Opioids in a Pandemic, with Dr. Nzinga Harrison
Stephanie chats with addiction medicine expert, Dr. Nzinga Harrison, about opioids and addiction in this new pandemic world. How are these unprecedented circumstances affecting those with opioid use and substance use disorders? As a result of social distancing, how have treatment and recovery models shifted? What’s happening with long-standing regulations around medication-assisted treatment? How can we best support ourselves and our loved ones with addiction during this time? Finally, we learn more about Nzinga’s new show, In Recovery, and how you can submit your questions.
Check out Nzinga’s recommended resources:
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[00:39] Stephanie Wittels Wachs: Hello, everyone. I’m Stephanie Wittels Wachs, and this is Last Day. So, as you know, we wrapped season one right as the world turned into a completely different world. And since then, many of you have written in to essentially ask how is this global pandemic affecting the opioids crisis, and specifically those with opioid use disorders? It’s a really good question, and one that I also have. So I thought I’d hop on today for a little mini-episode with Dr. Nzinga Harrison, who you know from episodes five, six, 23 and the finale. She’s kind of the MVP of the show. And if you don’t remember her, well, here she is.
[01:33] Dr. Nzinga Harrison: Hey, Steph. How are you?
[01:39] Stephanie Wittels Wachs: I am so much better now that I’m seeing your smiling face. How are you doing today?
[01:44] Dr. Nzinga Harrison: I am surviving with two teenagers and three dogs and a niece. But no real complaints. No real complaints.
[01:54] Stephanie Wittels Wachs: I see you that, and I don’t raise you, but I equal you. Two children, two and six, plus two dogs. So I guess you win.
[02:07] Dr. Nzinga Harrison: You win, Steph. Two and six is like the big joker.
[02:11] Stephanie Wittels Wachs: My Instagram stories this weekend were called like a heart attack series. And it was my son climbing six foot tall ladders, tables, chairs. He is — we need to get him to a ropes course or something. So anyway. That’s what’s going on here. So to start, can you just tell those who may not know who you are, who obviously haven’t listened to the show, a little bit about yourself?
[02:39] Dr. Nzinga Harrison: Yes. So I am Dr. Nzinga Harrison and I am a physician. My specialties are psychiatry, which means I’m a psychiatrist, and addiction medicine, which makes me an addiction medicine expert. I’m also co-founder and chief medical officer of Eleanor Health, which if you were listening to Last Day, you heard about in episode 23. If you were not listening, please go back and listen.
[03:06] Stephanie Wittels Wachs: I love all the shade. Like, if you don’t listen to this. It’s like quarantine has just made me whip my wagging finger, you know? Audience, I’m sorry. We are not trying to shame you or berate you. That is not what we do here at Last Day. We just want you to live a good life. And part of that is listening to Last Day. So let’s get down to serious business here. I wanted to see, to start, if you could provide a sort of general update on how Covid-19 is affecting people with opioid use disorders and substance use disorders. What do we need to know, sort of big picture?
[03:50] Dr. Nzinga Harrison: So the quick answer is that people with opioid use disorders, and substance use disorders more generally, are being disproportionately affected by Covid-19 for a couple of reasons. So if you’ve heard me before on the show, then, you know I always talk about addiction from biological, psychological and social perspectives. And so I’ll start with psychological and social, which is really the connectedness. So you’ll hear folks say, and it’s very true, that the opposite of addiction, or the antidote to addiction is connection. And so addiction treatment programs and addiction recovery programs are very, very heavily rooted in in-person and group contact. And so when Covid-19 came, social distancing like just threw a cold bucket of water and a big kibosh on that. And a lot of addiction treatment providers were not ready to deliver care virtually.
[04:56] Dr. Nzinga Harrison: AA, NA, SOS, certainly those in-person support groups were not really ready. And so what people with addiction experienced, even more so than the rest of us, was like this acute cut off of part of what is part of the magical formula for keeping a lot of people in recovery. I did that one call out for Last Day that was like from a harm-reduction perspective. One of the biggest things we drive to try to reduce risk of opioid overdose death is not using alone. And social distancing kind of like threw cold bucket of water on that, right? It’s like suddenly a lot of people are alone. Access to substances that folks were using was quickly cut, which put people at risk for detox and withdrawal syndromes, alcohol, opioid, benzodiazepines like Xanax. And alcohol and Xanax withdrawal can like actually be deadly. And so we kind of created this really acute situation very quickly because this pandemic kind of dropped down on us with no warning. But then also just specifically from a Covid-19 perspective, when they first started talking about the high-risk groups, it was people over 65, people with other chronic medical conditions. Getting infected with Coronavirus is a substantial risk just because of the way drug and alcohol use changes the function of the body. So it’s been a lot.
