Jeremy speaks with Dr. Stephen Loyd, Chief Medical Officer of Cedar Recovery, about the recent legislative changes pertaining to telehealth in the state of Tennessee, and how these changes have expanded access to treatment for opioid use disorder, especially in rural areas.

SMART Policy Podcast

Telehealth

If there's one thing Tennesseans can agree on, it's that the criminal justice system needs some improvements.  In the summer of 2021, the Reentry Success Act and Alternatives to Incarceration Act passed; at the same time telehealth permissions expanded.  Jeremy talks with Judge Duane Slone and Dr. Stephen Loyd about how these policy changes will affect justice-involved people with substance use disorder.  In particular, we learn about the novel treatment program in rural Jefferson County, which is the only jail in the entire state to offer in-house medication assisted treatment.

Criminal Justice Reform

Harm reduction does not mean drug use is condoned.  It simply means withholding condemnation of the behavior while the consequences of behavior are first addressed.  For opioids, this basically means keeping people alive so that you can treat them.  Jeremy speaks with Genoa Clark, Director of Harm Reduction at Choice Health Network about harm reduction in Tennessee.  

Featuring new original scoring by Duck Ryan & Ryan Dunaway.

Harm Reduction

Telehealth, broadband internet, criminal justice reform, harm reduction...a lot has been changing lately to expand access to treatment for substance use disorder.  But how well are these changes being implemented in rural areas, where the need is greatest?  And what about prevention?

I spoke with Trent Coffey, Executive Director of STAND, a coalition of Scott County businesses, organizations and community leaders focused on the health and well-being of youth.  

Rural areas have a lot of unique challenges, and my biggest takeaway from this conversation is that in order to make changes that last, we’re going to have to listen to the people who actually live there.

Rural Areas and the Importance of Prevention

At the end of 2022, the CDC released new prescribing guideline for opioids, replacing their last set from 2016.  Excluding patients with cancer and other terminal illnesses, this guideline strongly emphasizes alternatives to opioids and urges extreme caution for physicians considering new opioid prescriptions, while also recommending how to appropriately care for chronic pain patients with long-term opioid treatment.

Notably however, is how the new guideline answers the failures of the past.  According to the CDC, many laws, regulations and policies were “notably inconsistent and have gone well beyond its clinical recommendation.”  This led to rapid tapers, abrupt discontinuation, treating MOUDs like buprenorphine as opioids for pain that needed to be stopped as quickly as possible, setting arbitrary limits on prescriptions by insurers and pharmacies, and even patient dismissal and abandonment.  The fallout from this is “patient harm, including untreated and under-treated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior.”

Dr. Clay Jackson, a board certified pain specialist from West Tennessee who also serves on the Tennessee Opioid Abatement Council, speaks with Jeremy about the new CDC guideline for the prescription of opioids for acute and chronic pain.  Dr. Jackson uses his extensive and first-hand knowledge of the subject to dive deep into the story of how we got here in the first place, and taking us through some of the broader philosophical considerations of the treatment of pain and the future of the field.  This conversation also touches on the FDA, fentanyl, non-opioid treatments and medications, and other topics that are strongly impacted by this still young history of prescription opioid pain treatment.

The New CDC Guidelines: Correcting Past Mistakes

We are now in the fourth wave of the overdose crisis.  Fentanyl is the still the most common drug involved in these deaths, but stimulants, primarily methamphetamine, is increasingly prevalent.  In fact, the vast majority of all overdose deaths now involve multiple drugs.  Meth, cocaine, heroin; worse still, newer contaminants like the animal tranquilizer xylazine are showing up alongside fentanyl and its analogues.  Even more concerning are the novel synthetic opioids that are now being found in toxicology reports.  Some of these are even stronger than fentanyl - nitazine, for example.  

Opioid prescription rates have steadily declined in recent years, which is excellent news considering that overprescribing got us down this path in the first place.  But clearly there is something else going.  In particular, it’s evident that there is an incredibly high demand for stimulants, even stimulants known to be contaminated with extremely powerful sedatives like fentanyl.  

My guest this month is special agent Tommy Farmer of the Tennessee Bureau of Investigation’s Dangerous Drugs Task Force.  He also serves on the state’s Opioid Abatement Council.  In this conversation, we dive into the history of methamphetamine in Tennessee, and how law enforcement has responded over the past thirty years.  Drug trends have changed a lot during that time, and the federal and state legal landscape along with it.  Most importantly, how and where drugs are being produced has changed dramatically, resulting in profound consequences.  

