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
The Buprenorphine Waiver is Gone...Now What?
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You're listening to the Smart Policy Podcast, a production of the University of Tennessee's Institute for Public Service. There have been huge changes at the federal level regarding the prescribing of medications for opioid use disorder, particularly regarding buprenorphine or subacto. For two decades since the Data 2000 law, addiction clinicians had to get a specialized waiver through the DEA to prescribe buprenorphine, and many states passed laws with practice guidelines and limits on the numbers of patients they could see. There were other stipulations and regulations, and while well intentioned, there were quite a few negative consequences. Most of all, access to treatment was significantly limited for people with an opioid use disorder.
SPEAKER_02Anything you could mix up with regards to Data 2000, I think we probably did.
SPEAKER_00Recent legislation, namely the Mainstreaming Addiction Treatment or MAT Act, got rid of the X-Waifer altogether. This immediately granted every prescribing physician in the country with an active DEA license the ability to prescribe bucodorphine. This bill passed with bipartisan support and was hailed as the right call from just about everyone across the board. But in the years since, we haven't seen much of an uptake in access. And many states, including Tennessee, still have restrictions in place for nurse practitioners and physician assistants.
SPEAKER_02So I don't think that the MAT-made act will make the difference that people were hoping for. Matter of fact, we were over a year deep into it. I don't I haven't seen any literature that shows a discernible difference in the amount of prescriptions being written for buprenorphine products. If you could pin me down, back then I would have told you that I thought that within 10 years there wouldn't be a need for methadone anymore. What fentanyl has done is it has changed the game. Tolerances that we've never seen before, right? Withdrawal periods that we've never seen before. And and now you've got to do something about it.
SPEAKER_00You're an expert in uh medications for opioid use disorder. I think that's beyond question. There have been some significant changes at the state and federal level, uh, and there are still some that are that are pending. The biggest one, of course, was the Mat and Mate Act uh that got rid of the X waiver, among some other uh changes. In particular, the homogenization of addiction training. If you're gonna get a DEA license, you now have to receive uh some some continuing medical education in addiction. But I guess uh what I wanted to talk to you about today was mainly the gaps that still remain uh because a lot of things weren't changed, namely dosing uh recommendations are still based off of heroin era data, and uh we're now almost post-heroin in the fentanyl era. So I wanted to just let you go. Uh uh go go on, run us through how how the state of prescribing is.
SPEAKER_02Yeah, thanks, Jeremy. That's uh there's a lot of meat on that bone, as as you know. And let's uh I guess we'll just start off with the Matt uh MAT Act. Of course, the idea there is to increase accessibility, right? So, you know, in order to prescribe buprenorphine according to the Data 2000 Act, uh, which is funny because it went into effect at 01, but at any rate, uh it's uh, you know, that you needed eight hours of training in addiction and medications to treat uh opioid use disorder. And then you would be assigned what's called an X number, didn't cost any more on your DEA license, but it was a designation on your DEA license that would allow you, you know, at first to see 30 patients, and then those limits were increased through the years. They went from 30 to 100, then to 275, then you know, then finally lifted um, you know, last year, the year before last, whenever it was. Um, so that was you know, that was the original uh idea behind this. And it's funny because the original idea was that you know, if we have this available, we can have primary care physicians treat this in their office. So Jeremy comes in and he's got hypertension and he's got high cholesterol and he has opioid use disorder. And so we treat all of those right in the primary care doctor's office. And it and that works great theoretically until you realize that the vast majority of your physician and provider workforce. When I say providers, I'm talking about your prescribers. So you have three prescribing entities, uh, physicians, uh, both MDs and DOs, uh, nurse practitioners and physicians' assistants. So the the problem with that was that there's there's no training in any of those specialties or any of those pathways around addiction. And then so that's just not going to work. And so what sprang up out of that, Jeremy, as you know, is a cottage industry. Um, and uh at first insurance