SMART Policy Podcast
Podcast by the UT SMART Initiative. Host Jeremy Kourvelas speaks with experts from across the recovery ecosystem - representing healthcare, prevention, law enforcement and more - about local, state and federal drug policy to find out what is and isn't working to make this fight against addiction a little easier.
SMART Policy Podcast
What the Brain Disease Model of Addiction Gets Right — and What It Misses
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You're listening to the Smart Policy Podcast, a production of the University of Tennessee's Institute for Public Service. Something really has changed over the past 20 years, especially the last 10. Our culture has increasingly come to accept the idea that addiction is a chronic, treatable disease, not a moral failure. In fact, RFK Jr. said this almost word for word just about a month ago when President Trump signed the executive order establishing the Great American Recovery Initiative, adding that for too long, we have treated substance use disorder with, quote, fragmentation, stigmatization, and silence instead of science, compassion, and coordination. In the field of science, both clinical and academic, this is often referred to as the brain disease model of addiction, based on the definition of a disease as a condition that changes the structure or function of at least part of an organ or system. However, though this framework has done a lot to reduce stigma and increase the acceptance of evidence-based treatment, you don't have to go looking very long before you see that our health care, housing, and criminal justice systems are still stuck very much in the past. And on top of that, the recovery community itself remains split on what it even means to have the disease of addiction.
SPEAKER_00I came to the point where whether it was the spiritual malady or whether it was the brain disease model of addiction, as kind of put out there by NIDA, I actually didn't find it to be helpful for me. I had extremely severe consequences when I sort of hit my I mean, I went to federal prison for those of you who don't know me.
SPEAKER_03And I also feel like a lot of times from a social standpoint, I get a pass. You know, I was an MD when I went through my addiction issues, and so it's almost like I'm looked at differently than somebody who is struggling on the street corner.
SPEAKER_02My guests this month are Dr. Kirsten Smith, a researcher and clinical social worker who found recovery and earned her doctorate after going to federal prison for robbing banks in order to pay for heroin, and Dr. Stephen Lloyd, Chief Medical Officer of CETA Recovery and Chair of the Tennessee Opioid Abatement Council, who himself is also in recovery from opioid and benzodiazepine use disorder. Dr. Smith was recently featured in an article by The Guardian wherein she offered some intriguing criticisms and limitations of the brain disease model, and it caught our attention at the Smart Initiative, as well as that of Dr. Lloyd. Fortunately, the two agreed to come onto our show for a deep dive, and as you can see, this episode turned out to be longer than normal. It also contained some concepts that some might find controversial.
SPEAKER_03It's funny, Kirsten and I's conversation. Um, some rooms we would be accepted in and people would thank us for speaking out, and others uh they would tar us and feather us.
SPEAKER_02Um additionally, though we frequently discuss drug use on the show, we get a bit up close and personal to the topics of cravings, recovery, and more, so some listener discretion is advised. And as always, this episode is intended to be educational, showcases the personal opinions of the guests, and does not reflect any opinion or belief of the University of Tennessee. That being said, I found this conversation to be insightful and challenging, with compelling takeaways for everyone, no matter where they stand on the matter.
SPEAKER_03First up, thanks, Kirsten. I'm uh Stephen Lloyd. I'm an internal medicine and addiction medicine physician in Tennessee. I'm the chief medical officer at Cedar Recovery in Middle Tennessee. We do outpatient uh treatment of people with opioid use disorder. And I am uh also the chair of the Tennessee Opioid Abatement Council. And um I treat people with addiction uh pretty much and and try to raise awareness about addiction and the fact that it is uh treatable and people can recover. I'm also in recovery myself uh for coming up on 22 years.
SPEAKER_00And I am Kirsten Smith. I am a licensed clinical social worker and I have a PhD in social work as well that I got from the University of Kentucky and then the University of Louisville. And after I did my education, I ended up going to the National Institute on Drug Abuse Intramural Research Program. Uh, so that's NIDA under the National Institutes of Health in Baltimore, Maryland. And I completed a four-year postdoc before taking a faculty position at Johns Hopkins University School of Medicine, where I was an assistant professor for about three years. And I have the timing of this podcast is sterling. I just left, I just left uh academia not even a month ago, and I am now trying to pivot back to clinical work and write a book, and uh I do consulting as well on my area of uh you know interest, I guess you could say, which is Kratom. And I'm also in recovery and a native Knoxville. I miss East Tennessee deeply. And uh maybe Dr. Lloyd will give me a job and I can get back there. Um that's my introduction.
SPEAKER_02So neither of y'all have free time, is what I heard. Uh all right. So we're here today to talk about the disease model of addiction. I think it's become decreasingly controversial for the first time in my life uh that I've ever seen it so widely accepted across political ideologies, faith uh adherents. Increasingly, everybody can agree with the notion that addiction is not just a moral failing. Of course, there's still holdouts and we still hear it. Uh we hear it a lot. But something does appear to have changed. And before we get into the why and the how, uh let's talk about the what. What what exactly are we talking about when we say addiction is a disease?
SPEAKER_00I might take a first stab at that. So I think there's two ways that the disease uh label or framework gets used in the United States, and one of them is really kind of a 12-step approach, you know, the the spiritual malady. And I think a lot of people are introduced to the concept really loosely based on 12-step programming and you know, an allergy to alcohol, things like that. But then, you know, in 1997, um, NIDA's director, Dr. Leshner, came out with that seminal paper, you know, addiction is a brain disease and it matters, etc., etc. And really that's where I think we get this what you were referring to, Jeremy, you know, probably at a at a basic level, this framework in which we say, okay, drugs change the brain, there's neurobiology here, and it's a now chronically relapsing disease, and people can recover, but you know, it's lifelong and it's similar to other chronic diseases, typically characterized by loss of control and compulsive like behavior, etc. And I think this is where I'll stop because then we get into the weeds about different other definitions and broader definitions and narrower definitions.
SPEAKER_03Yeah, I I agree with Kirsten. Um, you know, I I try to boil it down to you know addiction itself, and for me, it's continued use despite consequences. And um, you know, I've seen all kinds of tools to uh to make the diagnosis and and I I understand the need for those, but I do clinical work, and so I need something that's pretty simple that I can teach other people. And and so when you see continued use despite consequences, um, you know, it's that's about 80%, and I'll take that to the track. You know, my first introduction to disease as a disease of addiction was uh just like Kirsten said in 12 steps uh when I got into recovery in in 2004, and I was always uncomfortable with it in 12-step meetings. It always seemed like something you you know blamed it on. Oh, that's my disease talking this or that. And it used to drive me nuts. I'd go crazy. I, you know, I'm a physician, I can't, I can't handle that. And and um, so I really uh Jeremy went on a mission to, you know, try to learn all I could about it and and uh every conference I could go to and and you know try to get a little better understanding of what was going on because in my own life I couldn't believe that I got to a point where this little I had to have this little pill out here or I thought I would die. I I just I couldn't get that in my head, you know, and and I'd been successful, you know, in my life up to that point, and I just couldn't get around that. And so um that's really been my quest for the last 20 plus years. And and I really like the idea of of the brain and it being a predictor of the future, right? I mean, that's probably for me, it's the the biggest role of the brain, you know, given a set of circumstances and actions, what's a likely outcome? And that's basically what our brain does. And and then separating those two parts of the brain, you know, the reward system from the frontal lobe, and you know, lack of insight and judgment. And then, you know, basically what I think of as hijacking of the of the reward system where your will and your desire to live is not the goal, whatever you're addicted to is the goal. And and then, of course, the phenomenon of cravings. But Kirsten, it's so funny you mentioned 12 steps because I've been uh I still go to 12 steps. I think they're a great way to lead your life. And um, I uh started rereading the first 164 pages the other day, and uh Dr. Silkworth's the doctor's opinion in there, and you know, he describes it as an allergy. And I keep, you know, wanting to go back to this type one hypersensitivity reaction, you know, which that's not what it is, but I think it's interesting to see how that's evolved over time because that was like 1935, 1937, somewhere in there. So yeah, uh hopefully that wasn't too convoluted, Jeremy. But I I do agree with you that I think it's being more widely accepted. And it but there's still pockets, and and you know what we faced here in in some of the rural areas in Middle Tennessee around that.