Produced and edited by Jeremy Kourvelas.  Original music by Blind House.

Methamphetamine and the Overdose Crisis

Everyone who’s gone to elementary school in the last fifty years has had some sort of “Just Say No” sessions and activities; we’re all familiar with this type of informational prevention.  But there is much more to the picture. 

My guest this month is Stephanie Strutner, CEO of the Prevention Alliance of Tennessee, an advocacy organization that represents dozens of grassroots coalitions across the state fighting substance use disorders of all kinds.  Over the last few years, she has rapidly become one of the most important voices for primary prevention in all of Tennessee.

Produced and edited by Jeremy Kourvelas.  Original music by Blind House.

What does "primary" prevention for SUD look like?

Purdue Pharma.  Cardinal Health.  CVS.  Walgreens.  I could keep going.  Drug manufacturers and distributors have rightly come under scrutiny in light of the opioid abatement settlements.   As these companies start paying hundreds of millions of dollars out across the country, in an effort to try to make up for the damage they caused by ignoring the warning signs of opioid prescribing trends over the last twenty years, it is easy to sit back and blame the whole thing on corporate greed.  And no doubt, corporate greed played a big role.  But the pharmaceutical industry is a complex web that extends far out from just drug makers and pharmacies.  It involves doctors and providers, pharmacists, governmental agencies, insurance companies, law enforcement, and of course, the patients themselves.  What happened to cause such a huge and complex supply chain with built in checks and balances fail?  Imagine a stack of Swiss cheese slices on top of each other.  As long as the holes don’t line up, nothing can pass through.  But something did happen that lined them up, making a hole big enough for the whole country to fall in.

My guest this month is professor Anne Smith from UT Haslam College of Business.  She specializes in organization failure in the context of disasters and catastrophes.  As professor Smith discusses in this episode, the opioid crisis unfolded not unlike the Challenger explosion, or the Black Hawk helicopter incident in northern Iraq during the Persian Gulf War.  Poor company leadership and values, regulatory failure, and other factors all happened to line up perfectly to create this disaster.  In this episode, we dive into all the different parts of the supply chain, as well as discussing how policymakers and the private sector can learn from this colossal mistake, and hopefully prevent another pharmaceutical catastrophe in the future.  

Produced and hosted by Jeremy Kourvelas.  Original music by Blind House.

Organizational Failure: How Bad Business Created the Opioid Epidemic

Starting with the multiple guilty pleas from Purdue Pharma in 2020, thousands of lawsuits across the country have lead to a series of settlements from numerous pharmaceutical manufacturers and distributors for their role in the opioid crisis.   From just the first and second wave of settlements with Cardinal Health, Janssen, AmerisourceBergen, CVS, Walmart, Walgreens, and several others, Tennessee is expecting to see a little over a billion dollars over the next 18 years.  

My guest this month is Dr. Jennifer Tourville, executive director of the SMART Initiative.  A fairly significant portion of our work lately has revolved around these settlements, and assisting the leadership of Tennessee’s cities and counties in understanding when and where these payments are coming from, what they can be spent on, and what reporting requirements there are.  

Tennessee is actually rather unique in how it has decided to spend these funds.  Unlike most of the other states, who have planned to distribute most of the money directly to counties, Tennessee has elected to open up a large amount of these funds to private entities, who can apply for grants.  This means nonprofits, prevention coalitions, clinics, researchers, and many other groups will have a chance at getting new projects funded, or expanding their existing services without having to appeal to local government.  Though of course, with a decent amount of money still going directly to Tennessee counties, they can try this route as well.  

So it’s a lot to consider, and it can be confusing.  We hope this episode can serve as an introductory guide to local stakeholders in both the private or public sectors, shedding some light on one of the most important public health opportunities in our lifetimes.  

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

What's Happening with the Opioid Abatement Settlements?

If you’ve been listening to this podcast for a while, you know that there is strong evidence for the effectiveness of addiction treatment, and that the biggest obstacle we face in combating the overdose crisis is an overall lack of access to that treatment.  Health insurance is of course a major factor, and in Tennessee our statewide average for people lacking insurance is over 12%, which is more than twice the national average.  But even for those with insurance, they face a provider shortage.  And then there’s the problem with appointment availability: even if a patient gets into a clinic, they better keep their appointment or it might be a long time before they can make up for it.  And if the patient lives in a rural county, they might have to drive 50 miles to get there!