weren't wasn't covering it, so it started out as a necessity of being a cash-only business. And of course, that you know put a lot of uh bad taste in people's mouths, right? It looked a whole lot like the pill mills that we'd seen, you know, years prior. So it's further stigmatized medication. So any anything you could misstep with with regards to data 2000, I think we probably did, right? And but but the thing with the with the waiver is that there are for a lot of years saying, well, the reason that people aren't prescribing it is because they have to go through the eight-hour training and get the waiver on their DEA license. I never believe that. I've I've talked to you extensively about this. I've never believed that because I don't believe that's the thing that prevented providers from seeing these patients. I think that they don't want to see them, and I think there's a myriad of reasons for that. Not criticizing anybody, just is what it is. And I think the biggest one of those reasons is a lack of understanding about addiction. All right, most people still view it as a moral failure. I think it's interesting that the first doctor that I ever saw write about addiction as a disorder of the brain was Benjamin Russ. And Benjamin Rush was a signer of the Declaration of Independence. So we're talking the late 1700s. So, but there's, you know, and here we are, you know, more than 250 years later, right at 250 years later, you still have a lot of the workforce that provides this care that look at addiction as a moral failure. The other thing is it's just people not wanting these types of patients, right? I mean, it can be difficult. They don't, you know, you get somebody who comes in with high blood pressure and commercial insurance. I mean, you go up or down on their dose of blood pressure medicine, have it track it for a month, come back, right? Not real hard. Um, when you're dealing with the type of patients we are, I mean, a lot of them have legal issues, they don't have a driver's license. Uh, you know, simple things such as, you know, being able to go to the grocery store are very difficult. Rides to the clinic just to see their doctor. It's really this is a public health issue. And I just don't think our physician workforce is trained to deal with public health issues. I can tell you for sure I wasn't until I got involved in this field. So I don't think that the MAT made act will make the difference that that people were hoping for. Matter of fact, we're over a year deep into it, and I don't haven't seen any literature that shows a discernible difference in the amount of prescriptions being written for buprenorphine products. Uh, and again, I think for the reasons uh that I've outlined. Now, with that said, does that mean I'm against getting rid of the X waiver? No, I wasn't against it at all. I'm just looking for something that has its, you know, the intended effect. And and Jeremy, my in my experience and my my background is medical education, I've been a residency program director. I've run multiple residency programs, I've overseen, you know, every residency program that the VA has. And I can I can tell you this people wind up going into fields based on experiences they had in their training that were positive, that they felt like they made a difference. And I think that whenever we get addiction education in the medical schools, the nursing schools, the physicians assistant schools, and more importantly, we have rotations in addiction medicine so that the young students or even older or middle-aged students are you know get that experience. I think it's going to be hard to draw people into this field unless they have the problem themselves, which is how I got into it, as you well know. The other thing I have a concern with used to, whenever you had the X number, you had to get at least eight hours of CME around this issue. And there's still a requirement there. But the thing I worry about is people getting involved in this as a money-making opportunity and not understanding hardly anything about addiction. And I think when that happens, I think that we can cause more harm with than good with the stigma uh that's associated with that. So, you know, those are some of my my thoughts around that. I think that, you know, I'm not against getting rid of the of the X waiver up. I think it's a I think it's a barrier. I think it stigmatizes things. You certainly don't have to have an X waiver to write Oxycontin. Okay. At the same time, I would love to see uh more robust training opportunities for people to get experience and realize what a fun field of medicine this is.
SPEAKER_00There have been some medical schools now starting to include addiction-based rotations into their training. I obviously this is a great thing to do. I I no question it should probably be standardized across the board. Uh, what do you think we should do for physicians already licensed, been prescribing for years?
