’s been on for the last seven years. Buprenorphine is a partial opioid agonist. Basically, the key fits into the lock. But instead of the door flying open, it goes just wide enough to provide the calming benefits of opioids with a much lower potential for abuse. The last MAT is naloxone, which is a little different. It’s known as an opioid antagonist. So instead of a key, it’s like jamming gum into the locks so that nothing’s getting in there. Got it. Full agonist, partial agonist and antagonist. Most treatment options will have some combo of these elements like you’ve probably heard of Suboxone. Suboxone is a combination of buprenorphine and naloxone. 


[38:33] Stephanie Wittels Wachs: OK. That was a lot. And if you’re anything like me, I know you’re sitting there and you’re waiting for the part where I tell you which MAT works best. I also love reviews, but sorry to disappoint. There is no best. Remember the one-size-fits-all fallacy. What works for you and your body won’t work the same for someone else’s body. But science aside, lots of people think MAT shouldn’t be used on any bodies. 


[39:09] Dr. Nzinga A.Harrison: And so when we think about the aversion that people have to MAT, it’s rooted in stigma. Because it’s a belief that these medications are still mind-altering drugs when we really have to look at these medications the same way we look at blood pressure medications, the same way we look at insulin. They are altering the biology of your brain and your body so as to reduce the negative consequences of your illness. 


[39:38] Stephanie Wittels Wachs: Why is this not, like, mandatory or standard operating procedure? 


[39:44] Dr. Nzinga A.Harrison: So it is standard of care. It is.


[39:47] Stephanie Wittels Wachs: That’s right. Standard of care. That’s the doctor term.

[39:49] Dr. Nzinga A.Harrison: That’s OK. SOP. We’ll take SOP. That’s fine!

[39:52] Stephanie Wittels Wachs: I was like standard of — what is medicine? 


[39:59] Stephanie Wittels Wachs: So if I’m being real with you, which I mean, what other choice do I have here? Before I started doing this podcast, I had some conflicting feelings about MAT that were not actually influenced by stigma. Everything Dr. Harrison says about treating these medications like insulin has always made a lot of sense to me. My misgivings are about the fact that when my brother was sick, he did try MAT in the form of Suboxone. Same with Jess. Both of our brothers tried various forms of medication assisted treatment at various points in their treatment and they are both dead. We mentioned in Episode 2 that Stefano died after being denied a Vivitrol shot because he wasn’t complying with the therapy requirements of the program. I mentioned this to Dr. Harrison in our conversation. And FYI: when she says ‘your brother,’ she means Jess’s brother. But honestly, it applies to my brother, too. So six of one, half dozen of another.

[41:08] Dr. Nzinga A.Harrison: First of all, that breaks my heart. And it makes me want to introduce this concept that is critically important, which is: treatment programs that have a harm reduction approach and treatment programs that have an abstinence-based approach and treatment programs that have the one-size-fits-all, right? And so that organization that that wouldn’t give your brother Vivitrol because he didn’t want to do the whole program, understood that he would have the best chance of maintaining remission of his substance use disorder if he had a plan that was biological, psychological and social. So that’s why they wanted him to be in therapy in addition to the Vivitrol, in addition to probably case management or other social interventions that they had. The problem with the system — and some of this is regulated, and some of this is law, and some of this is the way we’ve always done it, quote unquote, is that if what you need doesn’t fit our structure, the system pushes you into a pothole. And what happened to your brother is that he got pushed into a pothole. What it should be — the harm reduction approach is — and I love this quote by Monique Tula, who is the executive director of the Harm Reduction Coalition. She says ‘harm reduction is the practice of unconditional love for people who use drugs.’ And the way that needs to be operationalized in treatment is if your brother comes in and he says,’ all I want is the Vivitrol, I’m not interested in psychotherapy. I’m not interested in being evaluated for depression and anxiety. I’m not interested in you helping me make sure things are stable in my life or that I’m meaningfully connected.’ 


[42:58] Dr. Nzinga A.Harrison: Even though we know all of those pieces would increase our chances that your brother would be in remission in a year, we also know that saying no to Vivitrol and kicking him out the door increases the chance that he will be dead in a year. And so what we need to be able to do is bring him into the program. Start the Vivitrol. Maintain the relationship. And as he gets further into his recovery, continue to evaluate how we can support him with the additional services that we have. But it’s just not the way the system is crafted most of the time. 


[43:36] Stephanie Wittels Wachs: So that is the inconvenient truth. MAT is effective. But we can’t forget that it is medication assisted treatment, not just medication. It doesn’t negate the other parts of the magic formula. Comparing addiction to other diseases like diabetes and asthma is useful for fighting stigma, but it can also oversimplify the nature of addiction. I wish Suboxone had been like Harris having an inhaler in his back pocket, ready for a potential asthma attack. But it makes sense now that the reason the medication wasn’t effective is because it was only one small part of a way more comprehensive regimen. He needed that and more. 