So it really goes without saying that this is a difficult, frustrating, and sometimes humiliating experience.  Imagine trying to work a minimum wage job while dealing with all of this, for example.  Do you tell your boss that you can’t work on Monday because you have to drive to the next county for your addiction medication?  Would something like that even get you fired?  It’s not hard to imagine that the stress of all of this makes avoiding the temptation of drugs even harder.  Is there anyone you can turn to? 

Rachel Loveday is exactly the kind of person you could.  

Rachel is a peer recovery specialist at McNabb Center, one of the premier treatment centers in the Knoxville region.  She and her team are contracted with UT Medical Center to help connect people who survive overdoses to treatment.  When patients get stressed or confused or overwhelmed by treatment and its difficulties, Rachel and the other peer recovery specialists are there for reassurance and support.  So far, this program at UT has seen huge success, with a significant increase in connecting ER patients to treatment.  So what makes peer recovery specialists so effective?  It’s simple.  They’re all in recovery themselves.

I really enjoyed this conversation.  Rachel and I get into some good topics here, and address some of the more interesting aspects of addiction and its challenges.  

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House. 

Editor’s note: we reference two bills in this episode.  The first is in relation to the decriminalization of seeking medical treatment for an overdose; this is only guaranteed for the first presentation, and subsequent presentations are at the discretion of law enforcement.  The second is the cannabinoid regulatory bill; it is described as “in the legislature,” but was signed by the Governor on May 11th, making it indeed a law.  Finally, there are some unfortunate audio artifacts at one point in the episode; apologies that I was not able to edit them out without sacrificing the dialogue.

How Peer Recovery Patches Treatment Gaps

In 2020, the TN Together Student Survey found that the average age for first using a substance was 13 to 14 years old.  Identifying and intervening at that age is thus crucial.   Most of the time, however, the problem isn’t caught until later: usually when the person is college aged.  

My guest this month is Nathan Payne, director of collegiate recovery at the Tennessee Department of Mental Health and Substance Abuse Services.  We discuss how the attitudes on college campuses in Tennessee have changed over the last decade, becoming much more proactive about addressing unhealthy drinking habits and preventing substance use disorders.  After all, if we are going to make a dent in this crisis, we have to head the problem off before things spiral out of control.  We have to help the next generation.

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

What's Changing on College Campuses in Tennessee?

Earlier this year, three different bills were filed that would all increase the penalty for possessing fentanyl to a Class B felony.  One would accomplish this by reclassifying fentanyl as an agent of chemical warfare, though this bill was returned to the Clerk’s desk as two complementary pieces of legislation advanced.  Those bills, SB0193 and SB1398, the latter of which is known as the One Pill Will Kill Act, make a pretty straightforward change: they simply increase the penalty to a Class B felony without redefining fentanyl.  These bills were signed by Governor Lee on May 11th.  (For some quick drug policy trivia, this was the same day that he signed the cannabinoid regulation bill as well as the legislation adding the second wave of opioid settlements to the OAC trust fund).  

However, when these bills were passing through the legislature, we at SMART heard a lot of concerns about making fentanyl possession a felony.  Specifically, advocates wanted to know if this would lead to more Tennesseans winding up in prison with a lifelong felony charge on their record, just because they had a single pill.  

So my guest this month is Circuit Court Judge Duane Slone.  A strong advocate of drug recovery court and increasing access to medical treatment for addiction, we figured he would be able to give us a good insight into how these bills will impact Tennesseans.

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

Fentanyl Is Now A Felony In Tennessee

The Rocky Top Recovery Ambassadors are a group of college students, undergrad and grad, that identify as being in recovery and or having a mental health disorder.  Building a community on campus of students wanting a safer, sober college experience, the ambassadors hosted weekly all-recovery meetings and mental health events, as well as sober-friendly social events like group yoga, concerts, bounce house obstacle courses, and more.  They also partnered with TDMHSAS and the Regional Overdose Prevention Specialists to provide trainings on how to be a recovery ally, carry and administer naloxone, and more.  

My guests this month are two of the Ambassadors, Grace Hardin and Morgan Schmitz.  I wish I could have had on all of them, but there is only so much time to an episode.  As such, I strongly encourage you to check out the @rockytoprecovery instagram so you can see the reels the others have made, to get a deeper look into how the on-campus sober community is growing and thriving.  

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

The Kids Are Alright: Meet the Rocky Top Recovery Ambassadors

My guest this month is Karen Pershing, executive director of Metro Drug Coalition.  In the last legislative session, Karen played a significant role in pushing for a bill that reduced the barrier to opening new syringe service programs in rural Tennessee.  