SPEAKER_02I think you both have already framed the central uh the central dynamic I really wanted to to get to today. So on the one hand, there is the clinical neurobiological perception. You mentioned 1935, yeah. We didn't exactly have MRIs then. Uh so uh we we traditionally anatomically, there's measures in structure or function of a part or a whole of an organ as a central definitional component of a disease. That there is measurable changes to the body that changes function. And we do have data and uh empirical evidence for that happening with any kind of substance use disorder if there is a an alteration of structures that influence behavior, much like uh hypertension or diabetes, there's some commonalities. Uh likewise there's also behavioral components too. Uh and and in previous episodes we have had, I guess, especially more on the clinical side, talk about how, well, if you eat a pound of bacon every day, you're probably gonna have a heart attack sooner than you otherwise would have. And and that still has a behavioral component and everything else. But there is this definition and framework that's great for a textbook and great for a licensing exam, but seems difficult to translate into what we'll call it the medical lay. The people who don't have to work in this space or don't get to work in this space. What is some of this disconnect? I I'm noticing some interest that there's Kristen, you sort of touched on like a simplified definition that people get anchored on, and perhaps it in its own way leads to a weakness.
SPEAKER_00Well, okay, we have several cans of worms. All right, so I think No. I mean, almost taking a step back here, because I have a slightly different and I'm I'm not sure how much you've read that I've written or talked about this, but so I I think what's really confusing forget lay people for a minute, or even people with addiction histories or substance use disorder for a minute. Um, and just kind of going to the the whole idea of of addiction as a brain disease or not. I think the one thing that everyone agrees about, professionally speaking, like most clinicians, most researchers, the moral model is not what we're talking about anymore. And that's the really big paradigm shift that is great.
SPEAKER_02Yes.
SPEAKER_00Coming out of academia, the thing that I see that is divorced from clinical practice is that a lot of people in addiction science are kind of in these two camps. One is the camp of the brain disease model of addiction framing, and the other is behavioral economics and neurobehavioral economics. And I would say that these two camps agree about 95% of the brute facts, right? Like no one's gonna say they're not structural changes or you know, behavioral changes or all these other things. But, you know, is are patients and people best served by telling them they have a chronic relapsing brain disease or by framing it as, you know, a disorder of choice or um, you know, a very complex disorder that is really influenced by environment and choices and non-drug alternative reinforcers and all these other things. And I tend to fall into the behavioral economic camp, uh, which isn't to say that I don't, you know, think that there's value for some people. I actually know people who really benefited from conceptualizing this as I have a disease and therefore I need to do XYZ. So that goes back to like each person needs to be kind of, you know, take take what works for you and then leave the rest, kind of thing. But I do think that there are still struggles among clinicians to to really even understand what's going on with the brain. A lot of clinicians aren't psychiatrists, they're not um medical doctors, they are oftentimes, you know, master's level clinicians, or you know, not even that. And and that's not a bad or a good thing. It's just to say that, you know, in this in the classes I taught, you know, a lot of the social workers are going out and they don't really know much about the brain. So it's I think it's very hard for them to get to a place where they can understand, okay, well, what does this even mean? And then how do I explain it to a client or a patient in a way that will best serve them?
SPEAKER_03I guess one of my heroes in my my career has been Nora Vocal. And and um luckily for me, I read some stuff that she did really early on. You know, I was in I was in treatment, I'm an internist, so what I knew about addiction was zero. We don't get taught anything on this in in medical school or residency. And and so it it just became a quest and and discovered her very early on. And and I like the whole concept of the stop and go areas of the brain. Uh, most people I can understand that, including me. And and I I just for me, it really helped. You know, Kirsten talked about that. Some people, the disease model helps in their own recovery. And I guess I fall into that because, you know, I basically had two options. One, I was an uh immoral derelict, or, you know, I had something, um, you know, something that was wrong, and you know, as a result of genetics and and trauma and and then opportunity, which is how I still teach it as a slot machine. And so I think people can relate to that. And for me, uh as a clinician, I don't care what they get, right? I I don't care which route it is, you know, which camp they fall into. It really doesn't matter to me as in, you know, as long as I can get them to see that there is an issue and and that there is help for it. And then, you know, finding those underlying drivers of of why you know people want to change the way they feel, I think for me is always uh, you know, always really important. So I try not to get too hung up in that stuff. You know, sometimes you you get so hung up in it you you lose sight of what you're trying to help a patient with. And and um so uh, you know, I know that's probably not a not a great answer, Jeremy, but in my own addiction, when I started to see kind of how I got like I was, it kind of gave me some power and control over, you know, finding recovery. And, you know, it's one of the things I always hated about the 12 steps. You know, the first step says I'm powerless. And it it's I'm powerless when I use. I mean, that's the you know, that's the gist. When when I don't use, I actually have great power. I have great capacity to make choices, behavioral choices, and and uh and and and then the last thing I I get really interested in is is just the phenomena of cravings. Um, you know, Silkworth writes about it in the big book in the in the 1930s, but that's a concept that I can really get on board with. And and it's how I use, you know, how I teach addiction is because even if you don't have a problem with a chemical or a process like gambling or internet pornography or whatever, it it's hard to drive by a crispy cream donut. It just is, right? And everybody can relate to that. And and some of these pathways are are the same. And so that's generally what I try to do in helping people understand. But I don't get caught up in the nuts and bolts of it, and I'm not going to sit there and argue these finer points with with patients. Now, academic folks would be a little bit different.
SPEAKER_02Yeah, I was gonna say I I I wonder what direction you're gonna go in, because something that's been on the back of my mind, Kirsten, is is how I've read from you that you preferred recovered over recovery in one instance. And I don't know if that's the direction you wanted to go in. And I don't want to divert from what was clearly some eagerness, so please.
SPEAKER_00Oh, so yeah, I was raising my for those of you listening, I was raising my hand because I was eager. So it's interesting because I had a very different. I mean, this goes back to the heterogeneity of people with substance use disorders and addiction, right? We're not all the same, go figure. Um I know it's really easy to just put us in a big bucket, but but you know, I had a different experience wherein I had extremely severe consequences when I sort of hit my, I mean, I went to federal prison for those of you who don't know me, and I really blamed myself, you know, fully, right? I did not blame other people, I didn't, you know, I I kind of just blame myself. And then getting exposed to some 12-step programming, you know, that some of it helped, some of it didn't. But, you know, I came to the point where whether it was the spiritual malady or whether it was the brain disease model of addiction, as kind of put out there by NIDA, I actually didn't find it to be helpful for me today. And the reason I say this is not because I disagree with what I think, like I said earlier, I think most people agree about the the core facts of there are brain changes, there is this loss of control, there is there are adverse consequences. And for me, I mean, Dr. Lloyd gave it, you know, for him, you know, it's it's if continuing to use despite adverse consequences, but also for me, continuing to use when you don't want to, right? When you don't want to, and you continue to to, you know, when your intentions and your desires get totally decoupled from your decisions and behaviors, to me, that's addiction, right? Like like more so than other aspects. But with respect to the disease label, I did see other people who they first of all didn't really understand much about the brain, but that aside, they're kind of like, well, this is if I have this forever, right? If this is a forever thing and I'm gonna probably relapse anyway, well, then F it. I'm just gonna, you know, what's what's the point? Like, what hope do I have? And I kind of saw in myself that, you know, it is not some inevitable thing where I'm doomed to just be in this fate, right? Like there's a lot of complexity here. And so I actually came to really not like the brain disease like label that much because I think, you know, what is that? Well, two things. One, we know there's a lot of complexity here. We know that brains can change, right? They change from drug use. So when we stop using drugs, they will continue to change until the moment we take our last breath. And I think, at least personally, I encountered some people who never had an addiction, but who thought, well, if if you really have this disease, right? Whether it's a spiritual malady or whether it's a brain disease, you know, for for the more NIDO-centric like framing, well, why should I give you a job, right? Why should you get your children back? Why should you, why should we trust you, right? Why should we invest in you? And there are people I have met who honestly do think, well, if this is a disorder that a person has for life, you know, you might be in recovery, but are you ever really fully recovered? And are you ever going to be fully trustworthy? And I think there's the the thing that a lot of you know academics talk about when we whether these debates is like, you know, there is a stigma to telling someone that they have this thing and they're never gonna not have this thing, right? So, yes, to kind of go back to maybe your point, you know, I said like I'm in recovery, you know, when I did the introduction, and that's almost this like reflexive sort of language when I get into settings like this. There's kind of this you know vocabulary that just comes to the surface that doesn't necessarily come to the surface in other places. But no, I wouldn't consider myself in recovery. I would consider myself recovered in any way that makes sense to me. Now, does that mean that my likelihood of going out and buying drugs is the same as, let's say, you know, my husband's who he's never done any opioid in his life, right? Like he is the most normal person. I'm the weirdest thing about him, right? He's not gonna go out and buy drugs today. So if we're looking at this from like a probability standpoint, well, yes, I think the probability of me going out to buy drugs today is certainly higher than some random person in the general population. But I'm gonna tell you right now, I I I don't have I I would bet everything in the world, I'm not gonna go buy drugs today. So there is a point in which I think things that you know Dr. Lloyd brought up, even like craving, where 20 years out, what does craving look like, right? Is craving static or dynamic? Is it more visceral or cognitive? Does it change based on drugs? I mean, there's a lot of things that I don't know stay the same 20 years out. Although I would love to hear Dr. Not that I'm running this podcast, but I enjoy to hear his thought on that.
