Centering Harm Reduction in Addiction Treatment: Dr. Melody Glenn, Associate Professor of Addiction and Emergency Medicine at University of Arizona College of Medicine-Tucson

Caleb Furnas 

Hi, I'm Caleb Furnas, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. 

Despite encouraging news about a significant drop in overdose deaths in the US over the last few years, the opioid epidemic continues to ravage lives, burden communities, and challenge the healthcare system. Today, we're going to take a deep dive into this subject to learn about the ongoing impact of opioid use on communities, and the challenges of dealing with overdose emergencies, including information on how and when to use naloxone or other medications to prevent opioid overdose deaths. We'll also take a look at persistent stigmas, the treatment and recovery landscape, and understanding the history of how we got here. 

Our guide will be Dr. Melody Glenn, an associate professor of addiction and emergency medicine at the University of Arizona, who just released her first book, Mother of Methadone, A Doctor's Quest, A Forgotten History, and a Modern-day Crisis.

The book brings together the stories of two doctors battling the opioid epidemic half a century apart to reveal the origins of the public health crisis we're experiencing today. Thank you so much for joining us today, doctor.

Dr. Melody Glenn 

Thanks for having me. Happy to be here.

Caleb 

Awesome. So I thought it might help to starts by getting your perspective on the current state of the opioid use crisis in the US broadly, and how it is impacting your community on a day to day basis.

Dr. Glenn

Sure. I think pretty much everyone has had interaction with the opioid epidemic at this point or knows somebody who has some direct personal connection to it, which has not always been the case. Here in Arizona where I live, we're sort of average in terms of numbers of fatal overdoses. Some places are a lot worse. Some communities are much worse, such as Appalachia. Some places are a lot better. We're pretty average. That being said, when I work in the emergency department, I usually have one or two patients every shift who would meet criteria for opioid use disorder who are suffering from this still.

Caleb 

So as you say, you've been working a lot in emergency rooms. Help our audience understand what these challenges involve and how you manage these patients.

Dr. Glenn

So, there's the more obvious cases, such as people who have had an opioid overdose, usually from smoking fentanyl. Someone calls 911, the ambulance arrives, they revive them with naloxone, which very quickly revives people. About one third of people after that decline transport to the emergency department. They don't want to come in, they've had bad experiences before, faced a lot of stigma in the healthcare system, have no interest in facing that again, especially if they're not going to get any real help. Some people do come in.

In our emergency department now, I think that we offer them quite a bit of services, but that hasn't always been the case, and that's not the case everywhere. For many people, they come in after an overdose, and people sort of treat them badly. They get put into a back hallway, everyone sort of ignores them, and then they wander off at some point usually, like before they're even discharged. Because they're not getting any kind of help or care.

Other times we have patients who come in for other conditions such as pneumonia, a soft tissue infection. They get admitted to the hospital for IV antibiotics and while they're in the hospital, they start to go through opioid withdrawal and then we start to realize that actually this person has this use disorder. We didn't realize that. 

That's a large percentage I would say of the people I care for because I also work on our addiction medicine consult service. We get calls from OB-GYN, from trauma surgery from pediatrics, from internal medicine about patients who are admitted usually for other things and then start to go into withdrawal and are asking for help.

Caleb 

It seems like you see it almost everywhere, both in your working life and that sort of reflects how widespread it is. 

Dr. Glenn

Yes. Exactly, yeah. And without treatment, a large percentage of patients will leave the hospital before their treatment for their pneumonia, or their cellulitis is completed. So it's very important that we're there and can get people treatment for their use disorder so they stay to get better.

Caleb 

Gotcha. So I think most of our listeners are aware that there are medications such as Naloxone that can revive someone who has overdosed. Because it is relatively easy to administer and quite effective, there have been robust campaigns to make the drug readily available. In fact, in some communities, it's now available in vending machines. Can you tell us what Naloxone is and how to use it?

Dr. Glenn

Sure. So it's an opioid antagonist, which is exactly like you described. It reverses the opioid overdose. So if you imagine a ball in a cup, the cup is the receptor, the opioid receptors in our brain. The ball is an opioid like fentanyl or heroin, oxycodone, whatever. It binds to the receptor. When that happens, the brain sort of slows down, the breathing slows down, and that can, on one hand, feel good. But if it's too much, there's a fatal overdose. People stop breathing and they die. Naloxone is an opioid antagonist, so it removes that ball from the cup, so effectively, it undoes the effects of opioids. If it's given in time, people have no ill effects from the overdose. 

