EP. 84: ADDICTION AS A CHRONIC ILLNESS
WITH NZINGA HARRISON, MD
An addiction medicine specialist discusses why addiction is far more complex and nuanced than we all think, and shares how she helps her patients heal by connecting with their life purpose.
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Episode Summary
Addiction and substance use disorders have long been mired in misconception and stigma, seen as moral failings or a lack of willpower. But the reality is far more complex and nuanced. In this episode, we are joined by Dr. Nzinga Harrison, a psychiatrist and addiction medicine specialist who is the co-founder of Eleanor Health, a tech-enabled provider of comprehensive and longitudinal care for substance use disorder and mental health. Dr. Harrison holds a faculty appointment at the Morehouse School of Medicine, previously served on the Board of Directors of the American Society of Addiction Medicine, and is the author of the upcoming book "Un-Addiction: Six Mind Changing Conversations That Could Save a Life". Over the course of our conversation, we discuss our rapidly evolving understanding of addiction as more akin to a chronic illness with heritable and environmentally shaped components, the omnipresence of addiction in modern society, and the centrality of finding life purpose in truly transformative health care.
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Nzinga Harrison, MD, is a board-certified physician with specialties in psychiatry and addiction medicine. She is also the chief medical officer and cofounder of Eleanor Health, an innovative mental health and addiction treatment company. Dr. Harrison holds an adjunct faculty appointment at the Morehouse School of Medicine and sits on the Practice Management and Regulatory Affairs Committee for the American Society of Addiction Medicine.
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In this episode, you will hear about:
• 2:40 - Dr. Harrison’s early experiences — good and bad — with physicians and how they shaped her path to medicine
• 8:41 - What brought Dr. Harrison’s to a career in psychiatry
• 13:50 - How Dr. Harrison came to focus on the emerging subspecialty of addiction medicine
• 17:57 - The reckoning our society has gone through surrounding addiction in the face of the opioid epidemic
• 22:49 - The definition of addiction and its pervasiveness throughout our society
• 26:44 - How we can intervene in earlier stages of substance use disorders
• 31:23 - Approaches to speaking with patients about substance use without buying into the stigma
• 34:45 - A glimpse into Dr. Harrison’s upcoming book “Un-Addiction: Six Mind Changing Conversations That Could Save a Life”
• 39:17 - The most important question to address with a patient as they grapple with addiction in their lives
• 45:01 - The importance of valuing meaning and fullness over productivity in order to bring meaning back to medicine and to life
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Dr. Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Dr. Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] For too long, addiction and substance use disorders have been mired in misconception and stigma, seen as moral failings or a lack of willpower. But the reality is far more complex and nuanced than that. In this episode, we are joined by Dr. Nzinga Harrison, a psychiatrist and addiction medicine specialist who is the co-founder of Eleanor Health, a tech enabled provider of comprehensive and longitudinal care for substance use disorder and mental health. Dr. Harrison holds a faculty appointment at the Morehouse School of Medicine. Previously served on the Board of directors of the American Society of Addiction Medicine, and is the author of the upcoming book "UnAddiction: Six Mind Changing Conversations That Could Save a Life". Over the course of our conversation, we discussed our rapidly evolving understanding of addiction as more akin to a chronic illness with heritable and environmentally shaped components, the omnipresence of addiction in modern society, and the centrality of finding life purpose in truly transformative health care. This is a conversation that will change how you think about addiction.
Henry Bair: [00:02:13] Of note, we want to take this opportunity to spotlight National Addiction Treatment Week from October 16th to the 22nd. This is a week for us all to learn more about addiction and evidence based approaches to care, and to tackle the stigma surrounding addiction within the medical community. To get involved, visit www.TreatAddictionSaveLives.org. And now we bring you Dr. Nzinga Harrison.
Henry Bair: [00:02:40] Dr. Harrison, welcome to the show, and thanks for being here.
Dr. Nzinga Harrison: [00:02:44] Thank you very much for having me.
Henry Bair: [00:02:46] To set the stage for our listeners, can you share with us what initially drew you to a career in medicine?