[06:29] Stephanie Wittels Wachs: Ok, so your clinics, Eleanor Health, are an outpatient facility. And you were already doing lots of telemedicine and you seemed uniquely equipped to deal with this, especially when you look at how other facilities are working and how other programs work. But how has your treatment models shifted over the last six to eight weeks during all of this?
[06:54] Dr. Nzinga Harrison: Since Covid, what we had to do was bring our entire model virtual. And so that was a developmental process for us. I’m like a data nerd, so looking back at our data the first week of March, 9 percent of our visits were virtual. The fourth week of March, 91 percent of our visits were virtual. So the commitment that we made was we will not let our people fall through the cracks. And the regulations did not allow us to see new people virtually before coronavirus,
so our virtual support was really only something that we could offer to people who are already members of our community, already engaged in treatment with us. And so Coronavirus led to the change of the specific regulation, the Ryan Haight Act, which allowed us to start seeing new members virtually also. And so we had to create a capability for that because it had not even been an option before.
[08:04] Stephanie Wittels Wachs: So you mentioned the regulations that have shifted since all of this. Can you walk us through that? Because I’ve seen article after article on the MAT regulations and how those have changed because of this. What’s going on with all that?
[08:22] Dr. Nzinga Harrison: The two most heavily regulated MAT are buprenorphine, whether that’s buprenorphine itself or with Naloxone, which we call Suboxone. So I’m just going to capture all of that by saying Suboxone. Suboxone and methadone. Methadone is more highly regulated than buprenorphine because of the risks that come along with methadone. Number one risk being overdose, and number two being abuse. And so methadone clinics, you literally when you first start, have to go every single day to get your dosing. You cannot start methadone without going in-person for a visit. The same was true for Suboxone. The new regulation allows you to start Suboxone with a virtual visit as your first visit. That regulation has not changed for methadone. You still have to go first time in person to start methadone. This caused a lot of trouble for folks who were currently on methadone who were required to go daily, because like methadone clinics could not social distance. And so it was literally like you have to take this risk to go get methadone. And so they lightened those requirements a little bit to allow more days to be able to be taken home, depending how long you’re on methadone. But it is still very difficult from a methadone perspective.
[09:53] Dr. Nzinga Harrison: The other thing that changed is that to prescribe Suboxone or methadone, you have to have a specific DEA number for every state. And so emergency regulations have allowed us to use our DEA numbers across states. Right now in the Covid emergency — so like if I have a member that lives in Tennessee, but they cross the border to come to North Carolina for care, before I could only see them if they were physically in North Carolina for that first visit. There is more latitude on that now, and every state has kind of enacted emergency licenses. Those are the big changes that have made it easier to get started on MAT and to get started on methadone. And so I’m happy to say those regulations have been changed, but only emergency orders.
[10:47] Stephanie Wittels Wachs: So I have 75 follow up questions, but I’m going to try to make those go down to maybe two. Who made these regulations looser? What agency is responsible for loosening those restrictions in this climate?
[11:05] Dr. Nzinga Harrison: So it’s a combination, but it’s all at the federal level. So some of it is centers for Medicare and Medicaid Services — CMS. The DEA. The DEA is who manages waivers for buprenorphine and the regulations around buprenorphine and Suboxone and methadone. So it’s really a combination, but it’s all at the federal level. I will also say, though, Medicaid is at the state level, so it starts at the federal level for CMS, but most of the states’ Medicaid plans have been amazingly supportive in trying to make sure there are not barriers. Even like removing prior authorization requirements, or removing quantity limit requirements. So you could only get one week of buprenorphine and now they’re like, we don’t need people coming to the clinic every week if they don’t need to. Open up the number of quantities. So Medicaid and other insurances have been fantastic. Private insurances have, for the most part, waived co-pays so that people can get their care virtually. So, I mean, it has truly been a federal, state, private, public coordinated effort to try to make sure that we’re not pushing people in the cracks.
[12:25] Stephanie Wittels Wachs: Isn’t that partially frustrating though, because what it says is that we could remove bureaucratic red tape, we could serve people in a more effective way. And why does it take a global pandemic to make that happen?
[12:39] Dr. Nzinga Harrison: So the listeners can’t see me, but I’m doing like my black girl, “right?” And my neck roll because, yes, we have been struggling to take care of these people. I mean, like everything that literally happened in the span of three weeks, years and years and years have we’ve been saying this is how we remove barriers. So, I mean, you know, should’ve coulda, woulda, can look back, can be mad. Or can say, how can we let this pandemic change things for the better? And this is definitely a place where we have the opportunity not to slide back to where we were.