SPEAKER_02Yeah, that so you really you got two different things, right? You've got you've got the young trainees and and and really, Jeremy, I think that's where we move the needle. You know, sometimes old dogs like me are set in their ways and they're gonna do what they're gonna do. Uh I still think there are people who can change, but uh we really will move the needle with uh with the younger generation coming through. And and I'll address that one first because you know, I tell people all the time when it comes to getting this into curriculum, you go to med school curriculum committees, say we need, you know, we need to look for a spot for addiction. They say, well, we don't have room. And I'm sitting here thinking, well, we had room for maple syrup urine disease, right? And I've ain't ever seen a case of that in my life, but we had room for it. And the reason we had room for it is because there's a question on the national board exams on maple syrup urine disease. So I came to this conclusion a while back. If we want to entice schools and residency training programs to teach addiction, to have addiction experiences, first of all, it should happen because it's the second biggest medical problem in the United States. Get questions on the national board exams. And when you do that, then you you have to teach it in your curriculum. So I think that that is probably the easiest fix that will uh cajole people into doing uh, you know, into doing the right thing. Now, for those doctors still out there, states have made a really good effort. They have the CME that's out there is is very well done. There's a whole accrediting body for CME called the AC CME, the accreditation council for for um uh continuing medical education. And so it's a lot more formal than it used to be. And so that's one approach. States have required that two hours of that CME, uh, every licensure cycle has to be around addiction and prescribing. Tennessee did that way back, uh Governor Haslum did that in like 2012. So we were one of the first states that did that. We still have that requirement. And uh, and so I think that there's some things you can do around that. Uh, I really think that that it's going to be difficult, Jeremy, because I've done this for a long time. And I really think that, you know, once you've been out there, this is what you do. You would rather just somebody else take care of these folks. And I see that and I understand, you know, I did a thing in North Carolina the other night where I had a bunch of family medicine doctors from rural county. And what what the health system was trying to do was get them interested in treating people with addiction in their private offices, which I think is a great idea. So my job was to come in and tell them why you want to do this, and I did, and I believe it, right? This is a fun area of medicine. Patients do really well. You think, oh, nobody ever gets better. Golly Jeremy, you've seen it. I mean, you don't even recognize them in a week. It's the most beautiful thing. But then the flip side of it is when they when when people you know relapse and slip, and but it's a fun area of medicine. So the whole gist of the talk was getting these providers who are already out there and show them the benefits of treating their patients. Now we'll give you one interesting thing, Jeremy, that I think that payers could do. Okay, because payers can influence behavior.
SPEAKER_00Okay. Yeah, yeah, yeah.
SPEAKER_02So in people with opioid use disorder, it would be interesting to have the provider, you know, look and see what their utilization of services are. How many times they go to the ER in the last year? Right. And then incentivizing those primary care providers to treat their addiction based on uh outcomes like not going to the ER and maybe pay them a supplement on top of their normal uh on the normal rate for those patients. So that would be a way to incentivize behavior and it's a shared savings model. Whereas, you know, this patient had opioid use disorder. Last year they utilized the emergency department eight times in a year at a cost of you know$3,000 every time they did it. And you've treated them this year, they only utilize that service one time. And so therefore, your savings is seven times the amount it, you know, in that amount where they didn't show up. And so I think you can incentivize um uh providers uh using mechanisms like that, because one thing we know for sure is reimbursement will affect doctors' behaviors, and we do know that.
SPEAKER_00That's certainly true. It fits right within uh this broader movement towards value-based care, these bundled payments. I really like this idea of reimbursing based off of preventing overutilization of emergency services. That's genius.