Dr. Nzinga Harrison: [00:02:51] Oh, I can. So I actually decided to be a doctor when I was like 5 or 6 years old. I don't have any doctors in my family. So how I came to this conclusion is interesting, but I was just really fascinated with the way the human body works and learning about bones and anatomy and... Funny, which gives you probably a peek into my personality both then and now. At five years old, I didn't think my pediatrician was a good doctor.
Dr. Nzinga Harrison: [00:03:24] How a five year old... Looking back now, I know how a five year old knows this.
Dr. Tyler Johnson: [00:03:29] Was your Pediatrician a good doctor?
Dr. Nzinga Harrison: [00:03:31] He was not. He was not by my standards today or or by my standards at five years old, apparently. And it was... I actually told my parents I'm going to be a doctor and a teacher. Looking back, pediatrician was the only doctor I had until 12 years old, diagnosed with scoliosis, went to see an orthopedic surgeon. And the contrast of the experience is what was making me draw that conclusion. I now know, looking back. So my pediatrician never saw me, which is so unusual for a pediatrician, right? But like walked in the room, didn't talk to me, asked my mother. What is she here for? How is she feeling? What symptoms is she having? Like literally did not see me. I was invisible and then also, like, I could sense the way he talked to my mother was dismissive. And that's what was making me draw the conclusion that he was not a good doctor, I can look back on now. I probably couldn't articulate it at that time. My surgeon, on the other hand, Dr. Mark, whose last name I don't know because otherwise I would find him and be like, thank you. I was only 12, but he's like, oh, you're interested in being a doctor? Here's the anatomy of your Scoliosis. And here's how we decide when you need surgery. And let's look at your X-ray together and tell me about cheerleading. And mom, do you understand all of this? Right. And I was like, that's good doctoring. And so that... I decided to be a surgeon at 12. And obviously today I'm a psychiatrist. So there's the story. I was going to be a pediatrician, then it's going to be a surgeon. And I landed where I needed to land, which is an addiction doctor and psychiatrist.
Dr. Tyler Johnson: [00:05:06] It's so funny, though. I just have to remark in passing that as a dad who has kids that are going through sort of the stages of school right now. That ability, I don't know if it's an ability or a skill or a gift or all three of those things, but the gift that some people have of seeing kids as whole people. Yes, honoring them as like whole little people and like understanding that when you are seven Pokemon may actually be the most important thing in the world. And like being in that place where you can like honor the importance of Pokemon. Not in like a condescending pretending way, but... but in a way that you like actually care about it. Like we have this teacher who our youngest now has who like she is like Miss Honey, but times a thousand right, from Matilda. Like she is the best teacher ever. And I still remember the first time I went to parent teacher conferences with her. She was like, you know, people tell me that I'm like, such a great first grade teacher and whatever, whaterver. And she's like, but they don't understand first graders. These are my people. And I just was like, oh my God. Like, I will walk over hot coals to have our children in your class because it makes such a huge difference. But I think that that's I mean, it's one thing with children, but I think that's such a actually such a universalizable, if that's a word, lesson for any kind of doctor, you're really just for being human, right. Like learning to see a person for who they are and where they are is so deeply important.
Dr. Nzinga Harrison: [00:06:44] 100%. So I am enthusiastically allowing the word generalize. What was the word you just made up?
Dr. Tyler Johnson: [00:06:52] Universalizable.
Dr. Nzinga Harrison: [00:06:55] I allow it, I allow it, and I endorse it because same. So to bring this in, I'm a psychiatrist and my specialty has always been people with severe substance use disorders, serious persistent mental illness. And what I've said is what that first grade teacher said, which is these are my people. And I think exactly what you said, like, yes, it is a skill. Yes, it is experience. Yes, it absolutely is a gift to be able to see a human as a whole person, regardless of their current situation. And so we tend to discount kids, right? Because like you're a kid. Being able to see a kid as a whole person and genuinely make that connection is a gift. We discount people with substance use disorders because a quote, 'you make bad decisions', right? Being able to connect genuinely. We discount people with serious, persistent mental illness because 'you don't really know what's going on in reality'. I'm obviously... These are not how I feel about it. These are the stigma that exist, right? It's being able to make that connection. And I think you're right, not just in medicine, hugely important in medicine, but just in everyday life. You met a barista at Starbucks that had a gift for seeing people. You met a ticket person at the Georgia Dome if you're in Atlanta. Oh, that was old school. The Mercedes-Benz Stadium. The Georgia Dome has been torn down. Right. That had a gift, I think, in medicine. Many of us come to medicine with that gift. I think the system beats that gift out of a lot of people. But it should also be a skill we're intentionally developing. IMO.