In this episode, we discuss the impact of the bill, how it made it through the legislature, her behind-the-scenes role in the policymaking process, how young people can get more involved in the policy world in Tennessee, and more.

Produced and hosted by Jeremy Kourvelas.  Original music by Blind House.

Links:
SB 292/HB 275 - https://wapp.capitol.tn.gov/apps/BillInfo/Default.aspx?BillNumber=SB0292

SSPs in Tennessee - https://www.tn.gov/health/health-program-areas/std/std/syringe-services-program.html

Metro Drug Coalition - http://metrodrug.org

The SMART Initiative - http://smart.tennessee.edu

Are More Syringe Service Programs Coming To Rural Tennessee?

TEMPO, or Training and Empowering Musicians to Prevent Overdoses, is a multi-partner initiative to distribute naloxone and train musicians and concert venue workers to identify and prevent opioid overdoses.  TEMPO recently made waves in Nashville with a pilot program in partnership with Hikma, who makes Kloxxado, as well as ONEbox, to distribute high-tech overdose reversal first aid kits to music venues, and we at the SMART Initiative were impressed by their immediate results (they saved lives).  Just a week after we extended the program to Knoxville, another life was saved at a music venue.  

In this episode I interview both Dendy Jarrett, Executive Director of Gibson Gives, about TEMPO and this program, as well as the manager of the Knoxville venue where that life was saved.  Being a musician, a fan, or a venue employee in the age of fentanyl is unpredictable, and as a musician myself this project means a lot to me, personally.  You don’t want to miss this one. 

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

Learn more: 
tempomission.org

findthepurplebox.com

kloxxado.com

smart.tennessee.edu

Training and Empowering Musicians To Prevent Overdoses

If anyone has gotten a true bird’s eye view of the drug problem in the United States, it’s someone like Special Agent Karl Colder of the U.S. Drug Enforcement Administration.  From starting in Philadelphia when crack cocaine was the top concern to overseeing the region containing West Virginia and D.C. when the opioid crisis progressed from prescription pills to heroin and fentanyl, finally directing the entire department of internal affairs at the DEA, Special Agent Colder has seen the whole drug trade up close and personally.  In this conversation, he reflects on some of the changes and challenges experienced by law enforcement over the past thirty years.   

Now retired from the DEA, he works as a consultant, providing education and training to faith communities and law enforcement organizations on evidence-based practices relating to addiction and mental health intervention.  A big focus of his work centers around improving such resources for law enforcement and first responders.

Agent Colder has a lot of fascinating insights covering everything from the southern border to rural communities, from youth education to telehealth.  His structural and systemic perspectives on what’s happening with law enforcement are particularly interesting. 

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

How Law Enforcement Is Rethinking Mental Health And Addiction

In May, 2023, Governor Lee signed SB 378/HB 403, which imposed significant regulations on the production and sale of hemp-derived cannabinoids, including Delta-8, Delta-10, and all other compounds known as cannabimimetics, which have effects on the same neurological system as marijuana.  

Due to changes in the 2018 Farm Bill, these compounds abruptly became legal across the country, and many prevention advocates were saying that we had effectively legalized weed but worse, as many of these chemicals were being produced and sold without any oversight or restrictions, and kids could purchase these products just about anywhere.  

The bill that is the subject of our episode today sought to change that.  It goes into effect this July. 

My guest this month is Stephanie Strutner, CEO of the Prevention Alliance of Tennessee, which represents anti-drug coalitions across the state.  We dig into the weeds of what this bill does and doesn’t do, what its expected outcomes will be, and what cannabis-related law in Tennessee might look like in the future.  

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

Learn more:

The bill: 
https://wapp.capitol.tn.gov/apps/BillInfo/Default.aspx?BillNumber=SB0378&GA=113

Prevention Alliance of Tennessee: 
tncoalitions.org

SMART: 
smart.tennessee.edu

How Does Tennessee Regulate Cannabinoids?

When the CDC reports that almost 4,000 Tennesseans died of a drug overdose in 2023, it can be easy to forget that each one of those numbers represents a human being that was found deceased, investigated by law enforcement, and analyzed by a medical examiner.  Every death is an individual story, and each story is only known insofar as we have all the facts.  Determining the facts comes down to forensics.  And when it comes to the overdose crisis, with drug trends that are constantly changing, forensics is no simple game.  Especially when it comes to new drugs like xylazine, designer benzodiazepines, and rare fentanyl analogues.