Overdoses don't need to be fatal. Fatal overdoses can be completely prevented if people using opioids are around others who have naloxone.

Caleb 

So what's your take on educational efforts around Naloxone? Do you think more could be done to help people understand when and how to use it?

Dr. Glenn

Definitely. I think we've seen a large increase in naloxone access over the last few years and that has included education. It's pretty easy to use. Most of the time it's sold as an intranasal formulation. So people just have to spray it up the nose. Very easy to do. If you suspect someone has overdosed, you can administer it. There's really no side effects if someone has an overdose. 

You know, if someone had a heart attack and fell to the ground and you gave them naloxone, nothing bad is going to happen to them. The biggest concern is if you give it to someone who might be high from opioids but is not overdosing. That is, they're still breathing. They still have enough oxygen in their body even though they're not waking up to talk to you. If you give that person Naloxone, it could make them very, very sick. So I think there is more education that can be given around those instances. 

I think we still have two problems still. One, lots of family members of people who use drugs don't know how to use Naloxone, and may not feel comfortable with giving it; or the other extreme where people are giving too much naloxone and maybe in inappropriate instances. So yes, more education could be done around those two areas.

Caleb 

There are also effective prescription medications for treating opioid use disorder that reduce cravings and withdrawal symptoms, and I'd like to dive into those for a moment. Let's start with methadone. Can you give us the basics on that?

Dr. Glenn

Yes, this is such an effective medication. It's one of the most effective medications we have for any chronic disease. For our medical folks out there, the number needed to treat it is two. So, for every two people taking methadone, one gets the clinical benefit. That's huge. We give baby aspirin for people with heart disease to prevent a heart attack, but over 50 people have to take it for one person to get a benefit, which is pretty wild. I don't think most people realize that.

Caleb 

No, for sure.

Dr. Glenn

So, methadone is so effective, but it's very, very underutilized. It doubles someone's retention in addiction treatment. It halves their risk of fatal overdose. It helps people go back to school, back to work, get their lives back. But unfortunately, very few physicians know how to start it or how to give it, and half of the country doesn't even have access to a methadone clinic.

Caleb 

Can you elaborate more on why that is? Like why is methadone, for instance, only available in specialty clinics? Is it for the reasons you just described? Is it more elaborate than that? 

Dr. Glenn

It's more elaborate than that. I think the easiest place to start is that methadone is itself an opioid, so people could overdose off of it. If a kid gets into someone's methadone prescription, they could die. It also has some interactions with other medications. It could interact with people who have heart disease, so there are some side effects. It should be monitored. There should be a doctor monitoring it, and for that reason, people have to go every single day to the methadone clinic to get their daily dose. Our country has decided is necessary. 

It's federally regulated. There's really no wraparounds. So if someone is on methadone, they have to go every single day to the clinic and the nurse has to watch them take their medicine, and if there isn't a methadone clinic in their community, that's not an option available to them. The entire state of Wyoming doesn't even have one methadone clinic.

Caleb 

There are some other medications that are available in doctor’s offices and clinics such as buprenorphine. What's different about those medications?

Dr. Glenn

So buprenorphine or “bup” for short is a little bit safer than methadone. It's a partial opioid agonist. So if you think about a dimmer switch on a light fixture, with methadone, you can keep moving that dimmer switch all the way up so it's very bright. Same with oxycodone, same with heroin, same with fentanyl, same with morphine. The more you take, the more of an effect there is. With buprenorphine, that dimmer switch is just sort of in the middle. So people can take more and more and more, but there's not really more of an effect.

So there's less central nervous system depression, less respiratory depression, and so it's much harder to have a fatal overdose on buprenorphine. It's safer. There's less drug-drug interactions, less dangers in people with cardiac history. So it's a safer medication. It's not quite as regulated. People can get that prescribed by any clinician with a DEA license, which is pretty much all of us, and can be picked up at any pharmacy.

Caleb

So there are critics of medication-assisted treatment who argue that all of this is just swapping one addiction for another. What's your response to that?

Dr. Glenn

I just find it so sad. I've had so many patients who do so well on these medications and then they've internalized this stigma. They've heard it from family, from friends. They want to get off the medicines and then they relapse on fentanyl. So first of all, I just have this deep sadness that this is a stigma and misinformation that's so prevalent out there. And I don't think it's true. I don't think it's true at all. 