Henry Bair: [00:08:41] So I want to come back definitely later to this skill and how to develop it. But first, I think the contrast between your resolve to become a surgeon at 12 versus what you ended up going into. It's pretty much anyone who's been through medicine will immediately recognize just how.
Dr. Tyler Johnson: [00:09:00] They're exactly the same.
Henry Bair: [00:09:02] There you go. Sorry.
Dr. Nzinga Harrison: [00:09:04] No difference. No difference at all. Exactly.
Dr. Tyler Johnson: [00:09:06] Orthopedic surgery and orthopedic surgeons and psychiatrists are, like, always in the same club together. It's just like they're the same people.
Dr. Nzinga Harrison: [00:09:14] That's right. Those are my people.
Dr. Tyler Johnson: [00:09:16] That's what you were going to say, right, Henry?
Henry Bair: [00:09:17] Exactly.
Dr. Tyler Johnson: [00:09:18] Uh huh.
Henry Bair: [00:09:20] Yeah. Well, I mean, how did you go from one to the other? What happened in in the interim?
Dr. Nzinga Harrison: [00:09:27] Yeah, what happened in the interim? So I went to medical school thinking I would be a pediatric surgeon, because those were the two types of doctors that I knew, a pediatrician and a surgeon. And I was actually did not know that psychiatry was a medical specialty. It just it didn't exist in my world. And so, you know, in medical school, you have to rotate through all of the major systems and all of the major specialties. And so there's a requirement to do six weeks psychiatry rotation. I was a vocal opponent. I was like, why in the H E double hockey sticks would I have to do six weeks of psychiatry, which is not even a real medical specialty?
Dr. Tyler Johnson: [00:10:09] Just for the record, the psychiatrist said that, not Henry and I.
Dr. Nzinga Harrison: [00:10:13] The Psychiatrist. Not the Orthopedic. Surgeon.
Dr. Tyler Johnson: [00:10:15] I'm just saying.
Dr. Nzinga Harrison: [00:10:16] That's right. I was a vocal opponent because I did not see how that could be valuable to me. When I wanted to be a surgeon, I was like, I could be doing more surgery, I could be doing emergency medicine, anything. But like wasting my time on psychiatry. This was literally my mindset.
Dr. Nzinga Harrison: [00:10:31] So this is an important backstory. I grew up in Indianapolis, Indiana in the 70s and 80s. My father's full time job was founder and commander of the local Black Panther Militia, and then his part time night job. He was an electrical engineer. My mother's job was public school teacher, and so I had two activist parents. I was raised in activist. You raise your voice for those who are being mistreated. You always stand up for what's right. You see everybody for their innate human value. You work against the system to break down things that are trying to tell them that people are not valuable. So I was raised with that in my bones and my DNA. And then remember, what made me want to be a surgeon was the relationship that Dr. Mark executed with me. Right. And so, like activism and relationship, those are my bag. Then I decided to be a doctor because I loved physiology and anatomy from a very early age. So if you take those three prongs, this really is the magic recipe for a psychiatrist, right? So like I did my six week psychiatry rotation. Immediately I was like, oh my God, this is the coolest. I loved every rotation up till then. And I was like, this is the coolest rotation I've been on. I'm having a bit of an identity crisis because I was a vocal opponent to having to do this psychiatry rotation. I took care of a girl. I was in a community hospital as a residential unit, and she was 16 years old and she had Catatonia. She was locked in and it was Catatonic Depression. She was locked in. We were doing ECT. We were treating her with Benzodiazepines, the evidence base for Catatonia.
Henry Bair: [00:12:09] Sorry, could you explain just for our listeners who may not be aware, what do you mean by she's 'locked in'?
