We have guest Dr. Lisa Najavits joining us this episode. Dr. Najavits is the author of several books on the topic of substance abuse including Seeking Safety, a treatment model we follow at Landmark Recovery. In this episode she’ll be talking with us about and her latest book “Finding Your Best Self”, which explores the connection between trauma and addiction. Following Dr. Najavits, we’re joined by Nancy Campbell, professor and Head of the Department of Science and Technology Studies at Rensselaer Polytechnic Institute. Nancy will be discussing her most recent book, OD: Naloxone and the Politics of Overdose.
Welcome to Recovery Radio by Landmark Recovery with your host, Zach Crouch. In this program we’ll discuss the root causes and treatments of alcohol and substance addiction, speak with experts in related fields, and help navigate the road to recovery.
Now, here’s the host of Recovery Radio, Zach Crouch.
Zach: Hi. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and don’t forget to subscribe to get the most up-to-date information from leading experts.
We have guest Dr. Lisa Najavits joining us today. Dr. Najavits is an adjunct professor at the University of Massachusetts Medical School and was on the faculty of Harvard Medical School for 25 years. She has served as president of the Society of Addiction Psychology of the American Psychological Association and is the author of over 190 professional publications.
She’s also the author of several books on the topic of substance abuse including Seeking Safety, a treatment model we follow at Landmark Recovery and her latest book Finding Your Best Self which explores the connection between trauma and addiction.
Thank you so much for coming on the show today, Dr. Najavits. I really appreciate it.
Dr. Najavits: I’m delighted to be here.
Zach: Tell me a bit about Seeking Safety. I know that we practice Seeking Safety at Landmark Recovery and of course you developed that model yourself. Can you briefly describe Seeking Safety and its purpose?
Dr. Najavits: Yes, certainly. Seeking Safety is a model that was designed to address those addiction and trauma at the same time from the start of treatment by any provider. I began developing that model in the early 1990’s based on a grant from the National Institute on Drug Abuse.
At that point, people in addiction treatment were rarely assessed for trauma and trauma was rarely addressed. To some extent that was for good reason because historically trauma treatments have focused on opening up the trauma story, telling the narrative, exploring the painful details.
The goal of Seeking Safety was to try to find a way to address trauma at the same time as addiction but without delving into that trauma story which can be too intense and too emotionally destabilizing for clients who are currently addicted or have other of the vulnerabilities that often occur with addiction such as homelessness or violence or suicidal feelings and so on.
I developed Seeking Safety as a way to try to work on both at the same time which is called integrated treatment. In the years since then, it’s been widely used for people who might have just one or just the other issues of people with addiction with no trauma even though that’s relatively uncommon. Those people with addiction do have some sort of trauma history or trauma history but no addiction.
Zach: Right
Dr. Najavits: The bottom-line is the title, Seeking Safety captures the goal. It’s trying to help people attain safety from unsafe behaviors such as addiction, self-harm and so on, from relationship problems, and from…so it’s cognitive, behavioral, interpersonal and there’s a heavy case-management component in helping refer clients into additional services because we certainly know the more treatment the better when people struggle with these.
It basically has 25 different topics. The topics are things like creating meaning, compassion, recovery thinking, setting boundaries in relationship, honesty, taking good care of yourself and so on so very practical skills, applies both to addiction and trauma, but also help people address and learn about the connection between trauma and addiction.
Zach: Excellent. A lot of this is present-oriented to your point, correct?
Dr. Najavits: Yes, very glad you mentioned that, Zach. It’s present-focused so we’re not going into that past narrative of trauma but we’re focusing right on the present. What’s going on right now in your life? How can you learn to be more safe?
It’s also very much designed as an empowerment model, not telling people there’s one way to do it. We certainly know clients who struggle with trauma and addiction there are many, many different stories and pathways into treatment and sobriety levels and contacts of their lives so basically they’re offered a wide variety of strategies in the present to try to cope with trauma.
Zach: Fantastic. I think last thing on the topic of your model here, I know that there has been quite a few studies done with Seeking Safety, correct?
Dr. Najavits: Yes. It’s definitely an evidence-based model meaning that there have been studies of it and a wide variety of studies. That includes pilot studies meaning small initial trials with various populations. It includes randomized control trials which are the gold standard as it’s often said sort of a higher-level of scientific testing and then what are called effectiveness studies meaning using it out in the world with large numbers of counselors and large numbers of people and just seeing how does it play in the real world.
I’m also happy to say that due to colleagues in various different countries that’s been translated now into 13 different languages and it can also be done by peers. It doesn’t require a professional because it is present-focused and coping skills-oriented.
Zach: That’s fantastic. It helps out tremendously I’m sure with cutting down on costs, too. Go ahead.
Dr. Najavits: Yes, exactly. I appreciate what you just said. That’s exactly right. Peers now are considered for so many reasons such as cost, also what they bring to the work in terms of their own experience or ability to relate and connect with people in recovery. Yes, peer-led is so important at this era.
Zach: Fantastic. Let’s dive into your new book Finding Your Best Self: Recovery from Addiction, Trauma or Both and you explain the link between addiction and trauma. Can you tell us a bit more about what inspired you to write it?