SPEAKER_03Yeah, it's it's it's so funny, Kirsten. And as long as my folks do well, I don't really give a crap what they think.
SPEAKER_01I would agree with that. Amen.
SPEAKER_03I mean, yeah, you know, that I agree with you. Um you know, I I talk about being in recovery, you know, that happened in in 2004. I'm not the same person. I think the likelihood of me going out and buying drugs today is is pretty daggum low. Right. Right. And has been for you know a really, really long time. But but I will tell you this. Um, and and Jeremy, you know Tommy Farmer. Um, Tommy Farmer, uh, Kirsten is uh head of our dangerous drugs task force here in Tennessee. Uh Tennessee Bureau of Investigation. Great guy. And Tommy and I have done talks together on this subject for I don't know, 15 years, long time. And and I've seen Tommy's talk so much, I can do his and he can do mine. But we were in Chattanooga about two years ago or three years ago, and Tommy changed his slides. And he had this, he had this slide up that you know, he used to show the oxycontin 80s, right? But it was the new formulation and it's a different color. And so that's the you know, that's the pill slide he usually used. And he changed it for whatever reason. And the picture he put up on the slide he used in Chattanooga was the old 80s, the ones I used to use. And I'd been, let's see, that was around 2021. So I'm what 17, 17 years out. And I looked up because I was on next and I froze. And it was really weird because I hadn't thought about using, I hadn't, it hadn't crossed my mind in so long. And then all of a sudden, there it was, and I was paralyzed. It caught me so off guard that I I don't know of another word for it. And and so I'm not sure, you know, I'm not sure when that goes away. I mean, that was 17 years and it hasn't happened since. Now, what I've learned in the time, and you you talk about the behavioral thing, what I've learned with time is is that's the first time something like that's happened, but immediately, you know, I'm the next speaker, and I get up and I'm in front of the audience and say, Hey, I want to tell you what just happened to me. Right. And it almost like took it off of me uh right then, and and really hadn't thought about it until we're talking right now. But uh, you know, I don't think I'm still sick. Now, will I change that based on an audience I'm in front of? Heck yeah, because I'm a chameleon when it comes to that stuff sometime. I gotta get people in my corner, right? Right. But, you know, I I look at myself as, you know, that was I haven't done anything in in 22 years. You know, I do I still have to, you know, call myself this? Do I still have to? And and and I do just because it doesn't bother me, but but I also got lucky because I didn't have the consequences that the Kirsten had I should have. I mean, I should have gone to federal prison for, you know, the rest of my life, but I didn't have those consequences. And and I also feel like a lot of times from a social standpoint, I get a pass. You know, I was an MD when I went through my addiction issues, and so it's almost like I'm looked at differently than somebody who is struggling on the street corner who winds up in the carceral facility. And so um, I guess I've had issues with that through the years as as well, because to me it's no different, it's just the the level of consequence you had. So I'm not sure if that answer uh made sense, Jeremy, because I I do believe that. I don't I don't think I have that same tendency. And I will tell you this um I have ADD, and that's not hard for anybody to believe. And Kirsten, if you and I got to spend about 20 more minutes together, you wouldn't have any problem with it either.
SPEAKER_00Oh, we'd be off to the races because I have it too.
SPEAKER_03So yeah, I usually get along really well with people who have it because we're kind of on the same wavelength. But you know, I just haven't taken uh I haven't taken a stimulant medication for it. Um and I guess in the back of my mind, I guess I I listen and say, hey, I, you know, I wouldn't want to go down a route here that that I wouldn't have control over. And I guess in some regards, I'm still scared. Um, I still have, you know, I still have nightmares about use. I have still have nightmares, and it's what you said, Kirsten, waking up in the morning and not wanting to do it and doing it again anyway, because you for some reason you feel like you have to. And and so um uh I know that's a kind of a wishy-washy answer, but but I agree with it and disagree with it at the same time.
SPEAKER_02To bring this up though, I I I'm so glad you did, is I've noticed there's a broader trend with mental health in general in our culture right now. On the one hand, uh unprecedented awareness and acceptance of mental health issues of all stripes. Just even the fact that we have multiple elected US Congress people with mental health diagnoses, inpatient hospital stays for it. I mean, there are people who resigned in the 70s uh when it was revealed they had uh gotten treatment in the past. Like it that it's astounding how different it is. And while on the one hand, that's wonderful, but I've also seen a lot, I wonder if y'all have as well, of concerns of this over-embracing of a diagnosis as an identity. That I'm not just sad, it's my depression. I'm not a little nervous about having to go on my anxiety is getting in the way. I'm oh, I must have a social anxiety disorder, or or even the self-diagnosis of autism from TikTok videos. Uh and not to not to downplay any mental health issue or mental health condition of any kind, I'll never do that. But I think there's some valid concerns about on the one hand, you do have people who say, Oh, finally I understand what's going on with me, and now I have a pathway, now I know where to go. But on the other hand, it seems that some people keep themselves in a prison almost by by making a diagnosis and identity. Do you think that's there's something broadly happening and addiction is getting tied up in that?
SPEAKER_03Oh Kirsten, you gotta take that. I gotta hear what you say. I'm so fascinated.
SPEAKER_00Oh man, I mean, I I think there's several layers here. One is that, you know, there are just there's just a generation of people who have been raised, you know, where, you know, this is post, you know, like Prozac, and where there was a I think normalization of of medication and and and frankly, I mean, there's a lot of medication that just gets pushed, right? So not to sound cynical, but there's a lot of money and and industry that is tied to a lot of you know our healthcare system and and how it works. And so I think, and and not to say that these aren't legitimate medications for legitimate conditions, but there's a lot more awareness that has been brought about by the people, you know, selling this stuff. But then there are also, I think, very well, you know, well-intentioned clinicians who um, you know, we we are now assessing for things that we were not assessing for 50 years ago. And so there's a question of are we having higher rates, as we all know, are we having higher rates?
SPEAKER_01Right.
SPEAKER_00Uh, or were these the rates always here at approximately the same level and we just weren't diagnosing them or identifying them, etc. So there's a lot, you know, and and I think for some, there's kind of a to get to more of your question, there's almost, I don't say a glamorization, but you know, some you know, music or art even, you know, can can like glorify some of some things, and a lot of you know, famous people I think can be like you know, uh decreasing stigma around this. But all of that to say, I think, yeah, I mean, some people are potentially hindered in terms of self-efficacy beliefs and and other things with this, well, it's it's my condition, insert whatever condition you want.
SPEAKER_01Right.