SPEAKER_02Yeah, we you know, we we do that here at Cedar, and we're a pilot program for one of our MCOs. And so those of you that are listening don't what an MCO is. It's a managed care organization. So there's three MCOs that administer TIMCare. Tim Care doesn't do it, they farm it out, and and so we were working with one of our MCOs on this, and and the metric that they chose was actually the right one, uh, which is unusual, but but it was the right one. And it was retention and treatment, right? I mean, that's you know, I mean, the only the only predictor for long-term outcomes we have in this field, because we just you know don't have enough data is retention and treatment. So the you know, the long and short of it is the longer you're in treatment, the better your outcomes. And we've done very well with it this year. And I can tell you what, it changed, it changed our approach, Jeremy. And and I'll tell you how. We know when we lose patients, right? We track everything from the first phone call to them showing up to the office to them getting a prescription to them showing up for the second visit, right? And we know in that process where we lose them. You're gonna lose around a third in the first month. You're gonna lose probably a third from that first phone call to them showing up at the office, you're gonna lose half at six months, right? And so, you know, when we started tracking this and we started looking at it very closely, it became paramount for us to continue our people in treatment, don't lose them. So, so one of the things that the value-based care did was there's now great incentive to do that, and there's a mechanism that we can pay for it. So the secret sauce here are peers, like peer navigators, people with lived experience who have training certification from the state. And so now when you call one of our practices from the phone call, I mean right then the phone, you're on with a peer. Right now, we do we do a screening medical intake, but before you get off there, you're gonna establish a relationship with a peer. And when you come into the office, that peer is gonna see you, all right? And when you leave the office in that first week, before you come back next time, you're gonna get at least two phone calls, if not more. Right? And so what that allowed us to do was to hire peers to help us to retain people in treatment. So that's an example of how a reimbursement model can actually lead to better use of evidence-based practice. But if you look at reimbursement for it, right, this is strictly from a third-party payer. And for those listening, I hate to use the lingo, but the insurance companies, okay? Right. Um, so they reimburse about$8 every 15 minutes. And so if you look at that over, you know, if you had four patients an hour every hour, which you're not gonna have, it'll be about$32 an hour. And it'd be really tough to do it on that, believe it or not, because once you take salary and, you know, where you pay somebody a decent living and their benefits, right? I mean, it's pretty tough to do it on that. However, now if you flip at it and look at the patients that you retained in treatment, therefore you can bill for. So it's one of those situations where it's the right thing to do and you get paid for it, and you're incentivized on top of that to retain them in treatment. Now you can start to look and see, okay, the bang is definitely worth a buck here.
SPEAKER_00I'd like to talk now about the medications themselves. A lot of these prescribing guidelines also include ideal dosing, dosing limits. I think in some situations you have to uh uh justify or in some ways ask for permission to maintain higher doses. I understand this is uh tied to reimbursement in its own right, but none of that has changed. And all of these dosing guidelines come from the era of heroin, which is now effectively gone. It's still around, but it it's it's essentially all fentanyl and fentanyl analogs, which are way more potent, respond differently. There's differences in responsivity from my perspective anyway, that I've seen from broader analyses on is methadone working better, is buprenorphine working better, what dose of buprenorphine, so on and so forth. I was wondering if you could talk a bit about dosing in the age of fentanyl.
SPEAKER_02Well, you've already, I mean you know we'll start off with with what you started off with is that the guidelines need to reflect what we currently see. Jeremy, probably in the mid-2000s, early 2000s, 2008, 2009, somewhere in there, I came to Nashville and argued against the methadone clinic for the tricities. And you know me, I'm an MAT guy, right? I mean, it keeps Medicaid, people keeps people alive, but this particular clinic uh was really bad. And I knew the TriCities are my home. And I knew if the if the first clinic you got in there was a bad one, that that was really going to do a number on it. I mean, it was hard enough as it was. I mean, they had coalitions forming and people, you know, carrying picket signs, you know, we don't want these people here and that kind of stuff. So it was very difficult. And if you could pin me down back then, I would have told you that I thought that within 10 years there wouldn't be a need for methadone anymore. And I believe I believed that back then, because we were dealing with prescription drugs for the most part, and we still had this small subset of people using heroin, but for the most part, it was still prescription drugs, and and buprenorphine does a great job with that, right? I mean, geez, we were able to get people under control that could live you know decent lives. I mean, I would have thinking, okay, you know, as time goes on here, we'll need less and less methanone and and more and more buprenorphine. And I think all of us uh or a lot of us in this field saw that whenever we started restricting uh the prescribing of pain medication and teaching our doctors and and healthcare providers more about prescribing, I think we I think we all knew that prescribing was going to go down, utilizing monitoring databases and requiring it and putting some teeth in it, you know, decreased the number of MEDs prescribed in the state of Tennessee now by over 2 billion for when we started. I mean, it's a massive number.
SPEAKER_00Yeah, massive change.