Dr. Najavits: Yes, definitely. In the context of my work which now over several decades has meant really seeing up close on so many levels the impact of trauma and addiction, I really became sensitive to the idea that there are many people and really perhaps most people who struggle with trauma and addiction who will never end up in professional care for various reasons — resources, fear, access, location and so on.
I always had wanted to do a self-help book because it just provides one way that just gives another resource where people can maybe access some help especially if they can’t access professional help, but even if they can just the more the better. It definitely wants to be in the know. There’s no one model that will work with everything and letting people try out a variety of things.
That actually fits the spirit of the book because I wrote it as 35 short chapters. Each chapter is just a couple of pages. There are sort of quotations to kind of inspire, move into a bit of education and then has exercises and ends, and this is my favorite part of the book — each chapter ends with recovery voices which is a statement where a person who himself is in recovery talks about how that chapter relates to their own recovery work.
The 35 chapters have all kinds of different themes and people can move in and out of it in any way they choose. They don’t have to go in order, but it’s just trying to sort of captivate or engage people in going into recovery and maintaining it.
Zach: Yes, I appreciate that especially the pieces at the end there. I was just sort of briefly looking online in one of the chapters and it was entitled Things Turn Out Okay. It was about a gentleman named David and his experience. In his experience, I think he speaks to many people’s experience. I think it provides some hope.
Dr. Najavits: Beautifully said. That’s exactly it. I have to say I am so appreciative of David and the other people who also contributed their sections. I think it brings it alive. There’s a way in which you’re hearing it directly from people who have lived it so closely. It’s poignant and I think it really does build hope.
Zach: The exercises that are in your book, how would you compare them to exercises seen like I know there are obviously people in 12-Step Recovery and they have these steps to work? How could something like the exercises in your book complement people who are in the recovery process and have had trauma in their past as they work through even the steps?
Dr. Najavits: Yes, definitely. I am of course like hundreds of millions of other people I’m a huge supporter and admirer of 12-Step and all other kinds of self-help, anything that helps people move forward. It’s certainly an amazing movement and you said the words exactly. It can be complementary. It can be an adjunct to the work that they’re doing.
In terms of the specific exercises, the exercises really do go into a wide variety of aspects so I’ll just give a couple of examples. One of them for example is called the Scavenger Hunt Game. It’s designed to help educate. I always love games so it’s sort of a game-like format.
It can be done in groups. The model can be done as self-help, but it can also be done in clinical settings or by family members or sponsors from AA or family or friends or anyone else. Essentially this kind of exercise can be done in groups or it can be done individually or people on their own or with a counselor.
Basically that exercise gives a wide variety of terms that are used in the addiction field and then it has a separate section on terms used in the trauma field. It encourages people to kind of make a bit of a game about learning some of these key themes. For example in addiction, what is the abstinence violation effect, what is harm reduction, what does dry but not sober mean? In trauma, what is dissociation, what is splitting, what is betrayal trauma and so on?
That’s just one example but every one of the chapters has something that’s designed to kind of give some new angle.
Zach: Sure.
Dr. Najavits: In brief to come back to your question, I think it complements 12-Step because it’s pulling in the trauma just very explicitly and really giving language to it, giving people ways to move into that, but in ways like Seeking Safety that stay safe, that don’t delve into the painful trauma narrative.
Zach: Thank you. Who is the, would you say the target audiences for your book Finding Your Best Self?
Dr. Najavits: Yes. One thing we know is that because there, as I said earlier there are so many different pathways by which people engage in trying to get help; some of them do come through 12-Step, some of them go to primary care or medical settings, some go to homeless shelters or domestic violence programs and so on. There are so many different avenues.
My idea was to try to keep it as broad as possible meaning anyone in any setting can do this book on their own so it can be done as self-help, but it can also be done, as we said by counselors, by peer support workers or by anyone in that person’s life who is trying to help someone who’s struggling with trauma or addiction. It has a chapter that’s designed for family and friends. It has a chapter that’s designed for counselors.
It’s trying to kind of target those various different levels because we never know and this is part of the magic of recovery I think the real beauty of it we never know on the front-end who’s going to get the message from where and from what source. I think it’s just really respecting, if you will the grace of that moment can happen with anyone, with any person.
Zach: Yes. I just want to come back to something that you mentioned at the beginning of our conversation today about trauma treatment and one of the big reasons we didn’t teach it or use it in addictions treatment for a long time is we don’t want to open up those wounds and go deep into the narrative. Do you think at this point, we’re the year 2020 are we still early on in our understanding of being able to treat trauma?
Dr. Najavits: That’s a very interesting question. My best answer is yes and no. Basically it’s certainly still is early, no question. There are many different models out there. There continue to be a lot of clinical trials. There continue to be a lot of surprises with clinical trials and I’ll give you an example of that in a moment.
Certainly the clinical experience out there now because of in large part the movement what’s called Trauma-Informed Care which is a development where the idea is trauma is so pervasive that the idea is to address trauma no matter where, what setting, and context people are in. That’s been a great movement.
That being said, there’s been some really positive developments, but there still is a long way to go. There’s still a lot we don’t know about how to create sustained recovery from both, how these issues impact and how you can address physical health, certainly this stemmed from important work showing the impact on physical as well as emotional health, how to identify workforce characteristics to help give people the best shot at doing small and supportive help for people. There are a gazillion questions.