SPEAKER_00And I think this goes back to how complex all this is, right? So there are some people who might take that and say, well, because of this disorder or diagnosis or whatever, I'm gonna work 10 times harder and I'm gonna be stubborn and I'm going to find a way around this and get really creative. And it's inspiring to them, right? And then other people might actually have the opposite reaction and say, you know what, I'm not getting off the couch today. I'm gonna play video games and whatever, right? And I'm not, there's not a moral, I'm not condemning either, right? Or I'm not praising either. I think those trait and state factors that feed into resilience and all these protective and risk factors, we're talking about many, many, many, many, many, like, you know, conceivably thousands of different variables, right? And so the complexity here is just significant. With respect to addiction, I I personally, and I think I can't, I mean, I'm anticipate Dr. Lloyd's answer here. I do think that there is a risk of a person's addiction becoming isomorphic with their identity. Like, I'm an addict, I'm an alcoholic, right? And it goes back to like, you know, I've written about the I don't know, Dr. Lloyd, if you've ever heard this analogy in AA or NA about the pickle, right? And the cucumber. So people are cucumbers and then they are exposed to drug and alcohol, and they keep using to the point where it becomes problematic, and they cross over this magical line from being a cucumber into a pickle. And once they're a pickle, there's no going back to being a cucumber, which I think is horse. Sorry, you're gonna have to bleed that out. Because people are not cucumbers and they're not pickles. Well, it's a really cool, it's a cute analogy, right? But people are way more complex than that. But, you know, so I do think that people really have this I'm an addict, I'm an alcoholic. Now, back to something Dr. Lloyd said earlier. You know, if it's if it's my patient and that's what works for them, and that's what motivates them, and that's what gets them to where they need to be, good. And if it's not, well, then we need to help you reframe this, right? So it all goes back to pragmatically what is happening here. But yeah, I think, you know, and and I I'm rant, this is where the ADD is coming now. We're coming really full circle here. And I can't, you know, I do I do want to push back a little bit about, you know, the acceptance. I think that it's still very conditional, right? I think that the can that the the factors in which people can say, well, I've been hospitalized, I've been put on medication, I've experienced addiction, you know. I mean, yes, RFK Jr. is the HHS secretary right now, but he's also RFK Jr., right? So there's like, like, there are things that are um, I think, you know, I think we have a long way to go in reducing the stigma associated with certain things, whether it's medication for uh addiction or depression or or anything else, or other factors that come with addiction, such as incarceration, homelessness, um, having you know, contracted a communicable disease. There's a lot of other stuff there. And I think, you know, I don't know how um ultimately how accepting people are. Now, San Francisco might look different than Middle Tennessee. You know, I mean, I I think maybe some I think it depends on where you are as well.
SPEAKER_03It it's funny, Kirsten. I'm I'm glad you cursed first. Um, uh Jeremy will tell you that uh there are people that think if I can't use curse words, I can't communicate, which is probably pretty accurate. Um, most of the medicine I learned in my life, I learned from the movies. And uh Bull Durham uh is one of my favorites. Uh there's a scene in Bull Durham where Crash Davis, the old catcher played by Kevin Costner, uh catches Ebbie Calvin in a garter belt in uh in the locker room. And he looks at him and he said, if you think you're pitching well because you're wearing women's underwear, then you are. Okay. And so I've taken that approach to medicine. I mean, if you think that your attitude about this is this way and you're successful because of that, then you are. And and I'm okay with that. I try not to get too dogmatic in that kind of stuff. You know, I'm my job every day is to help the person in front of me find the path that's right for them. And for the longest time, that didn't include medication because I was from the school of, oh, I got sober this way or I got into recovery this way, so therefore this is the only way. And and so I fit in that like a lot of people I get mad at today. I did the exact same thing. So I just I don't want that to define me. You know, I can't remember the last time I called myself a drug addict or an alcoholic. Kirsten used those terms a minute ago, and I can't remember the last time I did that. It wasn't anything conscious. I just don't call myself that. I'm Stephen Lloyd. I'm a, you know, I'm a physician. I I I really care about helping people find paths um, you know, out of bad places that they're in. Um, you know, I I'm I'm very interested in the role of trauma in this because for me, when I got drug treatment in 2004, it saved my life. Uh, I held on to held on to two really big things that I wasn't going to talk to anybody about, and that was the physical and sexual abuse. And I wasn't gonna, I wasn't gonna touch that. And, you know, 12, 13 years deep into my life just going very, very well um professionally and personally. I mean, it couldn't have really been going better, that stuff started coming back on me. I started having PTSD symptoms, which I'd never had, and and uh really wound up nearly taking my own life. And and when I got help with those things, uh, that's when I really started to live like I do now. And so um I just don't, you know, as Kirsten has said multiple times, and I know she's exactly right. I mean, this is complex. And and I think that a lot of times 12-step groups want to put you in this is this, and no matter what, and you can't do this. And if you want to go back out, then here's some money to go do some field research. And I get really pissed at that uh because now field research will kill you uh in a day or an hour. And and so I don't believe that, but I do believe that the complexity of it is such that uh we have to be willing to uh, you know, sometimes compromise what we may believe internally about ourselves when we're trying to help somebody else. And I do that quite frequently.
SPEAKER_02If you can handle substances again and and the the the risk of death being fentanyl uh in the supply. Yeah, that that's it's not like it was a long time ago. That is also at the core of another shift in the conversation with measuring outcomes. And I think this is important for policymakers to to hear too. When we talk about recovery or remission, we have traditionally and still for the most part used pure abstinence for a sustained period of time as the only uh accepted uh positive outcome. But there's increasingly loud calls in the literature as well as uh the media to consider alternatives.
SPEAKER_03I'll take that one. If all I did 22 years ago was stop using, that's it. Right? There's a drug out there that says, Steve, take this and you won't ever use again, and I do that. I'm not where I am today. Um there's a lot changed uh in the last 22 years. Things that I've worked on, uh things that other people have helped me with, uh things I wasn't willing to touch. I've already given you two examples with the physical and sexual abuse. And I, you know, I've been absent it that whole time. What if I decided that, you know, I think I can drink beer on a on a social basis and I'm able to do that? Does that take away from my story? My guess is for a lot of people it would, right? You walk in a bar and you see Steve there with a uh, you know, with a with a beer in his hand. And so I think we do place too much emphasis on that. I I've got friends that are in, you know, had gotten sober a long time ago. And when I say sober, I mean from drugs, and they drink alcohol recreationally and they have for a long time. And I don't think a thing in the world about it. It doesn't bother me. It's you know, we're all individuals and it's a problem if it's a problem. And so I think we I think we do that. I work in legislative bodies um in Tennessee and West Virginia both. And, you know, I'm telling people all the time that you have to look at the totality of how someone's life is going, and and that's what I do. Um, we've got plenty of parents out there that are good parents that have had substance use problems in the past and they're they're raising their kids, they're they're going to work, they're providing for their families, and every now and then um, you know, they smoke a little weed. I don't care. I mean, it it doesn't bother me. It's not a deal breaker for me because I look at the totality of their life. We've got other people, and and I use methamphetamine as my example here, that have been off methamphetamine for three years. And they in no way need their kid back, right? Because they have so many of these other behaviors that have not changed. And in particular, you know, I do a lot of education of DCS workers and DCS lawyers, and what they want is one test to tell whether or not they can put a kid back with their parent. And I kind of think of that as as as you know, recovery. There isn't one test.
SPEAKER_01Yeah.
SPEAKER_03Uh, you have to take a look at at the whole person and and you know, how's their life going in general? And and for me, Jeremy, that's you know, that's what I do. That's not popular. Um, and I wonder if people would look at me differently if I drank a glass of wine every now and then. Would my story be the same? And my guess is it wouldn't.