[44:32] Dr. Nzinga A.Harrison: And so I’m sorry about that. Sorry. I feel, like, very emotional about that because your brother, one, should have gotten MAT on any of those other visits. And he certainly should have gotten Vivitrol when he was asking for it. 


[44:49] Stephanie Wittels Wachs: Oh man, you’re so human. It’s just really, like, it’s amazing to me. You know, you clearly do this work day in and day out, you know? And I just — I don’t know. It’s just really moving when — when you when you come across a medical professional that has such a deep ability to have empathy. 


[45:16] Dr. Nzinga A.Harrison: Well, thank you. 


[45:18] Stephanie Wittels Wachs: Over the years, Dr. Harrison has seen a lot of this. 


[45:22] Dr. Nzinga A.Harrison: It’s hard work. 


[45:23] Stephanie Wittels Wachs: Yeah.

[45:24] Dr. Nzinga A.Harrison: It’s hard work, but it’s also fulfilling work and it’s motivating. And I mean, like, I’ve been practicing addiction medicine now for 15 years. And in those 15 years, I certainly have seen tragedy. But the misperception for people that don’t work in substance use disorder treatment programs is that it is overwhelmingly tragedy. And the opposite is true. It is like overwhelmingly, joyously seeing people grab their lives back from substance use disorders. Once the — you know, once the correct formula is put in place. And either being able to keep those symptoms in remission — or even if there is a relapse, having that longitudinal relationship where they can get back to you quickly, right? Like one of the things we teach is what are your early warning signs? And the only way you can figure that out is the longitudinal relationship. 


[46:25] Stephanie Wittels Wachs: Dr. Harrison is so committed to this idea of the longitudinal relationship that she’s recently opened up her own treatment facility in North Carolina called Eleanor Health. So if you’re into her or this whole-person comprehensive care approach, look them up. It is impressive. But I think what’s most impressive about Dr. Harrison is that even though she’s an expert, and even though she knows that this work is so hard, she remains optimistic. 


[46:55] Dr. Nzinga A.Harrison: You know, it’s easier to focus on the tragedies and the potholes in the system. And we have to do that because that drives us to continually get better. But one, I would say if you’re experiencing your own substance use disorder, you have a loved one, someone, you know, who’s experiencing substance use disorder — trust and believe that people can get better and people can stay in remission. And put support around yourself. Whether you’re the you are the person with the substance use disorder or whether you’re the loved one of the person with a substance use disorder. Put support around yourself. And if there’s not in your kind of physical life, a way to put that support around you, on the Internet, so many incredible resources just to give education for people who have been there. That can just like wrap virtual arms to say, like, stick with it. Relationship first. Stick with it. Stick with it. Stick with it. It can be painful, but people can and do get better. And sometimes we have to hold that hope for people with substance use disorders, or their loved ones when they don’t have that hope themselves. And so if you’re feeling like you don’t have that hope for yourself, find someone who can hold that hope for you until you can get to a point where you can have it for yourself. 


[48:29] Stephanie Wittels Wachs: God, she makes me feel so hopeful. I mean, truly, this feels like the first episode that doesn’t end with me throwing my fists up to the sky and bellowing, what the fuck!? And, maybe you should sit down for this, but this sensation, this feeling of hope and promise it continues into next week’s episode. 


[48:57] Hiawatha Collins: I call it the no-judgment zone. And I call it the no-judgment zone, because a lot of times people come in and they are ashamed, they’re shy, and they want to get what they want to get and just go. Now we have people that come to us on a regular basis. They hold conversations with us. They let us know what they’ve gone through. Last year, around the holidays, one of the young ladies who was out on a site, boots on the ground, gave every participant that came up a holiday card. A gentleman instantly broke down crying because he stated that he hadn’t gotten a card — a birthday card, a holiday card, I love you, I thank you — in over four years. 


[49:43] Stephanie Wittels Wachs: Next week, we put boots on the ground and talk about harm reduction. 


[49:50] Stephanie Wittels Wachs: Last Day is a production of Lemonada Media. It’s produced by Justine Daum. Jessica Cordova Kramer is our executive producer. Jackie Danziger is our consulting producer. Kegan Zema is our technical director. And Our Music is by Hannis Brown. Special thanks to Westwood One, our ad sales and distribution partner. You can find us online at Lemonada Media. That’s Lemonada, like L-E-M-O-N-A-D-A. If you liked what you heard today, tell your family and friends to listen and subscribe. Rates and review us on Apple, Spotify, Stitcher or wherever you get your podcasts. And check out our show notes for a deeper dive into what you’ve heard today and how to connect to the Last Day community. I am Stephanie Wittels Wachs. See you next week. 

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