Just to go back to one example of one of the surprises in the field is that there often had been this sense of “We’re not going to have the person delve into the trauma narrative.” That’s sometimes called Past-focused Trauma Treatment or sometimes it’s called Gold Standard PTSD Treatment, PTSD being Post-Traumatic Stress Disorder which is sort of arises from trauma.
At any rate, for a long time it was said, “Maybe this addicted person at the beginning they need present-focused coping skills but then eventually they will definitely need to delve into that past story, that if you don’t get it out, if you don’t purge that story, if you don’t say it you cannot really fully recover.” I think one of the big surprises is that you can.
I say this with all respect because I think there are so many people benefit from all sorts of treatment, but recent research for example has shown that those sort of past-focused models like Exposure Therapy or Eye Movement Desensitization Reprocessing, EMDR, gold standard evidence-based models widely used and so on, sometimes various trials have now shown that other methods can work equally well, whether that’s body-based methods, meditation, yoga, things like that, other sort of present-focused methods.
I think there’s always new learning of course and there’s still a long way to go.
Zach: It sounds like there’s promising results though in those studies that you just mentioned.
Dr. Najavits: Yes. I think in the end, you’re exactly right. In the end, what it seems to show is that there are many different ways to heal. It goes back to the famous phrase in recovery which is “Many roads one journey.” I think that’s the idea — picking the method that work for a particular person with whoever they’re doing the work with, etc.
Zach: Thank you. You’re currently recreating for a study on grounding right now that focuses on adults ages 18 to 25 who struggle with substance abuse. Tell us a bit more about this study and more specifically, what is grounding anyway?
Dr. Najavits: Absolutely, happy to talk about that. I’ll mention that grounding is, and I’ve heard from so many people they say it is one of the most important skills they have learned in recovery and especially in early recovery. The idea of grounding is to help reduce any intense negative emotion or impulse or craving. It’s basically any sort of negative experience like that, whether it’s rage or sadness that they don’t want to feel at that moment or fear or so on. They can bring it down.
Grounding is basically a way of using their senses and using a lot of simple questions that anyone can do. Children can do it; really any age can do it. Typically as part of Seeking Safety for example, we have the 25 Coping Skill topic. It’s called grounding and we teach people how to do it. We use an out-loud script and we do questions. We have them experience it and then once they learn it they can do it no matter where they are.
If they’re driving to their work and they can use grounding as a way to calm themselves, bring themselves down or maybe they’re triggered from trauma or addiction craving whatever it may be. Basically I have learned that many years ago when I was a psychology intern in a psychiatric hospital and they used grounding all the time with these really severely struggling people who were constantly dealing with these intense emotions and impulses. Basically grounding is a way to bring down these feelings.
The project itself is designed to give a way for people to learn it without needing to learn it from a counselor or from some other person because as we said earlier, the majority of people with addiction, with trauma do not end up in professional care or even necessarily peer-led help.
The app is designed to help people learn it. It has an idea feature but it teaches some grounding. It helps them practice it. It creates some social engagement. They can connect with other people to do grounding. On the app, it has various what’s called gameification elements meaning game-like elements. They earn what we call ‘calm coins’. They level up.
There are videos. They can meet up with, by cellphone of course with a coping coach who can help them with their grounding. It has something called geo-sensing meaning that if there’s an area that’s a trigger location for them maybe where they’re dealer is or so on, they can get a GPS-based warning when they’re approaching that location, just a wide variety of elements.
The study we’re doing is basically for young adults, ages 18 to 25 who have a substance abuse problem and if they fill out a form online they can be assessed for eligibility for our project. If they’re eligible they then can earn assessments reimbursement. Basically they can earn up to $110 in Amazon e-gift cards or complete an assessment and they get the phone app for free.
Zach: In terms of your study, are you seeking out a certain number of people for your study?
Dr. Najavits: Yes. We’ve actually been recruiting now for a couple of months. At this point, we’re looking for another 40 people. The study is funded by the National Institute of Health in the US. The study is basically looking at how well does this app do compared to what we call the control app which has information on grounding and have all these elements. We still do need some people for it and then in the next couple of years we have several other projects where we’re recruiting people.
In fact, our next study which will start in the fall is going to be on Peer-led Seeking Safety using an app, a different app meaning a mobile phone support method.
Zach: Right. I’m curious to know why you chose to focus on adults ages 18 to 25. I’m curious to hear why that demographic.
Dr. Najavits: Yes, definitely. A couple of reasons, one of them is it’s a prime time developmentally for addiction so we’re trying to capture people who may be heading down that road or already struggling with it and need some help so that it doesn’t go on for years and decades so we’re trying to help while they’re young.
The other thing is it’s a prime age for using mobile phones. We certainly know people in that age group love their phones and we figured this is a great way to reach them.
Zach: Fantastic. In the app that you’re talking about, is that something that’s currently open to the public or will it be open to the public in the future?
Dr. Najavits: Yes, it will definitely be open to the public in the future. It isn’t yet because we first need to wrap up the study, continue to collect data, get the results, publish the results. It definitely will be available and I’m estimating certainly latest by the end of this calendar year, by the end of 2020.
Zach: Got it. What are you hoping the results of this study will show?