SPEAKER_02But even back then, you know, I raised my hand to go, that's great. You know, that's well and good. What are we gonna do with the people that have opioid use disorder? Right? And I got crickets. And so what happened over time is that the iron wheel of the market happened. And you've got a space here, a void, and there is a void, it will be filled. You and I know that. And the more risky it is, the more savor, unsavory characters you get filling that void. And so heroin was was one of those things. So black tar heroin, powder heroin made a comeback, and I think all of us saw that. I mean, we knew that was gonna happen. I've heard people say they saw fentanyl coming. I'm gonna, I'm gonna tell you the truth, Jeremy. I don't believe them. I didn't see it coming for sure. And I work in the field every day because when I think fentanyl, I think fentanyl patches, fentanyl lollipops, fentanyl spray, all hard to divert in massive quantities out of EDs and emergency rooms and ORs. I mean, I just couldn't see it. I had no clue about clandestine labs making fentanyl in powder form without the use of poppy plants. And uh, you know, basically you need the chemist, right? Like breaking bad, right?
SPEAKER_01Yeah.
SPEAKER_02And I just didn't see it coming. And and so there's several things that have come along with that is this when I went into treatment in 2004, my cow score was a 12. Clinical opioid withdrawal score, basically a measure of how dope sick I was. Mine was a 12. I sweated through nine shirts my first night, nine, didn't sleep, you know, pouring sweat, freezing, bones hurting. I mean, the most miserable I've ever been in my entire life. And my score was a 12. Okay. Oxycon. What we see today with the powerful drugs like the fentanyl analogs, that these folks are getting tolerances that I have never in my life seen. So when they come in, their cow score is not a 12, which is awful. Their cow score is a 30. And they're rolling around. On the floor. And I've seen this multiple, multiple, multiple times. And you can't send them to the ER because the one thing that's going to help them is medication. And the ER for sure isn't going to give them medication.
unknownNo.
SPEAKER_02So imagine this mess that you have out there. So what fentanyl has done is it has changed the game. Tolerances that we've never seen before, right? Withdrawal periods that we've never seen before. And now you've got to do something about it. So if you look in the state of Tennessee, our buprenorphine prescribing guidelines say the maximum dose is 16 milligrams. And at the time, that's probably okay, although I don't think you should ever get into artificial limits. Uh TIP 63, which is the Department of Health and Human Services Bible on medication-assisted therapy, talks about it all the time. No artificial guidelines on dosing, right? But everybody ignores that. So my experience with buprenorphine is that when you get to 16 milligrams, you're saturating about 93% of the opioid receptors in the brain. So the extra bang for your buck that you get with that another eight milligrams going up to 24 or 32 is very minimal. It's very minimal. Now, if it makes a difference clinically, that's a different story because I'm talking about saturation of opioid receptors. So the DNA of this thing says they don't need more than 16, but damn, they're doing great on 24. Okay, that's the phenotype. So I still am a believer that clinical trumps everything. I don't care what the x-ray says, I don't care what any of that says, clinical trumps everything. And so I think that we need to revisit the guidelines on prescribing bupenorphine because I think there is a subset of patients out there that that given fentanyl will do better on higher dosages. And uh, is it 24? Is it 32? I don't know. I think it would be the dose that that my patient does the best on. Now I think there's some responsibility that comes along with that. We, if you're taking that amount, we should know what your levels are because Jeremy, what everybody's scared of is the economic model. So we're going to prescribe you 32, which is four a day, four or eight milligrams a day. And you secretly know you only need 16, so you'll sell the other half and it'll pay your cash, you know, visit back to the doctor's office. So I think those are things that you got to have your eyes open about, but diversion never needs to be the reason that you wholly do or wholly don't do something. Let's flop over and talk about methadone for a second. So, methadone in the state of Tennessee right now, when you get up to 120 morphine equivalents, you have to have permission to go over that. And boy, that one needs to be dropped. I mean, fentanyl has changed the ballgame there. Remember, I told you, you know, you got to remember when you're taking an opioid from the outside, your brain responds by making more and more opioid receptors. So over time, you're gonna need more and more drug to fill those receptors up. But the feeling you're going for is dopamine mediated. Okay, and there's some other things, but dopamine's a big dog. And so the whole time that the opioid receptors are climbing, the dopamine receptors are actually going down in number. So now you need more and more for