SPEAKER_00So I'll add on to that. I mean, I mean, I agree with with all that, but you know, we're from the academic side, you know, I I certainly think there's been a shift in terms and the FDA even. I mean, there's a lot of government and you know, other funding entities who understand that if abstinence is the outcome that we care about, to the exclusion of a lot of others, that this is not necessarily going to make a lot of sense if, you know, not everyone going back to, I think, some pretty common sense clinical uh, you know, judgment, which is understanding what does the person want here, right? So if a person doesn't want to be completely sober, but our outcome measurement is complete abstinence, well then there's going to be a disconnect between our intervention and our assessment of the intervention. And, you know, like it, like we're measuring the wrong thing, right? So I think it's it's going back to, okay, you know, granted, this is harder to do in research than in like direct clinical practice, because in in direct practice, you can actually have a conversation with the person, assess them, and look at, you know, net benefits versus net detriments from this or that factor. Um, but you know, if you're looking at just outcomes evaluations from you know some intervention, well, did that intervention really take into account, you know, the person's specific desires or wants or whatever? Probably not. So all of that to say, you know, I think secondary outcomes, such as not just things like mental health and quality of life and employment and the like the low, not low-hanging fruit, but the more obvious ones. But things like for people who, let's say, have been using cocaine for 20 years, well, maybe we can get you to decrease your cocaine use such that we can also see cardiovascular improvements, right? So it's a whole set of physical, you know, physiological, subjective, and objective measures that we can look at. And even things like craving. Like, you know, is craving going down over time or not? You know, so there's just tremendous opportunity for looking at other outcomes. And frankly, you know, a lot of people, I know this from my kratom research, they don't necessarily want abstinence only, right? They might want something that is not necessarily intoxicating. And when I say kratom, I understand there's a lot of different kinds of kratom here. So let's just say the most basic uh, you know, like leaf kratom that's not high octane. Right. That's not necessarily. Getting someone intoxicated, but it's still a psychoactive substance, you know. I mean, wanting to use that, but also they're going to work every day and they're functioning. You know, I think there is this kind of movement, not, I mean, even with respect to alcohol, there's this kind of, you know, that sober curious, but really looking for not, you know, alcohol alternatives. I mean, this is something I've paid a lot of attention to because again, like kava, kratom, all these sort of legal middle of the road things, they're looking for something. And I think that for some people, abstinence really is what they want. And and frankly, I've heard people say, if I'm not abstinent, there's no middle ground for me, right? I will die unless I am completely abstinent. And for other people, they might need and want to stop, you know, using methamphetamine, but they're still going to smoke cannabis. And then I think that's the where we get into the weeds with social services and other things, which is like, okay, well, if they smoke weed on the weekend, but otherwise they're doing pretty good, you know, what does this mean? Right. And I think it, I think that depends on a lot of case-by-case factors. I I do drink alcohol. You know, I do, I have used, you know, this is something I've written about and talked about publicly. I have used uh opioids since getting what I believe to be recovered, and it has been very few and far between. And I'm happy to talk about those experiences and whether they were relapses or not, and that's its own separate thing. But have I used drugs anytime recently? No. And do I plan to use drugs anytime in the near future? No. But you know, what does that say that I did try drugs again after getting quote unquote sober, so to speak? And and again, that that that is like such a long conversation to have, but I think it's an important conversation because I don't I don't necessarily think that my trying drugs another time was emblematic of this chronic relapsing brain disease. I tried it and I was like, man, this is not what it what I thought it was gonna be. Like, like, like I really, you know, I I kind of was disappointed because I was like, you know, I bet I would really enjoy this with my 21-year-old brain. But my 30-something-year-old brain did not, it was not the same thing. And, you know, having having, I'll just say this, you know, living in Baltimore, Maryland, it's kind of a weird, I don't think I've really talked about this with many people, but I am from East Tennessee, and heroin was not widely available for most, I mean, talk about the OC 80s. That was where, you know, a lot of things started. And heroin was not just, you can't just not like go downtown and buy heroin. Like when I was growing up, like that was not a readily available thing. And then when I got into my early 20s, you had to know certain people, and then that's when heroin started to come into Knoxville and other suburban, you know, people I knew were doing it, but it was still not super easy to get, right? And I I had, you know, sometimes like gone up to Philadelphia or Washington, DC and gotten heroin where it's just very available, right? And when I moved to Baltimore, so I got my degrees in Kentucky, you know, again, not, you know, this is when heroin and fentanyl started to come about. But you know, I'm not I'm not using drugs. I'm I'm I'm you know, I'm I have no interest in any of that. But when I knew that I was gonna go to Baltimore to do my postdoc, there was a part of me that was like, man, that's the area where I could just go get heroin in. I mean, I I could just walk anywhere and it's gonna fall from the sky. And I really did think about that. And and I, of course, I didn't go buy heroin when I was in Baltimore at any point, but or fentanyl, but I could have so easily. And and you know, this this goes back to had my 19-year-old self been in Baltimore, I would have probably died, I mean, I would have died very quickly, probably, because I would have just continued to use. So all of that to say that there's a lot of, I think, factors that go into first of all, increasing or decreasing likelihood of use and abstinence versus use or you know, continued addiction over time. But even then, even given the opportunity to do, you know, my my drugs of choice, you know, I did choose to stay abstinent from them, right? And, you know, if we if we widen the circle to say, well, okay, well, you drink wine or you have a cocktail every now and then, so you're not absent. Well, I never really had a problem with alcohol. And I do think that they are different things. And methamphetamine, I tried methamphetamine one time in Atlanta, Georgia. And I have to tell you, it was one of the worst experiences of my entire life. So, all of that to say, you know, we can't just treat every substance like it's identical for people. I think there's a lot of differences here, and sussing that out research-wise, in terms of abstinence, maybe we want to say, okay, well, maybe we want to measure abstinence for the drug of choice, but maybe not for these other substances that the person's using but not having a problem with. That might be controversial, but we also have to kind of have a pragmatic approach if we're gonna try to keep people alive and functioning.
SPEAKER_03So I love the conversation. It's it's funny, Kirsten and I's conversation. Um, some rooms we would be accepted in and people would thank us for speaking out, and others uh they would tar us and feather us.
SPEAKER_01Right.
SPEAKER_03Um, yeah. I had a I had the hardest time a few weeks ago explaining to a state senator that using a quarter gram of heroin a day was better than using a gram and a half of heroin a day. All right. And uh it's uh it's it's just so interesting in how people, you know, and how people look at that. And I thought it was so interesting listening to Kirsten talk about, you know, I don't I don't want to use the word use like that, but having had an opioid issue and then using opioids after the recovery process and and not being the same. And you know, I always wonder about that. I haven't done that. Um I haven't said that I wouldn't say that it hadn't crossed my mind, but I wonder, you know, how much a maturing brain has to do with that. Um, you know, I I don't know. Um, I know that most people, you know, if they have an addiction issue and they don't die, kind of grow out of it over time, right? And and and so I'm I'm always curious about a developing and and maturing brain in that process because Kirsten kept going back to her 20s and and she, and I'm sorry, Kirsten, not this is not a slap, but you're not in your 20s anymore. And, you know, and and how different that is. And so I think I just think those things are really, really interesting. Now, at the same time, for that person who thinks, if I do that, I'm gonna die. That's me, that's in my nature, that you know, frog and scorpion type stuff, I'm fine with that. I don't find a philosophical problem with it, and I'm not gonna argue with them because it goes back to my bull Durham story. So um I think as a clinician, what I my job is is to try to help people find the path that's right for them. And and so many times I see people looking at it as such a moral failure that for me, when I kind of understood a little bit, kind of how I got like I am, it took this weight off of me and allowed me to assume control that I didn't think I had. And and so that's really true what I try to help my patients see.
SPEAKER_00You know, the thing that really lifted the weight for me was reading more about the brain. The whole reason I I think I ended up getting a PhD is I started really reading more about neuroscience and getting into like the split brain studies and you know, things about free will and consciousness. And so I came about this from a you know, the the guilt and self-blame that I had kind of got lifted by reading Robert Sapolski. Anyone who's not read Robert Sapolski should read Robert Sapolski because I'm in love with that man.
SPEAKER_01Oh yeah, oh yeah.
SPEAKER_00And that's like once I read, once I really understood when we talk about complexity and self-organizing complex systems and all this stuff, I was like, well, wasn't my fault. I mean, not that energy, there's a concept now. You can be held responsible, right? We can hold people responsible. We have to have consequences. I'm not saying that people can that this should be anarchy, right?
SPEAKER_01Right.
SPEAKER_00There can be people can be held responsibility, but that doesn't necessarily mean that there has to be this blame or moral, you know, indictment, right? And I think Hannah Picard's work, if no one's read her, I would I would recommend people look her up as well. But the the other thing I wanted to take a step back from this conversation and kind of point out something that is relevant both to research and clinical practice, which is we're talking here about addiction having defined it roughly. And this happens so often. We're kind of talking about like it's just very homogenous, right? Well, really, I mean, when we look at like the DSM V criteria, which are not perfect, you can diagnose 3,000 people with a different set of symptoms, and they're all having, you know, so there's there's a lot of limitations, but but the DSM V is really great in the sense that it's a clinical nosology in which is pretty universal, and we can mostly agree on the symptoms, I would say. And while it doesn't look at amount of use or motivations for use or something like that, it does get at a lot of the core concepts. And I the the thing that you know, my actual point in bringing this up is that we can break this out from you know mild, moderate, severe, right? And the DSM 5 actually does not use the word addiction. And in the chapter on substance use disorders that they they write, we refrain from using this term because of its essentially ambiguity and potential negative connotations, because it is a messy concept, but more severe presentations are maybe something we want to say are addiction, right? And so I think that goes back to explaining to people you can have problems with your use of a substance, right? But they might not be robbing two banks and going to federal prison kind of problems. They could be, I feel sleepy in the morning after I've drank too much. I mean, that there's just such a variety of symptoms, but also severity. And I think in general, it gets hard to see the nuance here because you know, people can go to treatment for a mild, moderate, or severe, and those are they're gonna look different. They're just gonna look different. And even within each category, they're gonna look different. And so that's when we talk to lawmakers, I think it's important to try to use terms that are more grounded in clinical reality, like mild, moderate, or severe substance use disorder. Because if we just lump everything together as addiction, that's not helping people who aren't professionals in this area understand the diversity here, right? It's not all the same thing.