Dr. Nzinga Harrison: [00:12:12] So she could not speak. She could not move her body if we put her body in a certain position, it would stay in that position. She was unable to interact with the outside world even though she was awake and alert. So she was locked in.
Dr. Nzinga Harrison: [00:12:28] And so my psychiatry attending, who was amazing, Dr. David Rowan, I mentioned him every time because he's like, the reason 1.0 that I'm a psychiatrist right now, taught me the biology of catatonia, the physiology, what we're looking for in the brain. And then from a relationship perspective, he said, she can hear you. So my job as the medical student was to talk to her every day for 15 to 30 minutes, even though she was completely unresponsive. So I did, and I was just like, 'Hey girl, like, this is what I watched on TV last night and this is what's going on'. And I was like, 'I'm just a medical student. I don't know anything. But my attending told me, you're going to be okay, so you're going to get this, ECT. And you're going to be able to talk to us and things are going to get better'. Like this is what I was saying to her. I get choked up every time I tell a story. We do her ECT She unlocks so like she can talk now, she can move her body. Now we get on antidepressants and she says to me, 'I heard every word you said.' And I was like, 'well, now I'm going to be a freaking zombie. Now I got to be a psychiatrist.' It was incredible. And like, I learned the the biology, physiology and then the stigma. Right? I was raised in activist, psychiatry is the redheaded stepchild of medicine. Then I did liver transplant psychiatry rotation.
Henry Bair: [00:13:54] I'm sorry. What was that? Liver transplant...
Dr. Nzinga Harrison: [00:13:57] Transplant psychiatry rotation.
Dr. Tyler Johnson: [00:14:00] What is that?
Dr. Nzinga Harrison: [00:14:01] So before all transplants, you have to get psychiatric evaluation. And then you usually spend time with the psychiatry team and like, God bless you trying to get a liver. If your liver disease came from alcohol use disorder or drug use like just let you die. And I was like, oh my God. Like, just let these folks die. Like, absolutely not. I was like, Black Panther activism on liver transplant psychiatry. Right. And so it tapped every single.
Dr. Tyler Johnson: [00:14:29] I'm picturing you in this dark clothing and like bungee and frames.
Speaker4: [00:14:34] Yeah.
Dr. Nzinga Harrison: [00:14:34] Cargo pants.
Dr. Tyler Johnson: [00:14:35] Some harvested liver and take it over.
Dr. Nzinga Harrison: [00:14:37] That's right. Some camouflage. I was like walking in with the black power fist. 'Here's a liver,' right? But no, we legitimately were, like, advocating for people's lives. This is why they should be able to get on the liver transplant list, even though they have alcohol use disorder. And it was perfect. And I came home, I told my roommate I was like, dude, I think I might be a psychiatrist. And she was like, Twilight Zone, what is happening? I was like, I know, and it's been the perfect fit. Addiction medicine.
Henry Bair: [00:15:09] Specifically, how did the addiction medicine piece come into play? I mean, obviously you probably encountered a lot of addiction medicine in the context of psychiatry rotation as a whole. But addiction medicine is, I would say it's a newish subspecialty. There's still a lot we don't know about it, and I think we're still building this subspecialty up. How did you decide to make this the focus of your career?
Dr. Nzinga Harrison: [00:15:31] Yeah. So addiction medicine is newish as a specialty. Call it last decade and really growing over the last maybe 6 to 8 years. Addiction psychiatry was a very small specialty. But like addiction used to be purely 100% the specialty of psychiatrists. That has changed over the last decade. And so being a psychiatrist now, I can look back into my childhood and developmental upbringing and say like, oh, wow, okay, I was destined to be an addiction psychiatrist. I have addiction on both sides of my family aunts and uncles and cousins and extended family. My dad himself, who definitely had marijuana addiction, although he might disagree with me and alcohol misuse when I was growing up in the context of PTSD, Vietnam combat veteran. And so like looking back the way my mother's mother interacted with my aunts and uncles that had addiction, which was like, you can always come home, you're my child. This addiction is not you. You can always come home. And that's what we were raised with. My father's side of the family. My grandmother had very severe alcoholism, died from associated complications when I was a senior in high school. Was like, we don't talk about that. Right? And so, like, I had these two contrasting things. So when I went to medical school and I started learning about the biology, the physiology, the psychology, the need for connection, the evidence base, when I started seeing how the system literally didn't care if people with addiction died and in many ways was designed in ways that increase the chances they would die. That was my activism bone. When I sat with people with addiction and like, really saw their innate beauty as humans and that other people in the medical field couldn't see it. That was my relationship bone. And so I very quickly knew I would specialize in addictions. I came to psychiatry residency to specialize in addictions. I've been doing addictions my whole life. It's Been perfect.