Yes, methadone and buprenorphine are opioids, but the difference between them and fentanyl are many. They're very regulated. We know exactly what's in them. We know exactly where they've been manufactured, what components are in there. With fentanyl, there's so many other drugs in there and other analogs of fentanyl. We have no idea how strong it is, and that's part of the reason why people overdose. With buprenorphine methadone, that's not gonna happen. It's a very safe, regulated product. Also, people get the prescription from their clinician. They're not getting it from the streets. They don't have to lie about it. They're not breaking the law to get it.

All these negative behaviors that go with addiction are broken through the healthcare system, through getting this medication prescribed. They go to a pharmacy, they have an entire healthcare team behind them. Also, they're not getting high on these medicines, they just feel normal. I've had so many patients tell me that for the first time, they feel normal again. They're able to reconnect with family who they've been estranged from, go back to school, go back to work, get their house back, get their lives back. And that doesn't happen with addiction.

So, it's not the same. Just because someone is dependent on medication does not mean that they have addiction. There's actual more criteria beyond being dependent on something to be addicted. It has to be causing harm in someone's life. They have to be using despite the harms that it's causing. In buprenorphine and methadone, there's not really those harms. It's not causing any harms. Another analogy is that we have people who are on blood pressure medications. We have people who are on insulin. When their blood pressure or blood glucose is in range, we don't tell them, “Oh, you need to get off that insulin now. You're substituting a drug for another drug.” We don't say that, and that's because of stigma.

Caleb 

Right. We've mentioned stigma a couple of times. Can you speak more about that? Why do you think there is this persistent stigma around drug addiction and treatment?

Dr. Glenn

I think a lot of people think that addiction is a choice and that people are making bad choices. But as an ER doctor, I see a lot of things that people could say are related to bad choices. I see people who get into car accidents because they're texting. You know, that might have been a bad choice. I see someone who's 75 who tries to climb up on the roof and falls off the ladder. That could be considered a poor choice. But we don't treat those people with the same level of stigma. We're helpful.

Caleb 

Right. Right.

Dr. Glenn

We get x-rays, we make sure their pain is addressed. We treat it very differently. So I think that's part of it. There's this misinformation that addiction is a choice. We don't realize that it's actually a condition in the brain where the drugs kind of hijack the frontal lobe and hijack different machinery in our brain to make people want to keep using despite the harms. 

I think part of that is historical. Addiction medicine was removed from the purview of medicine back in 1914 with the federal Harrison Act that forbid any physician from prescribing opioids to people with addiction. And ever since that happened and the agents started coming after the doctors who were doing it, the medical profession kind of just said, okay, we're not getting involved. We're not treating addiction here. And addiction became more the purview of law enforcement or behavioral health or religion. It wasn't seen as something medical, but now we know better. We know that addiction is a medical condition and medicines are very effective.

Caleb 

Right. So, related to this, I understand that you believe that the recovery landscape is confusing and difficult to navigate for patients. Can you provide some examples of that and help us understand why it is this way?

Dr. Glenn

Lots of the recovery landscape is not evidence-based. There are practices out there that are wonderful and there are other ones that I think are taking advantage of people and families in difficult situations, charging a lot of money, offering things that they say are cures but really don't treat addiction at all. I don't really want to throw anyone under the bus but there are podcasts about this. 

Shoshana Walters, a journalist, worked at Reveal and had a whole series called American Rehab and she has a book coming out soon as well with a similar title that goes into more detail about that. But I think part of this is related to the fact that addiction was removed from the house of medicine. That medicine washed its hands of addictions and said that we're not dealing with this, and so other people decided to fill the gap.

Caleb 

Yeah, and somewhat unevenly, obviously. Okay, so I'd like to turn now to your new book, Mother of Methadone, A Doctor's Quest, A Forgotten History, and A Modern Day Crisis. Tell us about it and why you decided to write it.

Dr. Glenn

I decided to write it because I became a really fierce advocate for addiction treatment once I realized it existed. I never learned anything about addiction in medical school, or least I don't remember anything besides a one-hour lecture. My emergency medicine textbook is huge -- it's probably a thousand pages, weighs several pounds – but there are only two pages about opioid use disorder, and that's about giving narcan or naloxone in an acute overdose. That's all that there was. I didn't realize there was a treatment. I didn't realize buprenorphine and methadone existed. 