Dr. Najavits: Yes. I always think with research all data tells a story in the end. No matter what that story is it’s informative. There’s something to learn from it. My main hope is just that we really value collecting good quality data to really also learn from the people who were using the app.
In fact, we’ve had and continue to have segments of interviews that we do with them to find out how we did in the front-end, what did they want to see in the app. We’ve done it at various points along the way after they used the app and so on. We certainly want to hear from in their own words what is their experience as they’re using it and what can we tweak and improve.
In terms of the actual clinical trial or the heavy-duty scientific numbers side of it, we’re just interested in learning does it help reduce substance use. The hypothesis is that it would, that helping people learn a skill like this can help them reduce substance use. In the end, whatever we find out it will be I think a contribution to better understanding.
Zach: Before you started the study, did you do a lot of research on apps that are already currently being used right now and that kind of helped you discern what you wanted to put into the app that you’ve developed?
Dr. Najavits: Definitely, yes. We’ve actually repeated that process at several points because this kind of project can go on for a few years and of course the landscape is always changing so yes, definitely a lot of looking at what’s out there. There certainly are a huge number of apps that can be so helpful for people. Here again there’s no one method. It’s really people choosing what works for them.
One thing I will say is that grounding is sometimes confused with methods like meditation or mindfulness or relaxation. I think that’s worth highlighting for a moment because mindfulness, meditation, all of those methods can be wonderful. They’re certainly hugely popular and for various reasons, but they weren’t specifically designed and really in some context really do not address people who are at an intense state of such negative emotion that they could be acting on their impulses.
Someone who’s about to hit a wall for example, enough to punch a wall, someone who’s that enraged and you say, “Meditate. Relax. Be mindful.” It doesn’t target where they’re at. Grounding was designed for those really high intensity moments. We certainly know with trauma and addiction that high intensity triggered moments happen and happen all too frequently. Grounding is a psychiatric technique rather than sort one of these more general methods that can be helpful in all kinds of other context.
I just mention that in part because there certainly are a life-ready that’s out there that are designed to help people calm and learn how to access these sort of safe places and things like that. Beautiful, beautiful work, but just to be clear it’s not the same as grounding.
The other thing about grounding is I think or in terms of apps themselves is what is the evidence base. There are many apps out there; most apps don’t have an evidence base. One thing I always appreciate with these grants from the National Institute of Health is that it does allow for testing. Is this app actually helping reduce substance use or not? Are there other symptoms it’s helping with? We can really look at questions like that.
Zach: I’m curious to know just in terms of the technique of grounding. If I were interested in learning more about it, where would you point me towards and our listeners for that matter towards to find out a little bit more about how to practice it?
Dr. Najavits: Yes, definitely. One resource that pops right into mind is one that’s right on our website. If someone Googles Seeking Safety for example, they’ll come to our website. I’ll just mention that if they want to take the screening for the grounding study or we have several other studies that will be active within a few months they can click Join Our Studies, but if they want to actually get a two-page version of grounding one place to do that is to click on our section Training on our website and then go to Materials and then Handouts.
There in the middle of what we call the Basic Handouts there is a resource called Grounding. It’s a two-page version of what’s from the Seeking Safety book. That’s one way. There are also some other resources there right in that Basic Handouts. More generally, I’ll just say that uses the method of grounding in Seeking Safety which actually talks about three different types of grounding — mental, physical, and soothing.
Another way, just very simply is someone can just Google grounding, what is grounding or how to do grounding. There are certainly some wonderful resources.
One of my favorite resources that I’ll mention is what’s called SAMHSA, the Substance Abuse Mental Health Services Administration which is the major federal agency that’s involved in trying to promote public health, to help people with addictions and trauma. They have something called TIP 57.
Someone just Googles Tip 57, T-I-P and the number 5-7, what they’ll come upon is something called, TIP stands for Treatment Improvement Protocol and 57 just means it’s number 57 in the series, but it’s basically designed to address trauma in any setting meaning addiction, mental health and so on. In that TIP, there are actually quite a few resources including something on grounding.
That resource is especially useful for counselors or peer support workers who are trying to help others, but even for individuals who are looking for some guidance and help. It’s free. It’s downloadable. It’s right there.
Zach: Fantastic. I think that we’ve covered a whole lot here today. I’m really, really excited for your book and for our folks listening to check that out. You can check out Dr. Najavits’ Seeking Safety, Finding Your Best Help and here newest study online at treatment-innovations.org. That’s treatment-innovations.org. Dr. Najavits, thank you for coming on today. I really appreciate your time.
Dr. Najavits: Zach, thank you. I really appreciate what you’re doing, what this podcast series and also your questions have been spot on. Good luck with all the future work you’re doing.
Zach: Thank you.
Zach: You’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and don’t forget to subscribe to get the most up-to-date information from leading experts.
We have guest Nancy Campbell joining us on the show today. Nancy is a professor and Head of the Department of Science and Technology Studies at Rensselaer Polytechnic Institute. She is also a historian of science and medicine who focuses on addiction research, drug treatment, drug policy, and drug-using subcultures.
Campbell is the author of many books including her most recent that was published in the MIT Press, OD: Naloxone and the Politics of Overdose which we will be discussing today.
Nancy, it is a pleasure to have you on the show.
Nancy: I’m really happy to be here, Zach.
