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.

What does "primary" prevention for SUD look like?

SMART Initiative

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