Once I learned that and once I saw firsthand how effective it was, I started teaching other doctors about it too, because they similarly hadn't learned anything. It wasn't just my medical school or residency, but a failure systematically across the country. So I started teaching people. That was going well, but there's a few skeptics who I just couldn't convince. I would tell them the data. I would bring them the scientific papers. I’d bring them the journal articles. I’d bring them all this stuff, all this data, all this proof and it still didn't change people's minds. And I think that's because there was stigma there. There's stigma influencing their decision making and stigma is not rational. 

So I thought, well, what if I told a story? What if I used a book to take a different angle to get to someone's empathy, to get to their heart, perhaps? I thought maybe a story would have that effect in a way that a journal article wouldn't. So, I started to write.

Caleb 

Amazing. And you wrote a lot about Dr. Nyswander. What was it about her that made it possible for her to overcome the odds and establish methadone maintenance as a treatment for heroin addiction?

Melody Glenn (17:18.374)

Dr. Nyswander was really remarkable and she's a major character in the book. You could argue that this is her biography. I sort of weave my story of addiction medicine with hers. She was a doctor back in the 1940s through 1970s, and I show how little has changed in terms of addiction medicine between our careers.

She was also the one who developed methadone maintenance. That's probably the most important thing. She developed methadone maintenance with her lab partner and husband, Dr. Vincent Dole, in the 1960s, which at the time was illegal. It was illegal because of this Harrison Act and the interpretation of it to give opioids to people with a use disorder. But Dr. Nyswander had, by this point, tried everything else. She had worked at the U.S. Narcotic Farm, which was an institution in Lexington, Kentucky that was half run by the United States Public Health Service, half run by the forerunner of the Department of Corrections because we couldn't decide even then is addiction a disease or is it a crime? We couldn't decide so we had this duly run locked institution. 

Dr. Nyswander was sent there to work. She wanted to work in the Navy but they didn't have a uniform for women so they sent her there to be a jail doc and she learned about addiction. They were just detoxing people. They started to use methadone actually in the 1940s, but just to detox folks off of heroin and then it would be abstinence based for the rest of their recovery. These are really nice farms. They had kale farms, had cows, had bowling alleys, they had baseball fields. They had all this stuff because they thought that clean outdoor activity would help people stay sober. And it did well for people while they were there, but 90 % of people relapsed once they left. So that wasn't enough. 

Dr. Nyswander saw that and she started to say, “Okay, what other barriers can we remove when treating people with addiction?” At that time, they thought that if you had addiction, you had to be institutionalized. She started to question that. She started to offer outpatient addiction treatment, which now is the norm. Now we would not think twice about this, but when she was doing it, people thought she was heretical. They wanted to come after her medical license, for example. So she did all these sort of iconoclastic things that moved addiction medicine forward, but still her patients were continuing to die from overdose.

So, she looks to Europe where they were giving opioids in the form of maintenance treatment and she thought that that was what we needed here. In comes Dr. Vincent Dole. He's a well-established, prestigious researcher in New York City. He was more of a metabolic disease kind of guy, but he sort of fell into this role in the City Opioid Commission. He fell into it. He said he should learn something about addiction. So he read Dr. Nyswander's books, read her studies, reached out to her and said, “We've been given funding, we've been given a lab, let's work together, let's study addiction.” And then at one point they decided they were going to give opioids to people with heroin addiction and we're going to see what happens. 

Dr. Dole was smart about this. He knew that this had been seen as illegal, so he reached out to his bosses at the Rockefeller Institute and reached out to attorneys and they put together a plan. They were all as an institution willing to support Nyswander and Dole no matter what happened. It's a good thing that they did because the forerunner of the DEA sent agents over to their lab once they realized what they were doing and told them to stop. And Dole just said, no, we're not going to stop. If you think what we're doing is illegal, you can sue us. And so that's how it happened. They did it and asked for forgiveness. 

Caleb 

Obviously, you did like a deep dive into the history of opioid use disorder. Did it change your approach to medicine in any particular way? Did it did it change how you approach patients?

Dr. Glenn

Yes. Having this deep dive and having this historical context helped me better understand where this stigma was coming from. It helped me have more empathy for my colleagues who were resistant to these treatments or maybe had different ways of practicing. Just having this understanding and this additional context made it easier to relate to everybody, and I think that relational aspect is very important when building therapeutic alliances.