Zach: Can you tell us a little bit about your background and how you got into studying the science and history of addiction?
Nancy: Sure. I grew up in Pennsylvania in a small town where I was very interested with drugs and medicines. Both my father and grandfather were doctors. Even as a child I got to observe how drug addicts were treated or people who were referred to as drug addicts. I became very curious about why it was that they were stigmatized and marginalized in ways that we do stigmatize and marginalize them.
As a child, I often observed people whose behaviors were pretty extreme so I became curious about what it was that was driving that kind of behavior. When I went to graduate school many, many years later, I got curious about drug policy and it was during the crack cocaine epidemic. I found it really an interesting set of questions about why we criminalize.
Zach: This was sort of in the 1980’s, correct somewhere in there I guess?
Nancy: Yes, yes. I began thinking about this in the 1980’s. I actually lived in Northern California at the time and there was kind of a paramilitary drug war going on over helicopters and automatic weaponry up in the hills. I was really interested in how the drug war could mean so many things, both this paramilitary kind of thing, the concern about urban crack cocaine use. I began to look into it and I got interested in the history of drug policy and drug science.
Zach: I want to come back to a couple of things you brought up. You said that your father and I believe your grandfather were both doctors. You became interested in how you saw drug addicts being treated back then. Can you explain a little bit about that and how that interested you at the time?
Nancy: Right. When I was in elementary school I lived in Philadelphia where…was kind of hooked up with the Nixon administration trying to really, I don’t know solve the problem of Vietnam veterans returning with heroin addiction problems. It’s always very visible in Philadelphia even to a child.
We would go towards the police station, for instance and we would be shown suitcases of drugs. I thought it was really interesting that all the grownups were really fascinated by drugs even when they were really clearly against them. There was also always this kind of pull towards them. When we moved to the small town in Central Pennsylvania, in a way those attitudes and those observations came with me.
That town was very concerned at that time about PCP and about speed and about other kinds of substances. I just got very interested for some reason. It always seems very compelling because on the one hand my father and grandfather were prescribing drugs, the good drugs to supposedly good people and on the other hand there were clearly people who were using drugs who were referred to as bad people that have character flaws.
Even then, even in the 1970’s we still heard that kind of idea that addiction is a result of moral weakness. I got really interested in people who were trying to contest that and saying, “That was a scientific problem. It’s probably a problem having to do with the brain or with the central nervous system.”
I ended up writing my dissertation and several books about a group of scientists who contested the idea that people became addicted because of character flaws or moral weakness. That became my…something that I’ve just always been extremely interested in.
Zach: You mentioned during the 1980’s you had studied crack cocaine. I’d like to hear your thoughts just because I think that the rhetoric around that particular substance has been relegated to the African-American population meaning that I think that there’s been some falsehood around that particular drug being primarily used by African-Americans. Can you clear any of that up?
Nancy: Yes. That was actually, that falsehood was specifically the thing that really galvanized me. My first book was called Using Women, Gender, Drug Policies, Social Justice and the chapter within that that was about pregnant crack cocaine usually African-American women helped to make the point that there was a real panic.
There was a real rush to judgement about crack cocaine and particularly urban African-American use of it because whenever studies were done during that time, white people were just as involved and in fact more involved in crack cocaine use at that time, but the laws and the policies were really targeted towards the African-American population.
It was a really clear instance of the way in which drug policy operates differently according to race. The surveillance of African-Americans especially pregnant women for crack cocaine use was just so intense.
Zach: Appreciate that. I want to talk a little bit, too about your most recent publication, OD: Naloxone and the Politics of Overdose. In your book, you talk about how naloxone moved from operating rooms into the hands of harm reduction activists. Can you talk a little bit about that transition?
Nancy: Yes. The question I started with naloxone, I had written a history of buprenorphine or Suboxone and I got curious. A harm reduction activist came to me and said, “Why don’t you write about naloxone? Why don’t you write about naloxone because what’s going on in the activist community around harm reduction is that we are trying to distribute naloxone to people who are highly likely to witness an overdose?”
I thought that was really interesting because here’s naloxone, a prescription-only drug. It’s an old drug. It’s been around. It was synthesized in the 1960’s, early 1960’s. It was approved by the FDA for opioid reversal, for reversing overdoses in 1971. That’s almost 50 years ago. My first question was that. Why did it take so long for somebody to think, “Let’s give naloxone to people who could use it to save a life in an emergency situation?”
When I looked into that question, I found a number of interesting things, but one of which is that naloxone is very common in operating rooms because anesthesiologists overdose people all the time and they need naloxone to draw them back from that and also an emergency medicine.
Emergency medicine is pretty young in this country. Late 1960’s or early 1970’s you start beginning to have paramedics and emergency medical technicians and you’d see nalorphene which is the predecessor of naloxone and naloxone in emergency medicine.
You begin to see naloxone is obviously used if an ambulance is called and if people get there in time and of course there are a lot of laws at that time that made it really a deterrent for people to call the ambulance if there was an overdose situation. I was interested in that.
How does naloxone leave emergency medicine and the operating room and why did it take decades, really decades because not until the really late 1990’s that you begin to see activists saying, “Let’s give naloxone out. Let’s make sure that people who are likely to be in a situation where there might be an overdose have naloxone on hand and know how to use it.”