less and less effect. Okay, that's tolerance. I mean, that explains it as good as I can explain it. I'm sure there's some bench scientists out there that have a heart attack at that explanation, but I think most people understand what I just said. So so now fentanyl has come along and it's so much more powerful, right? And these folks' tolerances have gotten so high, particularly if they're using intravenous, I can't get control of them with buprenorphine. So I always try, but when I get a patient that is injecting more than a gram or a gram and a half of what they say is heroin, which me and you both know is fentanyl, I know that the likelihood of me being able to get them under control initially with buprenorphine is almost zero. The tolerances are so high. And you know, buprenorphine has a ceiling effect. So, unlike methadone, when you go up on the dose, you expect more effect. Uh, and with with buprenorphine, you don't. You get to a certain level, and that's all the effect you're gonna give, no matter if you prescribe four or 10. It's not gonna matter. And so I think the ceiling effect has something to do with it, but really these fentanyl analogs are are just tolerances that I've never seen. And I'll have patients that we get up to 70, 80, 90 milligrams of methadone over time that are still in withdrawals because the fentanyl was so powerful that you know you you have to keep going up and up. So the judge looks at you and goes, Dr. Lloyd, you keep going up on the dose. Yes, judge, I do. I'm sorry. Why's that? You're just trying to get them hooked. I said, Well, no, they're already hooked, so I don't have to try to get them hooked. I hate that word, but I have to saturate their opioid receptors to get them to stop using other opioids. Well, how do you know when they're there? Well, their drug screens are only positive for methadone and nothing else. And that's how you use clinical, you know, you're also using your eyes, right? Looking at your patient. And uh, so that's how you dose methadone.
SPEAKER_00And of course, there's additional things like xylosine. Of course, xylosine is not an opioid, it would not have the same effect, but we've seen some preliminary data showing that MOUD had like buprenorphine methadone, patients have reported it has helped with even xylosine cravings.
SPEAKER_02Well, you know, and here's the thing, Jeremy. I've got patients that'll tell you that even though it's not made for it, it's helped their methamphetamine cravings. And so my experience has been that if opioid use disorder is your underlying, you know, your underlying disorder, that doesn't mean it's all you're going to use. And this is what people have got to understand, and some of the academic types that that I see from now up now and then, they put together an academic paper and they look at somebody addicted to one drug and they got exclusion criteria for everything else. Well, that doesn't exist in the real world. Okay. I can't tell you, you know, I was trying to think how many patients I've got in Newport, 400. I've got 400 patients in Newport, small town, 400 patients. I'll bet you there's not two of them that only had one drug in their drug screen. Not two. Now here's what I found. A lot of times when you control that underlying opioid use disorder, their desire for the other stuff goes away, particularly as they start to build a life. Uh, we don't have anything to withdraw people off xylozine or meth doesn't produce a physiological withdrawal syndrome, but certainly uh presents some pretty serious cravings. And as you know, we don't have any anti-craving medication for methamphetamine. So the best thing that we can do is treat the underlying OUD. But I'm going to run this one by you, Jeremy, just for our audience. So if you've got a patient that's doing well on medication, say they're on methanol, right? And they're doing well with their opioid use disorder, but they keep popping positive for meth. What do you do? All right. So that's a patient that needs a higher level of care. Okay. That's a patient that is probably going to need inpatient or at least IOP because there's something that's still driving it. So the equivalent I use there is I was an internist. I worked in the hospital. I dealt with my share of acute heart attacks and congestive heart failure and lung disease. All right, because about every heart patient that I had smoked two packs a day. Okay. So if I'm going to use that equivalent of, oh, they're using methamphetamine, so we're just going to stop treating their opioid use disorder. Right. And you're going to get that a lot. You're going to hear a lot of people say that. It's wrong. It would be the same as me taking one of my heart failure patients who had concomitant chronic obstructive pulmonary disease, i.e. emphysema from smoking, and he continues to continue to smoke. Do I stop treating his underlying heart disease? No, I don't. Why would I? All right, I can't control the smoking. He's doing that. All right. What I can control is his blood pressure, his cholesterol, his diabetes. I don't give up on those others just because of that. And I see this happen a lot. I see people discharge from clinics. Oh, they continue to use meth. Okay, I get it.
unknownRight?