Dr. Tyler Johnson: [00:17:34] I just wanted to note the fact that even though you became a psychiatrist when you were explaining your reasons for psychiatry, you're still referring to them as your whatever bone, like the orthopod, is still deeply embedded somewhere in the subconscious, just, you know, there with your ID working, doing something.
Dr. Nzinga Harrison: [00:17:53] That was very psychiatric of you. I'm impressed.
Dr. Tyler Johnson: [00:17:57] Thank you. So one thing that I wanted to bring up, I feel like society has gone through kind of a reckoning and a process of self realization over the last 10 or 15 years because like when I was growing up and granted, this was in a sort of a leafy suburb and whatever or whatever, but it was all about like the DARE program, and it was all about like Nancy Reagan and the what was the saying.
Dr. Nzinga Harrison: [00:18:25] Just Say No.
Dr. Tyler Johnson: [00:18:25] Yeah, Just Say No. And on the inside of like, candy wrappers and whatever. But apart from that, I think that the point of all of that is to say that drugs was seen as a thing that was done by a certain kind of people in a certain kind of place that was never your people and never your place. Right?
Dr. Nzinga Harrison: [00:18:45] That's right.
Dr. Tyler Johnson: [00:18:45] It was this... Kind of like this phantom that like lurked on the periphery and it was all about like, how do we keep that phantom out of our neighborhoods and whatever. Right. Which is not to I mean, you know, of course it would be good to keep any kind of thing that could predispose someone to a substance use disorder out of your neighborhood, but it's just to say that it was very much seen as a like a foreign thing that was trying to invade. And then I feel like over the, you know, maybe the or the late 20 aughts, but especially the 20 tens, then you have the opiate epidemic, and all of a sudden it becomes recognized that, no, this is a thing that anybody can be susceptible to it if they're put in in a situation. And the situation may be as simple as, I had surgery on my knee, and then my surgeon gave me what turned out to be an unnecessary prescription for Vicodin, and I started taking it. And that was the hook or whatever the thing is.
Dr. Nzinga Harrison: [00:19:40] Or a necessary prescription
Dr. Tyler Johnson: [00:19:42] Or a necessary one.
Dr. Nzinga Harrison: [00:19:43] And I was genetically and psychosocially predisposed.
Dr. Tyler Johnson: [00:19:47] Right. And so I feel like it's been this sort of in a backwards way. It's ended up, if we let it, being this deeply humanizing moment, because previously it's so easy if it's a foreign invader to think, oh, well, people who do that are people who fill in the blank, right? There are people who make a certain kind of decision, or they lack a certain kind of moral fiber or they, you know, whatever. But then all of a sudden, when it's your aunt or it's your brother or sister or husband or wife or mom or dad or son or daughter or whatever, it becomes much more difficult to view it as this sort of foreign thing that's trying to invade. Do you feel like that kind of tracks?