SPEAKER_02Well, even tying it back to other diseases, we do the same thing for hypertension. We we have radiation. In terms of clinical outcomes, I think we've almost accidentally danced around this. Uh Dr. Lloyd, I've heard you speak on this directly a lot, but there are a lot of people who some of the things you've both said in the context of potentially using alcohol, in the context of opioid use disorder and remission and so on and so forth, there are people who say methadone and suboxone are no different. Uh that these medications for opioid use disorder are no different than field research, for lack of a better term, or we hear, of course, switching one drug for another. And altrexone seems to have escaped that fate for obvious reasons. But uh I just wonder how does how is this similar and different from what we've been talking about so far?
SPEAKER_03Well, you know, I I get that all the time. Um, you know, switching one drug for another. And it it's funny how I've evolved. I used to get defensive and and you know, had all my all my stuff right, I'm ready to go to war. And and the truth is anymore, I don't care. Um, you know, see Steve, you you know, you've got somebody on methadone here, they're reusing heroin, they're just switching one drug for another. Okay, it's not gonna kill them. I mean, I don't know what to tell you. And, you know, if you look at, you know, it's funny because you can't use the word harm reduction anymore. It's it's a four-letter word. But you you know, you're talking about keeping people alive, and and I don't see anything wrong with that. And if you want to call it switching one drug for another, frankly, I don't care anymore. I I don't. Um and the thing that I hate about it is that it's stigmatizing and it may prevent someone else from stepping into that process. And and that's the part that that you know kind of wrangles my feathers, and I have to figure out how to deal with that because we do know. Uh, we do know that those are drugs of abuse. We do know that people will use those um uh in ways that are not meant to be used. And and so I just own that. I mean, I think you have to own it. I think it's really interesting. I I I work in West Virginia a ton now, and I don't know how either how familiar either of you are with the Rockefeller, Rockefeller Neuroscience Institute at WVU. Uh it's a pretty impressive place. It was on 60 Minutes, not long ago. But the lead researcher there in the neuroscience is a guy named Ali Razai, a fantastic guy, and and looking at some of the stuff that they do with you know, with manipulating the amygdala either with electrodes or or ultrasound waves and what that does to people's substance use over time to me is just fascinating. All right. And and those those effects, and I've seen them, you know, I've seen their outcomes. They haven't been published yet. They're getting ready to be, and I'm not sure what it is. I think Lance said, um, but you know, it it their their their cravings go markedly, markedly down and sustained for a really, really long time. And so, you know, I think that I think there's areas of research out there that maybe can take some of the stigmatizing, you know, medications that we use maybe out of the picture a little bit. Right now it's what we have. I know that buprenorphine saves lives. I know that methadone saves lives. They just do. And I'm gonna continue to use them as part of the armamentarium of trying to help people, you know, find the find their path. And as these other things come along, you know, what what do they look like? Where do they fit in? But you know, I was trying to I've been going back because Kirsten's challenged my beliefs on so many things here in the last hour. Uh, and and I love it. I mean, that's what it's what we obviously need all the time, you know, and and the the behavior component of this, you know, where does that come into play and and what does that look like? And I just I just think that stuff is so interesting. And I I think a hundred years from now, maybe whoever is is living in the United States will look at us and go, what in the living hell were those people doing back in in 2020, right? Or 2025. Uh, but I would also argue that with cis platinum uh for lung cancer as well. And so I don't think it's really that different from a lot of areas of medicine. I love medical history and I love going back and reading medical history. And some of the things we did in the 1800s, you have got to be kidding me, right? George Washington died of strep throat because these doctors bled him. Uh so uh, you know, and that was the that was the standard treatment of the day. So I I think that that stuff interests me.
SPEAKER_01Yeah.
SPEAKER_00You know, I'm I'm basically in the same place. I don't really care, but I I don't have to convince as many people because I'm not a prescriber, right? So there's there's that, but I think a lot of it has to go, it goes back to what I was saying earlier about what does the person want, right? And I think going to the the heart of at least medications for opdus disorder, a lot of it is let's just keep the person from dying, right? So once we have kept them from dying, then there's a question of do you want to stay on these medications, right? Because some people don't want to stay on them, some people do. And you know, if the if you know, at base we can say these medications save, you know, they save lives, then that I would like to think would be a unifying outcome that everyone would agree is good. But, you know, some people have said, you know, I feel like it is, you know, just replacing one thing for another. And and other people don't feel that way. So, you know, if it works for you, good, if it doesn't, it doesn't. But um, you know, the one thing I think is unfortunate that the methadone delivery systems that we have in this country are pretty medieval. I think that they should probably be performed. I'm not a big fan of how those are delivered. And I and, you know, ideally too pharmacotherapies should shouldn't, it shouldn't be like a pill mill 2.0, right? There should be some behavioral and other type social support interventions coupled with these, instead of just having people line up and take a pill and then maybe sign a piece of paper saying they sit in a group once a week. We shouldn't expect just the pharmacotherapy alone to be some sort of panacea that just cures everything. Because going back to trauma and other things, that pill's not going to necessarily take care of um all of the issues. And good that it helps keep you alive, but it's I don't I don't know that's a replacement for all of the other behavioral interventions, you know, and things like contingency management, which is essentially not used in America. I mean, it's used some places, but it's not really used. And it's such a, I think, promising um intervention that's just has a lot of stigma associated with it because it rewards things. I mean, we we're good at punishment in this country, but we're not really good at reinforcing behavior through rewarding outcomes, which is um difficult and horrible because people in early recovery don't have a lot of reward in their lives, and there's not a lot to reinforce the behaviors that we want to be reinforced. So yeah.
SPEAKER_02No, those are those are good points. Pill pill mill 2.0, avoid avoiding that. That's that's a concern I hear culturally, especially out in rural counties. I think that's a good framework of it.
SPEAKER_00In east, I'll see this in eastern Kentucky when I was doing outcomes evaluations and actually like in some intake stuff for this pro you know, treatment programs that had a research component. That is when I first encountered people who you know were using buprenorphine, you know, diverted buprenorphine, right? And they had never used another opioid, right? Like that was it. That was their first exposure to an opioid was buprenorphine. So, you know, I so and so all of that to say this is like anything. Uh, what is a person's intentions? Because if a person's intention is to take the medication as prescribed, then great. If it's, you know, to to to not, I mean, it it all goes back to I think a lot of other factors. But and when I said pill mill 2.0, I really just meant kind of this doling out of pills, but without any other interventions associated with it. You know, not not to say that the people who are taking the medications are doing anything wrong, but there's a lot more we could be doing for these folks, is my point.
SPEAKER_03It is my uh, what do I want to say? It's my drumbeat, Kirsten, that and Jeremy's heard me say it a million times. Um, in West Virginia this past week, I went up against a lobbyist for a telehealth company from out of state. Uh, they have 50,000 patients uh nationwide, and for $99 a month, you can go to their website and uh or their 800 number and call and get your prescription for buprenorphine. Keeping people alive, not a bad thing, but pretty, pretty low bar, right? And and how are we helping them change their lives? You you know, you you talk about your work in eastern Kentucky, and Jeremy's heard me say this before too. If you talk about the opioid crisis in the United States and you don't talk about eastern Kentucky, I don't listen to you because you don't know what you're talking about. And and I cut my teeth on treating pregnant girls from eastern Kentucky, uh, Jenkins, Neon, Lecher County, you know, these places I'd never heard of. And, you know, the thing that that caught me was was just the web that they were growing up in. A lot of them had been trafficked by their own families. And and in all honesty, I didn't know what trafficking was, you know, that it wasn't in my neighborhood. And I and I learned that stuff on the fly. And so, you know, if we give you a medication and we keep you from putting a needle in your arm and getting HIV and hep C and dying of an overdose, that's a good thing. Uh, if you're going home uh at night to the same guy that's beating the shit out of you um and because you don't have any other options, then how you know that to me we have to do better than that. And and there's a lot of things that goes into that, and it's about behavioral change. It's why I gave you the example. If all I did 22 years ago was stop using drugs, would I be where I am right now? The answer to that is no. I've had a lot of help in a lot of different areas, and the biggest area for me was trauma. It doesn't mean that's the biggest area for anybody else, but for me it was. And so I think we have to, you know, I think we have to continue that. And I think that, you know, there will be people who divert medication. Uh, both of the studies I've seen on diverted medication, particularly buprenorphine, are actually out of the University of Kentucky.