My guest this month is Chris Thomas, the Chief Administration Officer of the Knox County Regional Forensic Center, which serves 23 counties in East Tennessee as one of the state’s five regional forensic centers.  From his bird’s eye view of the overdose crisis, he can tell us a lot about what’s happening on the ground, as well as where there are gaps in the system.

There are many valuable insights into the state of overdose forensics in Tennessee in this conversation, such as how medical examiners rarely get access to mental health records, or the proportion of traffic fatalities involving drugs, but the biggest takeaway for me was what the next wave of the drug crisis might be. 

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

Learn more:
Knox County Regional Forensic Center: https://www.knoxcounty.org/rfc/
SMART: https://smart.tennessee.edu

LISTEN HERE: https://open.spotify.com/show/5qbzONIr0hlWxiQsPwkXHM

Decoding Autopsies: What Medical Examiners See That Others Miss

There have been huge changes at the federal level regarding the prescribing of medications for opioid use disorder, particularly regarding buprenorphine.  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 most people with an opioid use disorder.  

Recent legislation, namely the Mainstreaming Addiction Treatment or MAT Act, got rid of the X waiver altogether.  This immediately granted every prescribing physician in the country with an active DEA license the ability to prescribe buprenorphine.  This bill passed with bipartisan support and was hailed as the right call from just about everyone across the board.  

But in the year 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.   

My guest this month is Dr. Stephen Loyd, chief medical officer of Cedar Recovery and Chair of the Tennessee Opioid Abatement Council.  In this conversation, we discuss what policy gaps remain, especially surrounding the issue of dose limits for buprenorphine, and the difficulties of treatment in the age of fentanyl.  

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

Learn more:
Cedar Recovery: https://www.cedarrecovery.com/ 
SMART: smart.tennessee.edu

The Buprenorphine Waiver is Gone...Now What?

As the drug overdose deaths continue to climb, we have heard more and more Sheriffs and law enforcement officers across the state say “we can’t arrest ourselves out of this problem.”  That the criminal justice system plays an important role, but not the only role.  That there are many, many factors in the overdose epidemic.  

My guest this month is Sergeant Mike Hotz of Metro Nashville Police Department.  After a long stint of time as an undercover officer, Sgt. Hotz now leads the overdose response unit, which combines law enforcement with mental health care and social work to people who have survived an overdose - instead of simply arresting them.  The latest service that they are developing is perhaps their most surprising: when appropriate, the team will start the individual on medication assisted treatment…on scene.  Sgt Hotz says the success of his team is due to MNPD’s community partners like the Mental Health Co-Op, but overall, because the team is willing and able to do whatever they can for the individual, beyond what just a solo officer is capable of.  

Hosted and produced by Jeremy Kourvelas.  Original music by Blind House.

Learn more:
MNPD’s Overdose Response Program (and Spike Alert info): https://www.nashville.gov/departments/health/drug-overdose-information
SMART: smart.tennessee.edu 

LISTEN HERE: https://open.spotify.com/show/5qbzONIr0hlWxiQsPwkXHM

Nashville’s Overdose Co-Response Unit Brings Harm Reduction to Law Enforcement

Naloxone.  Access to treatment.  Housing.  Employment.  Educational opportunities.  We’re used to hearing about the need for these aspects of recovery.  But what about community?  A place to gather with others, especially those with similar experiences?  That’s where recovery community centers come in.   

My first guest this month is Dottie Greene.  She’s the executive director of the first recovery community center in the 8 county region of northeast Tennessee.  Dr. Greene is a person in long term recovery and has been providing recovery support since the 80s.  As you might expect, she has seen the field of recovery change significantly in that time.   

Our second guest is Bettina Hoeppner, who has joined Dottie to talk about her academic research on recovery community centers, or RCCs.  Dr. Hoeppner is an experimental psychologist who focuses on substance use disorder, and she directs the Health Through Flourishing Research Program.  Her work on RCCs highlight how their unique natures make studying them as complex as launching them.  

In this episode, we discuss the ins and outs of recovery community centers and how they fill crucial gaps in the care continuum, as well as how attitudes towards recovery have changed dramatically over the last decade.  

Learn more:
Johnson City Recovery Center: www.jcrecoverycenter.org
Health Through Flourishing: www.healththroughflourishing.com  
SMART: www.smart.tennessee.edu 

LISTEN HERE: https://open.spotify.com/show/5qbzONIr0hlWxiQsPwkXHM

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