Zach: Yes. I’m curious as well just around your thoughts on and I bring this up again how do you challenge or maybe even educate people around because there’s this rhetoric that goes around I think certainly in the Kentucky area I’ve heard it from various people that when we give these kits out, these naloxone kits, I have one in my car as a matter of fact that we’re somehow giving opioid abusers free rein into use as much opiates as they particularly want?
Nancy: Right. My book is about the US as well as the UK. In both of those places, activists and advocates really because in the UK they haven’t had to have such an activist slant for harm reduction because it’s kind of infused into the National Health Service. They have had to figure out how to do studies to contest that very idea, the idea that “Yes, people have naloxone. They now use more or more dangerously.”
There have been many, many studies actually designed to show that that’s not the case, that people don’t in fact view naloxone…you hear the same rhetoric around seatbelts or motorcycle helmets. If people have safety gear then maybe they’ll behave in a more risky way. Naloxone falls into that category. It’s very similar. Do you drive faster or in a more risky way because you’re wearing a seatbelt? Probably not anymore.
In other words, there may be an initial effect when something is put into place, but that very quickly recedes and it becomes kind of normal behavior. What people have tried to do with naloxone is try to make sure that having naloxone is kind of normal behavior. It’s something that you would typically have on your in your car or in your medicine cabinet as a matter of course somewhat like an EpiPen.
Now fewer people die of anaphylactic shock every year than opioid overdose every year and yet we don’t question people having EpiPens and carrying an EpiPen around with you wherever you go. In fact we even get concerned if EpiPens become too expensive and we feel like people might not have the kind of access that they need to for EpiPen.
Naloxone is in a lot of ways like that or it’s also like these automatic defibrillators that we see. They’re almost like wallpaper now. If you’re in an airport, of course now with COVID-19 we’re not in an airport so often but you know you see them all the time on the wall these defibrillators everywhere. People are saying naloxone should probably be somewhat more like that as it has become apparent, but so many more people are using both pharmaceutical opioids and illegal or illicit pharmaceutical opioids.
You begin to see if you have way more opioid users then you probably should have more naloxone on hand and more accessible, but that’s probably not really going to change people’s behavior. It’s a really interesting question to me. Why there’s been such opposition to naloxone as opposed to opposition to, I don’t know snake bite kits or EpiPens?
Zach: I think it kind of goes back in a lot of ways to our discussion prior to jumping on the podcast where we were discussing prior to this podcast about how I think that there’s still a lack of education on the science behind addiction so that people really do have a thick description of what addiction really encompasses. It is not a matter of character. If I just had enough character I wouldn’t use.
Nancy: Yes, exactly.
Zach: People I think have that idea and don’t get me wrong, they’ve been burnt. They’ve been hurt. They’ve been use-your-favorite-descriptor about anybody that you’ve been involved with who’s in your life that’s been addicted, using substances actively and there’s been a lot of consequences — financial, emotional, whatever it looks like, physical even. I think it’s a shift in people’s mindset that hasn’t happened.
Nancy: Yes, exactly, exactly. I think naloxone is a really interesting indicator of that. Sometimes the people who train others to use naloxone will go into a long description of the brain receptors and the way in which opioids kind of grab on to the receptors and naloxone comes along and knocks them off because naloxone has a stronger affinity for the receptors.
It’s really interesting to me. I’ve studied throughout my career as a historian I’ve studied brain-based models of addiction and they were older models of addiction in the brain even before the 1990’s, kind of courting the neuroscientists to bring them in to make sure that addiction is seen as a matter of neuroscience.
Brain-based models are interesting because they were pioneered by the group of scientists who I studied in order to contest the idea that addiction is simply a moral character flaw. Those scientists really felt that the idea that addiction was a moral flaw or a moral weakness was really problematic. They really saw this as an ideology, a 19th century kind of ideology; ironic because in the 19th century there were ideas about addiction as a matter of the brain.
These folks, the reason they put forward a model of addiction as a chronic relapsing brain-related condition was because they wanted to say, “People, it’s not a moral flaw and will alone is not going to be enough in order for people to overcome their addictions.” They were very interested in a cure although from the 1920’s on they were chasing a cure and they had begun to realize by the 1950’s or so that a cure was not going to be forthcoming and that they’d better figure out something else.
They better figure out were there medications that you could put someone on that would help them guard against relapse or are there other kinds of support like Addicts Anonymous or what became Narcotics Anonymous later. People were inventing therapeutic modalities and trying to understand, trying to get modalities that worked with the science rather than against it.
Zach: I don’t want to get too far off topic here, but we brought up earlier that the idea of harm reduction and we have quite a few needle exchange programs in our city. I think that they’ve been a game-changer for people. It’s helped with stopping the spread of disease. It’s helped people get an entrance into the treatment process. Talk to me a little bit, too about your experience or research or knowledge of injection sites. Are those becoming more popular and do you think that those are an effective way for people to get help or inject safely?
Nancy: Yes, yes, definitely. A lot of the people both the advocates and the activists who I interviewed for the book, for OD are now working on safe injection sites and getting them implemented. This movement that I write about in which naloxone is really a technology that they use to create a kind of social solidarity around naloxone, that movement grew out of the movement around HIV-AIDS, in response to HIV.