SPEAKER_01And about
SPEAKER_0318% of the people who who diverted divert it for illicit reasons. The other people are using it to bridge to stay off the bad stuff or until they can get the, you know, get the medication or get get their drug of choice. And so I think we have to be really we have to watch out when we make blanket statements about diversion sometimes. Cause I had a had a guy in East Tennessee who's on the news one night, a cop, this sheriff, and he said, you know, he's standing across the street from a service station, and he could clearly see from across the street at a service station somebody pumping gas that they were illegally using their buprenorphine. Right. And and I just I look at that and it makes me crazy. It makes me crazy because you you don't know, and everybody is not the same. So I appreciate the comments, uh, Kirsten. I I agree with them.
SPEAKER_02Do we have free will?
SPEAKER_00Oh dear lord. All right. So I'm gonna just go ahead and jump on in because I can't uh literally I have no choice. Um so I get it. Um sorry. Um I mean I think free will as a concept. Oh, this could just get so horrible. So I mean, I just don't think the concept is even useful. I think it's it came about because of you know religion. And I'm not here to poo-poo on religion. That is not that is not the point here. But the concept really was about you know what the will of self versus God's will, right? And that's kind of where this, at least in the West, this kind of concept of free will even kind of got traction. Because if you look in nature, we don't look at other organisms and talk about their free will or not. Um, but for me, uh I so I just don't find the concept helpful. But I'm I am a big uh proponent of, you know, we have agency, we have volition, and these are constrained by numerous exogenous and endogenous factors, right? And I actually want to, because we're we're talking about addiction, I want to bring up Warren Bickle. I'm a big Warren Bickle fan, uh, and he passed away recently. But, you know, you know, in in thinking about factors that he he used this term like system of constraint, right? So we're these complex organisms and we're kind of constrained and bounded by factors in our cells, genes, uh, you know, basic anatomy that we have no, you know, we can't govern. It got it governs us. And then environmental factors, going back to eastern Kentucky for a minute, right? Growing up in eastern Kentucky is very different than growing up in Kansas City or Baltimore or a lot of other places, although there are some similarities uh across across these, you know, Baltimore and Eastern Kentucky, you'd be surprised at how a lot of similarities exist. But all of that to say, you know, I think this goes back to we are shaped by so many, literally thousands, of complex and dynamic inputs that I don't really know that we aren't essentially kind of determined, right? Now, does that mean we're not stochastic in terms of uh predictable or unp or unpredictable? I mean, this is where and I promise I will not go on long with this, but I I think it's important to note that you know, although I don't subscribe to the notion of free will, obviously we do have capacity for choice and decision making and behavior, and those are all influenced by a lot of things, and ultimately we're not predictable, right? So we don't know exactly what will happen, and what's gonna happen is is literally self-organizing every moment of every day, right? My brain is getting formed in this particular moment by all of the things around me and by all these antecedent conditions, meaning to say that you know, just because I don't think there isn't free will doesn't mean that, you know, there aren't um, you know like ways to manipulate people. And I don't mean that in like a negative way, but just behavior to reinforce behavior towards better ends. So I personally don't think there's free will. Um I would be very interested to hear what Dr. Lloyd says. Um, because I do believe in agency and volition. So with that, I'm gonna stop talking.
SPEAKER_03I could keep going, but we we we don't differ a lot there at all. Um, I agree. I mean, there's so many things that that that that shape it. And um, you know, I I I can't find anything in there that I disagree with. I was kind of curious as to what you were gonna start talking about when you started someone's uh interest, but I I don't disagree with any of that.
SPEAKER_02Yeah, I think to you mentioned Robert Sapolsky earlier. I I I normally I don't try to do this too much, but the the book Behave, I I think everybody should read it. It's unbelievable. Even its structure it's is is amazing. It's just here's the central premise someone throws a punch at someone else. What happens seconds before that? It analyzes the the anatomy of muscul muscular control. Uh and what happens minutes before that, hours before that, days before that, all the way, you know, for example, are you hungry? You know, that that'll that'll influence mood and and so on and so forth, all the way back to childhood, uh adverse childhood experiences, which I'm actually surprised. Although we've talked about trauma, I'm surprised the phrase adverse childhood experience hasn't come up yet.
SPEAKER_00I I'm actually a little surprised. I mean, usually like usually I get hateful looks when I really start talking about this. But I I I mean, for listeners out there, I I just want to echo, I really think Robert Sapolsky makes so many things very approachable.
SPEAKER_01Yeah.
SPEAKER_00And, you know, you don't have to be a scientist necessarily, and even some of Michael Gazanaga and Dan Dennett and Michael Bratman, and there's a lot of um, and you have to agree with all of it, but I think there's a lot that um philosophers and neuroscientists, you know, can help, you know, inform your opinion. And what I've found to be so great about this is it doesn't mean that we shouldn't intervene and try to make the world a better place. Things matter, right? Every input into our brains matters, and so we need to be kind to others, we need to help others and try to make brains better. They are capable, and this is where I think this comes full circle to the the brain disease model of addiction. Brains can change over time, right? Like it is, it is you know very possible. So to say that, you know, we you know, going back to the cucumber and pickle analogy, to say that we are just cucumbers and and we turn into pickles, and that's the end of the story, is really um missing the complexity here. Uh, but also it I think it enables people who might not be naturally empathic to be able to understand why people behave the way they do, right? You know, how could this person commit this offense or make that decision? And if you understand all of the different thousands of inputs that went into that exact moment in time, it doesn't necessarily excuse it or make it okay or make it something that we we shouldn't intervene on or deal with, but you can start to have a lot more sympathy and empathy for how it got to be like that in the first place, right? And in that sense, I think it takes away like a lot of anger or judgment, right? Ideally helps us make more informed decisions about how we want to intervene without, you know, morally condemning people.
SPEAKER_03Yeah, I'm I'm so glad Kirsten said that. I mean, that's probably the biggest change in me over the last 20 years, is what she just said. Um the way I used to look at things compared to how I look at them now has changed so dramatically. And and back then I was such an angry person all the time. And I'm really not angry now. You know, I have things that that light my fire inside, but you know, when I'm able to show empathy, to put myself in and not be judgmental on how they got like they are or how why they did this or why they did that. I just became, I think I became a better person. Um, I know I became a better me, and I know I allowed myself to start looking at myself in the mirror again. I went the longest time without doing, I mean, really, you know, look at my not just, you know, well, I can't fix my hair, I don't have any, but but you got my point, right? And um, and I I anytime that I see legislators in particular trying to deal with some of the issues we're talking about, they want things to be black or white, and and it doesn't exist. Uh it doesn't exist at all. And then and then they also want to look at it and and say, I had a legislator tell me one time, he says, dare it work for me. Why didn't it work for you? You know, should it work for everybody else? Well, you you were born with a silver spoon up your butt, and and not everybody else was. And and and and so when I'm in that mode and I can't look at things in the way that I'm able to look at them now, I'm not, I'm not very much, you know, I'm not very much good to anybody. But when I'm able to to do the things that you know that Kirsten just talked about, then then I am able to do that. And and I think I can help people uh find their path. I've got no idea, right? We we put this thing out not long ago in West Virginia, if we're gonna allow people to choose their own treatment. And I had folks came unglued on me. What are you doing? Choose your own treatment. I'm like, we do it all the time in every single disease process I can think about, every single one. And and and you know, it's not any different. And and so I I uh when I find myself getting in these very rigid, you know, rigid things uh of it's this way and and it can't be any other way, then then I'm really in a bad spot. So I'm really grateful for that over the last 20 years because I am I'm a markedly different person when it comes to that.
SPEAKER_02So what what do policymakers need to hear? Uh this is federal, state, or local level, county, city. What do they need to understand? What what ideas should they be thinking about? Uh when to in terms of coming up with solutions that makes this fight a little bit easier.