[13:20] Stephanie Wittels Wachs: I mean, that was my next question, which is what is the likelihood that these things that make a lot more sense will become the norm?
[13:29] Dr. Nzinga Harrison: So you can think of it like the pendulum was all the way to the left and the pendulum has swung all the way to the right. I don’t know that the pendulum should stay all the way to the right. For example, you can do a new start for buprenorphine by telephone only right now. In a pandemic, you can probably accept the risk of that. Outside of a pandemic, there’s a physical exam and there’s value to putting eyes on people that help you make safer medical decisions. So like in that respect, the pendulum needs to swing back a little bit. I think there’s zero chance the pendulum can swing back to where it was.
[14:09] Stephanie Wittels Wachs: So if you have a person with an addiction, but you’re still in quarantine or social distancing, how can you best support them from afar?
[14:19] Dr. Nzinga Harrison: It’s a great question. So you really have to be very intentional about it. So I’ve taken to saying, although we can’t be in the same physical space, we have to be intentional about being in the same emotional space. It’s like, I am going to call you every day. I am going to connect by video so that I can see you. And then I would just also say, like, there are so many support resources online. One of my favorite for families and support systems is We the Village. We are offering free support groups for Eleanor Health. Oh, my favorite new app is this app called I Am Sober. Like it is absolutely amazing. Just encouraging and uplifting. And then the last thing I’ll say is like, turn off the news. Turn off social media. You don’t have to completely disconnect yourself, but you don’t realize when you watch the news, and when you’re crawling through social media, that you’re absorbing all of that grief. You’re absorbing all of that grief, and it’s reducing your internal resources. And you need your internal resources because we’re in a very difficult time.
[15:36] Stephanie Wittels Wachs: And nobody panic, we’re going to include all this in your show notes. So you don’t have to do anything. OK. So I want to talk a little bit about In Recovery, which is this new show that you are hosting that launches May 18. And she’s doing another dance, everyone, on Zoom. She’s dancing right now. First, can you just tell us a little bit about the show, what it is and how is it going to work?
[16:01] Stephanie Wittels Wachs: It’s basically like an old-fashioned call-in radio show, except no call-in and no radio. It’s a podcast. But basically, listeners can send in their questions about anything addiction. And I mean, like anything, sex, gambling, drugs, opioids, of course. But also those things we don’t typically think of that might turn into addictions like work, exercise, things that we usually assign positive value to, but that can become harmful to us. And then I answer from my medical expertise, from my psychiatric expertise, from my addiction expertise, but also just like from being a human, from being a mom, from being a wife, a daughter, a sister, and going back to like my central belief in all things living, which is that it’s about relationship and trust.
[17:01] Stephanie Wittels Wachs: So what kinds of questions or topics can folks expect on this show?
[17:06] Dr. Nzinga Harrison: Every kind of question and every kind of topic. So there will be short questions, just like what even is addiction, right? To deeper questions like why does addiction run in my family? To painful questions like I feel like it’s time for me to cut my person off because it’s starting to kill me. What do I do? So literally just the whole range. And I’m counting on the listeners for this to bring me every piece of experience that they’ve had. Every question that they’ve had. Every place where they wish they had known something. Every place where they learned something. And they’re like, I have got to share this because it can save somebody else’s heartache or life. All of those things. No wrong questions. No stupid questions. Like literally, if you’ve had that experience, one, someone else has had that experience, so getting people off of the island that they think they’re on. But two, if you have that question, someone else has that question. So send it all in. We want it all.
[18:18] Stephanie Wittels Wachs: We do. We want it all. So please email your questions to InRecovery@lemonadamedia.com. You can also record a voice memo and email it in, or you can call and leave a good old-fashioned voicemail at 833-453-6662. You can also find Dr. Harrison on Twitter @NAHarrisonMD. In Recovery launches May 18th, but you can subscribe now wherever you get your podcasts. Thanks so much for listening today, friends. Stay healthy. Stay sane as best you can. I love you all. I’ll see you soon.
[19:09] Stephanie Wittels Wachs: Last Day is a production of Lemonada Media. This episode was produced by Claire Jones. Kegen Zema is our technical director. Our executive producer is Jessica Cordova Kramer. And our music is by Hannis Brown. Special thanks to Westwood One, our ad sales and distribution partner. You can find us online @LemonadaMedia. And you can find me online at @WittelStephanie. I’m Stephanie Wittels Wachs. See you next time I feel like seeing you. Bye.
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