This is really the history of harm reduction as an international but also within the United States kind of movement. It grew out of needle exchange. People are thinking about needle exchange as a way to reduce transmission, as a way to reduce harm and actually needle exchange came about first for hepatitis-C, the European version.
The needle exchange came about first in response to hepatitis-C and then when HIV came along and people realized what they could do with needle exchange to cut transmission ways that where that movement went.
Actually the overdose epidemic, overdose death epidemic that we’re now in began and was kind of undetected at first because HIV-AIDS masked it. People began to study heroin injectors in San Francisco who were young. They were beginning to realize that people were dying of overdose before they were dying of HIV.
Harm reductionists began to focus on overdose and began to collect information about how much overdose was occurring and where it occurred and among what population it occurred. What’s truly interesting is that many cities did not track overdose deaths.
I write in the book about overdoses in the 19th century. In the 19th century, there was a lot of opioid use although the main users of opioids in those days were white women and they were not thought to be a dangerous class. There wasn’t nearly as much concern about them. After the criminalization in the Harrison Act of 1914, you began to see many more.
At first it was white men, older white men who began to see these problems among and then after World War II you begin to see this racialization in particularly African-American and Puerto Rican communities on the East Coast and then also later then on the West. There’s a kind of progression of populations that we think to always go through and this concern with overdose in the 1990’s that it emerges among youth.
Once we begin tracking that better, we begin to see there’s more of this and there also begin to be other kinds of issues that intersect with opioid use – so-called depths of despair and so forth. We begin to see a lot of population change in who is dying and when and where and how they are dying of overdose. The activists were part of that in the sense that they understood because they were working off and around needle exchange.
They understood, “Something’s happening here. Overdose deaths are rising. Let’s do something different. What else can we do?” They begin to turn to naloxone and in particular the Chicago Recovery Alliance. There was a guy there named Dan Bigg who unfortunately he’s deceased who really put it together that naloxone was a key in a way that giving naloxone out to people communicated more than simply having a narcotic antagonist on hand.
It also communicates something about we actually care about you. We actually recognize that you are a human being. They started using the term ‘any positive change’ for the meaning of recovery. They started to talk about harm reduction practices and any positive change.
There began to be a kind of convergence around recovery and harm reduction and I write a lot about that in the book about that process and the way in which harm reduction and recovery are no longer…by the time the book finishes and it took me seven years to write this book, Zach.
Zach: Wow.
Nancy: By the time I get done, there’s a new world out there where there’s a real convergence between harm reduction and recovery and people recognize that you’ve got to have both and that each is intertwined with the other.
Zach: Talk to us a little bit, too, Nancy about the politics, the ethics, the politics in, I guess behind the social justice questions that are written in current drug policy as an example.
Nancy: Yes. As you know, there’s a lot of politics around should we have a public health approach or should we criminalize, should we medical-ize, what forms of treatment really work. There’s the politics of what’s an evidence-based treatment. I’ve written a lot about that particular politics because I think it’s very interesting and it’s very interesting in your state.
Zach: Is that all shared in this book, the politics, as you said about an evidence-based treatment?
Nancy: Right. In the book, yes there is because I think the politics of what counts as an evidence-based treatment it’s a real politics and there’s also the role of the pharmaceutical industry in deciding that because many of these products including treatment products like methadone or buprenorphine are products of the pharmaceutical industry. Naloxone itself is you have to have morphine base to make naloxone and really to make any of the opioids that are on the market except for fentanyl which is entirely synthetic.
You have actors who like the pharmaceutical industry who are going to want to get their drug approved or that their drug paid for on Medicaid or their form of treatment. This is a thicket of politics and it always has been. It has been for a very long time. We brought methadone back from the Germans at the end of World War II.
Zach: Right.
Nancy: The politics of methadone…
Zach: It was actually called Dolophine I believe.
Nancy: Yes, yes, exactly. There were doctors who even put people on to Dolophine or what we would now call methadone even before the mid-1960’s when Vincent Dolamarie Nice wandered in New York City began to say, “You can maintain people on this. This can be therapeutic. It can help reduce crime. It can help people kind of regularize their lives.”
Zach: Nancy, did Rockefeller have some say in implementing that? Was he behind a lot of that?
Nancy: Oh, wow. I could talk about that all day. Some would say Rockefeller…in 1973 you have the infamous Rockefeller Laws which are not just for New York State and which really heavily, harshly sentenced and heavily criminalized, but many states imitated the Rockefeller Laws.
What’s really interesting about Rockefeller is that in the years leading up to 1973 when the Rockefeller Laws went into effect and were responsible for fuelling mass incarceration, before that Rockefeller had something called the Narcotic Addict Control Commission. That was more like we should treat people. We should commit them civilly to these…they were kind of jails but they were for people who were addicted.
They were not supposed to be jailed. They were not supposed to be barred. They were a little bit like the Narcotic Farm. Rockefeller had an attitude that rehabilitation was actually really important for the State of New York because that was the epicenter at the time of opioid use in the country. Rockefeller tried that and then became so frustrated. The story is he became so frustrated that then these really harsh draconian Rockefeller Laws are put into place in 1973.
Zach: If I remember correctly, Nancy it was something along the lines it was indeterminate lockup meaning that they would be locked up for an indeterminate amount of time.