Dr. Nzinga Harrison: [00:20:29] I think that is exactly spot on. I'm going to tweak just a little bit. So you said it allowed us to see or something like that. I don't have your words exactly. I think it allowed us to accept. Right. Because part of the 'it's them, not us', is self-protective, but in reality it has always been us. So yes, while drugs were characterized as being someone else's problem, there's legitimately close to zero people who have not had someone in their orbit, whether that's family, friend, work yourself, who has dealt with an addiction, whether that's mild, moderate or severe. And so what the opioid epidemic, which, by the way, I've been practicing psychiatry and addiction medicine now call it 2006 when I got out of residency, even though throughout residency also, so almost 20 years. I've been taking care of people dying from opioids for all 20 of those. It has been a crisis for all 20 of those. But as the media and the publicity starts to change because it feels like it's getting closer and closer and closer to home. The thing with opioids is that you're here today, gone tomorrow. And so as humans, we can really, really attach that cause and effect. Cigarettes. Alcohol. Cocaine. Methamphetamine. We have love affairs with all of these drugs in America. And it's just that the death is slower. It's not here today, gone tomorrow. And so we don't make that immediate connection or have that sense of urgency. And the face of those epidemics were not inside our house. Right. And so I think you're spot on. The opioid epidemic has brought an opportunity for compassion. It has brought an opportunity to have conversations that we were unable and unwilling to have before. It has brought an opportunity to talk beyond opioids. So do you see now all of the media around the risks of alcohol? And the rise of the popularity of mocktails. Right. And so it has allowed us to get to these other substances as well. And it starts with it's not us and those people. It's us people.
Dr. Tyler Johnson: [00:22:49] Well, and even... I don't know how familiar you are with the work of Anna Lemke, but we had her on the podcast probably about a year ago. And part of the argument that she made is that even beyond physical substances that we take in, that we usually think of like substance use or substance abuse. She makes the argument that society has been set up in such a way now, especially with like the digital revolution and whatever, that everyone is addicted. It's just a question to which things you're addicted to, right? You could be addicted to. Yes, to substances, the ones that we normally think about, but even things that we don't normally think about, like highly processed sugars and whatever that there is even an element of addiction to the way that we take all kinds of things into our bodies. Right. Which is just to say that I think at some point it becomes more a question of understanding, a really fundamental part of our wiring that is just sort of inclined towards an addictive mode of engaging with all different kinds of things and then figuring out what does that say about us, and how do we grapple with that inclination in a way that allows us to be happier, healthier humans?
Dr. Nzinga Harrison: [00:24:01] Totally. So one, I endorse her message and I would include work there. Right. So I had a podcast in the past. It was called In Recovery with Dr. Harrison. You can find it wherever you get your podcast, right.
Dr. Nzinga Harrison: [00:24:18] And so the definition of addiction that we used on that podcast was the same definition that I use in the book UnAddiction, which is the same definition I'll use on The UnAddiction podcast coming October 3rd. You can hear it wherever you get your podcasts. Is 'any behavior we continue to engage in despite negative consequences.'.
Dr. Nzinga Harrison: [00:24:37] Now, what's important about that definition is that humans don't do anything if it doesn't have positive consequences. And so drug use has both positive and negative consequences. Sex addiction, gambling addiction, work addiction, exercise addiction, anorexia. You could think of it, right? Addiction to starvation. Right. All of these things that we do, it's just we place value on work addiction. We value that. Tech addiction. We place value on it until it starts causing problems. We place value on all of these things until they start causing problems. And so like anything that you are continuing to do, I use the Cage questionnaire. You all learned it in medical school. Have you ever thought you should cut back? Have you ever felt annoyed because somebody else had the nerve to say something to you about what you were doing? Have you ever felt guilty about what you were doing? Have you ever thought about that first thing in the morning or needed to do it first thing in the morning? Get going. You can literally apply that to anything. Have you ever thought, I'm working too much and you're still working too much?
Dr. Tyler Johnson: [00:25:44] Well, I want to know is if there's any person in the United States who would not test positive on the Cage questionnaire about their smartphone. Like anyone.
Dr. Nzinga Harrison: [00:25:55] There is someone somewhere.
Dr. Tyler Johnson: [00:25:59] We'll try to find them.
Dr. Nzinga Harrison: [00:26:01] Yeah. Good luck. But like when you look at the bell curve. But even though we know a lot of negative consequences coming out of our smartphones, we're not putting a moral judgment on that. For most people, it's not making them stop, go to work. That's really what we value in the US, right? Like, can you go to work? Can you pay your bills? Because we have plenty of very high level working people with alcoholism, with cocaine use disorder, with opioid use disorder, with work addiction, with exercise addiction, with sex addiction, with gambling addiction. But as long as you can go to work and pay your bills. Then we're like, that's cool. When it's not.