SPEAKER_00All right, you're laughing. I'm gonna say one thing that, and I think it's I hate to say impossible, but some of the bigger issues when I try to explain addiction, and a lot of other things too. I mean, addiction is just one of many other potential conditions that we could be talking about. But, you know, they a lot of the most like intractable, severe presentations of anything, whether it's addiction or some some other thing, pathology or circumstance or whatever, a lot of it goes back to this whole, you know, what what is going on, you know, in utero to early childhood. Like what goes on the first six years of your life and the first 13 years of your life? I'm not saying that that bakes every cake and that some of the cakes can't be unbaked because certainly people are resilient and brains do change. But I I think a lot of issues when we talk about prevention, really get at things that are environmental or um not even directly related to what we think we ought to do, right? Like dare. Well, let's have a class about drugs and tell no, no, no, no, no. We need to make sure that kid's not getting the kicked out of it when it goes home, right? Like, like, so there's poverty, like all of these factors that we know, I think we don't talk enough about how stress as an actual physiological stress response, oh yeah, and arousal, all of these things influence our behavior and drug taking, and you know, so helping wire up the brain for human beings in the healthiest way possible. What I would tell lawmakers is what we need to do for not only addiction, but so many other things, right? And to the extent we can invest in programs that help people ensure that their children are, you know, getting, you know, optimal conditions, right? That's gonna, but that, you know, the thing that's so politically unsatisfying about that is that the dividends from any program or set of programs, right, it's gonna take years and years, it's gonna take a generation before you know if it was even, you know, what what's gone on here. And politicians have a lot of self-interest that is only as good as the next you know, election cycle. So all of that to say, I, you know, as unsatisfying as it sounds, we have to do some really long-term investment in things that don't have a clear payoff immediately, right? And that's very hard to sell people on. And with that, I'll let Dr. Lloyd pick up with hopefully something more useful.
SPEAKER_03No, no, it's it's very useful. I talk about it all the time. You you know, you're you're looking at you know, prevention efforts, and and that's the biggest bang for our buck along the continuum. And and I'll say this publicly, I say it to legislators all the time. The reason that we don't invest in that is because you can't show a change in a two or four year election cycle. It's inconvenient, but it's the truth. And um, you know, I've I've uh the thing I love most, you know, what what I want politicians to understand in what I try to do every every day in you know in the field I work in is that the opposite of addiction is not recovery. The opposite of addiction is community and relationship, right? I mean, it's what we're talking about here. And, you know, how do you build that? Uh I've always I always go back back when I've you know first started studying, you know, opioids and pain medication addiction, all the stuff that I've looked at for a long time. You know, children who are burn victims and they require morphine to relieve their pain, the amount of morphine that they required was directly proportional to the attachment and relationship with their mother. I mean, to me, that's that's amazing, right? And and I and I think it I think it is about community and relationship. One of the things I love about working in West Virginia is they have that. I mean, that is prevalent through that whole state. It is a rural state, uh, totally contained in Appalachia. I live in Nashville. There's no such thing as a native Nashville, right? They are uh unicorns. And so I'm not saying that people aren't friendly here, but there's not a sense of community and relationship like there is in West Virginia. And so I think they have something that you can build on there uh in going forward. But uh, you know, if you want to know who these kids are at risk, I mean, ask their kindergarten teacher or their first grade teacher. They're gonna tell you because most of the time their behavioral issues or relationship issues with their classmates. And so I would like to see more focus put on that and and moving as far upstream as as possible. Uh, there's only two juvenile facilities uh for treatment in in West Virginia of any kind of substance use disorder. And in both of them, you've got to be about five layers deep in trouble with uh the law to get into them. And so, you know, that tells you where you're putting your priorities, and it's it's just absolutely it's mind-blowing to me, Jeremy. So, you know, those are my messages. And and then at the same time, I've got to advocate for the people who are already suffering for this and and keeping all available pathways open to them.
SPEAKER_00I fully agreed with that. I'd uh I'd add one more thing that is something that I'd is personal to me. And I and it's not where I immediately go because again, I do think we have to kind of start with like biggest bang for your buck, long-term investment. That's not to say we shouldn't help people already suffering, but man, if we can stop future generations from getting this bet off, we'll be in a much better place. But you know, for me, corrections involved people uh are a population I've studied, and I am one. And ultimately, and this goes back to brains as well, people do have to have consequences. We have to, you know, address behavior that is illegal, and you know, people should have to experience something as a result of breaking the law. Now, that said, do we want people to come out of the criminal justice system with brains that are way worse off than when they went in or potentially better off? And I think that given that, you know, most people who go to prison are gonna get out of prison, we want people with better brains to come out. You know, all of that to say, I think a more, you know, not an issue that everyone's gonna get behind because no one really wants to champion this population, but from just a practical standpoint, getting people who are, you know, incarcerated because of a drug-related offense, or any offense really, but particularly a drug-related offense, evidence-based treatment and some help with some issues that are underlying. There are a lot of people who just have severe childhood trauma that's not been addressed, and educational deficits, and a lot of things that are actually addressable, or at least can conceivably be addressed. And some of the substance use treatment programs are just not evidence-based and they're sh and like that's all there is to it. And there's I guess something is better than nothing, but at this point, there's no excuse in the year 2026 to not be providing people with treatment that is evidence-based for something that we don't want them to do anymore. Like, if we don't want to spend taxpayer money to lock them back up, maybe we should spend a little bit of money to just help them while they're already incarcerated. And again, you don't have to um, you know, this isn't like a gift to them. This is just dollars and cents. You don't even have to care about these people if you just want to we're just pure economics. Right. It's just cheaper to help people uh reform than not reform, is my right.
SPEAKER_03Well, it's cheaper, it's cheaper to help them reform than it is to pay for them on the other end when they don't.
SPEAKER_00That's exactly. Exactly. Yeah, you don't have to be a bleeding heart in order to just get behind, you know, from a from a financial standpoint, it is just going to be cheaper for taxpayers.
SPEAKER_03So I think that I think that people that that argue against that in incarceral settings ought to actually have to go to, you know, go into some of those settings. I've been into them many times. And the thing I always walk out of there with is the line separating me from the people who are incarcerated is pretty deadgum thin and and sometimes not even existent. And you know, 95% of the people who are incarcerated will walk free. That is a fact. And and so I um uh Kirsten, I tell people all the time, I deal with strings, two strings, heart strings and purse strings. Right. And if I can't get you with one, I can I can get you, you know, I can get you most of the time with the other. And um one of the I'm getting ready to have to do this in in West Virginia because we're looking at re-entry and and trying to get people help while they're incarcerated, they're already there. Uh, you know, why don't we do something besides, you know, let them mark time? And and and so many of them have trauma past and all that. And and it and it and it's really an opportune time to do it, and you have control of their setting. I mean, really, it's uh in in so many ways, it's such a really, really good thing and and would intervene. But to incarcerate somebody in in West Virginia is $38,000 a year, and that's not including, you know, paying for their kids, uh, that they that they're not parenting and and all that. It's room board and and and kind of the ancillaries around that. Uh one the first one year of tuition at West Virginia University is $21,500. So you could actually save about $17,000 per person by getting them a college education at WVU. That's not my it's not my point, right? We don't need to send everybody to WVU. My point is that you're already spending these dollars, and and why not spend them in a way that that gives people a chance long term rather than than what we do right now.
SPEAKER_02Okay. Really some excellent things to chew on, uh to say the least. I didn't even mention health insurance, but uh I've kept y'all, I think, long enough. So I I I uh unless there's any final thoughts, I'd like to extend that opportunity.
SPEAKER_03My final one is always this. Uh Jeremy is one of my mentors, um, and you know, getting away from using the word addiction. I still I still use some of the terminology because people understand it, right? The DSM5 talks about substance use disorder. Um, and and I do that a lot, but but you know, I'm gonna use this because it works for what I want to say. Addiction's treatable, treatment works, and people, you know, people recover. And and and even if you want to put recovered, I'm good with that too. You know, uh, they do. And so I think we need to keep that in mind, and and and they're not the same person. Uh they've made a lot of changes, and and I think that we need to work uh to where the more people have that opportunity to step into that process.
SPEAKER_00People can change, and recovery or remission, whatever you want to call it, does not need to look the same for everybody. So I'll keep it.
SPEAKER_02Cheer. Agreed. All right, Kirsten Smith, Stephen Lloyd, thank you both so very much for joining me on the Spark Policy Podcast. I appreciate you both very much. My pleasure, Jeremy. For more episodes on in depth discussions on tennis tea policies related to substance use disorder by a range of local experts. Please subscribe to Us wherever you get podcasts and visit our website at smart.tensee.edu. I'm Jeremy Corvellis. Thank you for listening and see you next month.