Nancy: Yes. It was actually modeled on mental health. It’s not something that one could advocate from a civil rights standpoint or even from a human rights standpoint, but what’s interesting about it is that it seems still to me like both that approach, the first civil commitment approach and the Rockefeller Laws approach were bad for people who used drugs. Both of them messed people’s lives and families up pretty severely.
Zach: I know you mentioned Kentucky a minute ago. I know that you’ve written about the history of naloxone and how that is tied to Kentucky specifically. How did Kentucky play a role in the use of nalorphene?
Nancy: Right. All of the science that we had about opioids, the world’s only dedicated laboratory to the study of opioid addiction was in Kentucky from basically 1935 to the late 1960’s when there began to be more interest outside in other laboratories as well. The Addiction Research Center which was at the Narcotic Farm, the US Public Health Service Narcotic Farm which is about six miles outside of Lexington, Kentucky was the world’s only laboratory dedicated to that.
That laboratory was congressionally-mandated. The US Congress when the Narcotic Farm enabling legislation was passed in early 1929, the US Congress said, “You will find a cure. You will have a laboratory in the Narcotic Farm that studies drug addiction and tries to find a cure for it.” They were really helpful in early 1929 before the market crashed. That could be done and the Narcotic Farm was built. It opened in 1935.
There was a laboratory and they did what were called re-addiction studies. They took people who had failed the treatment, who had no intention of stopping opioid use and who said they would volunteer for these studies. They’re small studies. Usually there were about six people in the early years. They basically put them through re-addiction and then withdrawal so that they can study what happens to them scientifically.
All of our scientific knowledge about human drug opioid addiction comes from that time, comes from that place, comes from Kentucky. It’s really interesting how that whole science kind of grows up and over the next decades they begin to realize a cure is not going to be easy to find. They begin to realize that messing around with the morphine molecule and trying to make it so that it keeps its pain-killing properties but doesn’t have dependence-producing potential that that’s scientifically extremely tricky.
They have a lot of difficulty. They tried a lot of different routes. They’re pretty resourceful, pretty interesting scientists. They’re very interested in drug addiction and in what addicts go through. They would call them addicts, not people with addictions. They believed that they treat them much more humanely actually than they’re treated in jails and prisons throughout the rest of the country. They really see them as not that different from themselves.
They in a sense humanized and they also tried to make the point that this is not a moral problem. This is not a weakness of any kind. This is a neurophysiological condition. They don’t always use the term disease but they see it as, “If you take anyone and you expose them to an opioid at this dosage level on this time schedule they will become addicted.” That process was really important.
One of the things, I am getting to answer your question; one of the things that was also important was that they would do clinical trials on methadone. When methadone came to this country after World War II, the large clinical trials of methadone were done at Lexington because the people there knew how to do trials of that kind with opioids specifically and also the subject, the volunteers for those studies had a considerable experience with opioids outside of the institution and they knew what they were signing up for.
In these large studies of methadone, there were a couple of people who overdosed. Merck, the pharmaceutical company Merck had a product called nalorphene which was known…it was the first narcotic antagonist.
Zach: Okay.
Nancy: Naloxone is a narcotic antagonist and so was nalorphene. Naloxone wasn’t invented yet but nalorphene when these overdoses occurred in the middle of this trial, I read about this in the book the scientists thought, “You know what? These guys are going to die. If we don’t do something,” because they tried everything that they knew how to do, “let’s try this narcotic antagonist because pharmacologically it should work.”
They tried it. It did work. It reversed the overdose. The people who had overdosed there were two of them and they were both African-Americans. They overdosed from cumulative doses of methadone. There’s even a photograph published in a scientific journal of the before and after. The photograph is the guy in the overdose situation said to be turning blue, cyanotic and then the guy with the big smile that his overdose has been reversed and he’s breathing again as they put it in the journal, “breathing like a train,” regular breathing.
They learned from that what a narcotic antagonist could do clinically that it could reverse an overdose. They wrote obviously all of their research was published in the major scientific and medical journals of the time. They began to put the word out that opioid overdoses can be reversed. There were overdose situations especially with people who were terminally ill.
There were also occasional heroin overdoses, not as much because people didn’t use intravenous methods until after World War II. Syringes weren’t very widely available. There were some people who did before the war, but after the war it was much more common. There began to be more commonly heroin overdoses. Major urban hospitals would have nalorphene on hand in case there would be an overdose.
Zach: This is all obviously the history behind naloxone is very, certainly to me and a lot of our listeners very interesting. I want you to talk, too just in terms of what’s one thing you want our listeners to take away from this conversation today.
Nancy: Yes. I think probably the biggest thing is that overdose deaths do not need to happen. These are preventable deaths. The convergence between the harm reduction movement and the recovery movement is really important because these really are preventable deaths and we can all be working together in order to prevent these deaths.
Zach: Listen, I appreciate your time today. This has been a very informative discussion and I hope that people take away from this discussion some useable information that they can implement if they really do want to get behind helping people.
Nancy: I hope so, too. That’s why I wrote the book and it was really delightful to talk with you.
Zach: Listen, if you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn more about substance abuse programs that are both saving lives and empowering families.
Until next week, I’m Zach Crouch with Landmark Recovery Radio.
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