Henry Bair: [00:26:44] So it's interesting that we have explored, in a way, a reconceptualization of what addiction is, right? Because instead of, in the past, something that's a personal choice or a personal failing. Now it's more accepted, at least, that there is a component that in your some of your writings, you describe it as a chronic illness, Like, yeah, many of the other chronic illnesses that we talk about. Lifestyle disorders that we often just do not stigmatize necessarily. So now that we have this understanding, how does this shape the way that you approach your patients?
Dr. Nzinga Harrison: [00:27:21] Yeah. So and not just the people that I'm taking care of, but just like the whole wide world, if you see any content from me, this is the content. So one, yes, it is more accepted. And that's because we have medical evidence that substance use disorders perform just like the rest of our chronic conditions. Hypertension, diabetes, asthma. And so I just want to drop a couple of statistics here. And then I'm going to get into your question.
Dr. Nzinga Harrison: [00:27:45] Substance use disorders are equally, if not more heritable. So the portion of your risk for developing the illness that is coded in your DNA the day you're born, then type one hypertension, type two diabetes and asthma 40 to 60% genetic loading, which means we have 40 to 60% or 60 to 40%. That is psychosocial, cultural, political. And so when I talk to people about understanding their risk for developing a substance use disorder and identifying if they have, just like the rest of our chronic conditions that are on a mild, moderate, severe spectrum, substance use disorders are on a mild, moderate, severe spectrum. And the issue even as physicians, but definitely as the broader world, is that we don't recognize it until it's stage four cancer. And so, like all of that work that we did around breast cancer and all the other cancers, colon cancers to identify earlier in the illness is the same work that we need to do for substance use disorders.
Dr. Nzinga Harrison: [00:28:48] And so, like I already told you, I'm genetically loaded. I'm genetically loaded for schizophrenia, ADHD, alcohol use disorder, cocaine use disorder, and heroin use disorder. Based on my family history, coming from both sides, baby. Right. So when me, I have two sons, 18 and 16, we just sent the 18 year old off to college. From three years old we were like, you know how you look just like mom? And you look just like dad? That's DNA. You know what else is in our DNA? Schizophrenia, cocaine use disorder. Heroin use disorder. Alcohol use disorder. So let's open our eyes. Your friend might be able to do a line of cocaine... we didn't say this when they were three. I said this when they were 13. Your friends might be able to do a line of cocaine and be fine. And our family? A line of cocaine turns into prostitution, losing kids, being not with the family. And so like you have a different level of risk. So if you can empower people with what their biological risk is, what their psychological risk is, what their social, cultural, political risk is, and give them ways to recognize when they see red flags. This is how we start to prevent the development of substance use disorder. This is how we start to intervene at the earlier stages of substance use disorder. This is how we start to curb the epidemic. So that's how I approach it, not just with patients, but legit.
Dr. Nzinga Harrison: [00:30:13] I'm going to tell you a funny story. Over the weekend I was at brunch, one of my mentees who just finished psychiatry residency getting her first job. So proud of her. And so I was sitting in the car cleaning out work emails on my device, per our earlier comments. And a guy walks by and he, like, stands in front of my window. So I'm like, oh, he wants this spot because parking was tight. So I rolled down the window. I'm like, 'oh, you want this spot?' He's like, 'no, do you have a light for this cigarette?' And I was like, 'oh, I don't have a light.' I was like, 'I don't smoke.' He was like, 'well, do you have a lighter?' I was like, 'I don't have a lighter.' He was like, 'well, do you have anything else in there? Like there's no lighter in your car?' And I said, 'there's no lighter in my car.' And I was like, 'guess what else? I'm an addiction doctor. So I'm going to take this opportunity to talk to you about the risk of smoking the cigarettes.' And I was like, 'and also, you know, like not asking for a decision today, but just like, maybe this is an opportunity, it seems like a hassle having to ask people for a light, like maybe this opportunity to think about if you want to change how much you're smoking.' And he was like, 'no.' And he was like, 'roll up your window and stop talking to me'. And then he walked off and it was like, funny, but like literally every opportunity.