SPEAKER_02But they're not using opioids, and that's a good thing. Now let's try to see what that underlying driver is that's putting them to the methamphetamine. Most of the time, it's something acute going on in their life.
SPEAKER_00Love the metaphor. There's there's very rarely one thing wrong, even just with regular medicine, let alone addiction medicine. Uh, which really, even just saying regular medicine versus addiction medicine, I I right there shows uh shows the how the thinking is so pervasive.
SPEAKER_02Yeah, even even us, right? We do this, we fight against it all the time, yet you and I both, you and I both use the language, right? And and it happens. I do it too, Jeremy, and I'm out there railing against it every day. But you know, and sometimes I'll say, you know, a real disease, right? Right, like hypertension. And because what we what we have tended to do for forever, um, is we have stigmatized anything associated with mental health, as if somehow, if we tried hard enough, we could overcome that. And and so I would like to, you know, challenge those folks, you know, and and say, you know, if you've ever been depressed, all right, how was it when you tried to make it go away? Right? It's very difficult, right? And and and so you you've got a couple of choices there. You can look at it as, well, it's a moral failing, or there's something wrong with me that can be treated. And I would argue that that second option we're gonna get a whole lot further with than we are any of the others.
SPEAKER_00We did talk out an awful lot of policy, but uh are there any other policy recommendations that you'd like to see at the federal, state, or local level?
SPEAKER_02Yeah, you know, uh first of all, I would always I'm always grateful for our politicians who are willing to engage in this because sometimes there's a lot of negative blowback, and you're not being tough on this or tough on that. And and so I'm always encouraging, you know, and particularly in our Knoxville area, we've got some real some real friends, uh, Senator Briggs, uh, Becky Duncan, Massey. Um, you know, we've had a few retire through the years, some of our representatives that have been, you know, really, you know, influential in the state house and helping us get things we need, and not the least of which is uh former governor and uh Knoxville mayor uh Bill Haslam. And so, you know, I want to thank them always, but I think from a policy standpoint that our policy uh it needs to be directed by people who are in this field. And so I think of our smart policy group there at the University of Tennessee that you and I know each other through. I think I think places like that that don't have a financial interest in the game and can help um policymakers design effective policy, I think we need to utilize that as much as we can. And at UT, we're grateful for Randy Boyd and President Boyd's support of this because it wouldn't have happened without him and then what that group has been allowed to do and working in our community. So I think from a policy standpoint, Jeremy, that that it's got to be groups like Smart that help guide that policy that'll make a difference going forward and get it out of red and blue stuff because it's not a red and blue issue. Golly, if you'd if you'd have told me this, Jeremy, when I was in med school, I would have fought you. And now I've got to admit it's true. It doesn't matter what your ideas are, it doesn't matter what your goals are, it doesn't matter what your treatment empathy is like. If you have policy standing in the way of making it happen, it's not gonna happen. Policy becomes really, really high up on the priority list. It just does. Because there's so many things that can be done there that can that can either prevent or enhance a large number of people access having access to evidence-based care. And so that's why I think this stuff's so important. And it's the only reason I would ever darken the doors of a of a statehouse.
SPEAKER_00Dr. Lloyd, thank you very much for joining us again. Uh it's a pleasure, and and thank you for doing all your work in your treatment clinics and uh with the opioid payment council.
SPEAKER_02Thanks, Jeremy, and and uh you know I appreciate your work as well. I I saw this on my calendar today and uh said, well, at least at least one good thing is going to happen on a Monday, and uh, and that's it. So I enjoy our time. Any any time uh that you need me, let me know. And you know, thanks to your listeners. Uh, you know, take some of this stuff that you can use and go out and use it. What you don't need, just leave it here.
SPEAKER_00For more episodes on in-depth discussions on Tennessee 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.tennced.edu. I'm Jeremy Corvellis. Thank you for listening and see you next month.