Caleb 

Yeah, in my experience working with a lot of faculty and students, it does seem that because there's so much content that has to be learned, what gets overlooked is this empathetic part of being a clinician. Do you have ideas for how you would train the doctors of tomorrow to have that empathy more front and center given the challenge of just covering all the content that they have to get through?

Dr. Glenn

That is such a great question. I was teaching narrative medicine at the medical school for a while and I was teaching poetry. I really hoped that that might be an avenue to get into students' empathy and the art of medicine. Maybe for some people it was, but for lots of the students, I think that they just felt very stressed being away from the textbooks that were going to be on the test. You know, they wanted more material on the kidneys.

Caleb 

Right.

Dr. Glenn

They didn't want to be talking about this poem. So I don't have a great answer for that. But I think that medical humanities does offer something. How to actually make it applicable and make the students excited about it, that's the next level. They probably have some answers over at Columbia because they have that whole department of narrative medicine there.

Caleb 

Right. What else have you learned about yourself, either as a private person or as a clinician in working on this book?

Dr. Glenn

Working on this book really helped me with this existential question that I had about how can I be a doctor without falling into the savior trope. Because I feel like we see that so often in physician narratives. Doctors are put on this pinnacle. They're supposed to be a savior or a hero who comes in and fixes everything, and I felt very uncomfortable with that.

I still feel very uncomfortable with that, but I think I've found alternative approaches to practicing medicine and making a difference without trying to be the hero. 

I think part of that was because Dr. Nyswander was not perfect, and seeing her imperfections -- but still holding her up as a mentor as a woman in medicine -- was useful for me in that regard. And also I just have fallen more in love with the idea of harm reduction, which was not something that had a name back in Nyswander's day, but it does now.

We think about this in terms of giving out naloxone, or giving out clean syringes for people so they're not sharing or reusing used syringes. But it's more than just that. We're all practicing harm reduction all the time. When we get into our car, which is this metal contraption going way too fast that has the potential to kill us, we put on our seat belts. We have airbags. Those are examples of harm reduction. We're reducing the harms of life. Here in Arizona, I put on sunblock. You know, that's another example of harm reduction. Those are all the practices, but it's also this philosophy where we treat the patients as the experts in their own lives. We meet them where they are. We listen to their concerns. 

I've tried to integrate that into all of my medical practice now. When I'm in the emergency department dealing with someone with a CHF exacerbation, I'm trying to practice that philosophy of harm reduction, and I think that has really helped me as an antidote to the savior complex.

Caleb 

That's a nice way to think of these two approaches for sure. So, you got an MFA in creative writing and you've obviously just written a book. How do you think medicine and writing are related?

Dr. Glenn

For me, they are so intertwined. They share so many of the same skills. To be a good physician and a good writer, you need to learn how to listen. You need to learn how to have empathy, how to watch, how to be observant, how to tease out what the important story is, whether for your book or for your patient. Why are they concerned? Why are they here in the emergency department? What story are they telling? 

I think the art of medicine has been strengthened just by the arts in general. And for me, that's writing. But I think any art form makes you a stronger physician. There's detective work involved in both. I sort of bring in this aspect of investigative journalism to my book that's very similar to the emergency department where we're trying to find the diagnosis. It helps me relate better to my patients. So, I feel like they're very intertwined.

Caleb 

Okay, we're almost at time, but I'd like to end by getting your general advice to our audience of future caregivers. How should they meet the challenge of caring for people in the future based on your experiences and based on what you've seen?

Dr. Glenn

I think harm reduction should be the foundation of everything, both as a philosophy and as practice. It helps reduce the moral injury of being a physician in this setting where we're bearing witness to horrible situations that people are in -- things that we cannot fix oftentimes -- which can cause moral injury. Most people would say, that's just burnout, but it's not. It's something deeper than that. 

I think having harm reduction as the foundation can prevent some of that, can keep us healthier as caregivers and make us better caregivers, both. This dual aim. I think remembering our humanity and however you do that, whether that's going to the gym, whether that's going to yoga or painting, whatever it is, make time for that. I think that's key too.

Caleb 

Well, that's really good advice, and I think even just your tone and your approach is something that I think a lot of caregivers could benefit from being exposed to. Thank you so much, Dr. Glenn, for being with us today.

Dr. Glenn

Thank you. Thanks for having me.

Caleb 

I'm Caleb Furnas. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.