Dr. Tyler Johnson: [00:31:23] So here's the thing, though, actually, that I really like about the candor of your approach is that there is this like imaginary - I think it's mostly imaginary, Maybe it's really not, I don't know - but there's this image that I think most medical students have that in the past if somebody came in to the doctor and was like, 'oh yeah, I'm a smoker', that the doctor would like put their stuff down and be like, 'that means that you are a bad person and you should stop doing that'. And so all of them have this imaginary archetype of that happening. So then when we're doing like standardized interviews and they're like learning how to talk about difficult things. It is, I say this in a loving way, but it's so funny because then what happens is then they're doing the interview and they're like, 'so Mr. Smith, do you smoke?' And the patient is like, 'oh yes, I've smoked two packs a day for ten years'. And their reaction? They're trying so hard not to be that other person that they're like, 'Oh, that's great. I'm so glad to hear that.' And I'm like, no.
Dr. Nzinga Harrison: [00:32:21] No, no, no, no. We are not glad to hear that.
Dr. Tyler Johnson: [00:32:23] This is not like, I know what you're trying to do and what you're really trying not to do, but this is not the way to not do that. Right?
Dr. Nzinga Harrison: [00:32:31] That is so funny.
Dr. Tyler Johnson: [00:32:33] But the thing that's so funny about it is that I think that the reason for that is because there's such a like discomfort with the perceived stigma that it's like, oh my gosh, like, I can't even suggest that it's a bad idea because then I'm buying into the stigma. Right? And so you have to... It's like you have to deprogram the stigma first so that you can then be like actually drinking alcohol that much is bad for you and for your health. You really shouldn't do that. Right? Or like the way that you talk to your kids like, no, actually, trying cocaine would be really stupid and it might kill you.
Dr. Nzinga Harrison: [00:33:07] That's the risk. You just empower people, like 100% agree with you, you have to start by cleaning out the stigma, especially as physicians like we have to be able to talk about this stuff. Listen, we have to be able to talk about who are you having sex with, how are you doing it? What drugs are you using, what other behaviors? We have to be able to talk about all sorts of things that are quote unquote taboo arose my eyes because whatever, talk about all of it. Right. Like, just don't do it in a judgmental way. So it is harm reduction.
Dr. Nzinga Harrison: [00:33:39] If you look at the ten principles of harm reduction, one of them literally says being honest and transparent about the harms of drug use. But it also says respecting the autonomy of that person to make their choice and empowering them with information to drive those choices. So that's what I'm doing with my kids. I wouldn't say like using cocaine is stupid, because using cocaine might not feel stupid in the context of being the only new person at a party trying to break into a new group of friends when you just started college, and that's what they're doing, that might not feel stupid from that angle. It is still extremely risky for anybody, and your DNA makes it even more risky for you, right? So how do we prepare you to navigate that situation and not choose to use a line? Or if you do choose to do a line, how do we prepare you to recognize when that line is turning into two lines? It's turning into three lines so you can intervene before it turns into the alley.
Henry Bair: [00:34:45] So your upcoming book, right, UnAddiction, is going to be released I want to say next year. Is that correct?
Dr. Nzinga Harrison: [00:34:51] January 9th, wherever you get books.
Henry Bair: [00:34:54] So the book subtitle is Six Mind Changing Conversations That Could Save a Life. Well, with a title like that, I feel like we have to talk about it. If you could share a little bit about what those conversations are, can you give us a taste of what you will be sharing in the book?
Dr. Nzinga Harrison: [00:35:10] I'm excited to give a taste. First of all, this whole whatever 30 minutes that we've been talking is a taste. So the first part of the book is called UnAddiction: Six Mind Changing Conversations That Could Save a Life. Like you just said, we made up the word UnAddiction, and the idea is like to stem this addiction crisis we have, what do we need to unlearn? What stigmas do we need to undo? That's what we were just talking about. What conversations do we need to uncover? Which is the question you just asked me. And so we talked about unlearn early on. We have to unlearn that. It's dangerous and uncomfortable to have these conversations with our patients. We have to unlearn that addiction is a choice, not an illness. We have to unlearn that it's everybody else and not our people. Right? Like those are all things we have to unlearn, the stigmas we have to undo. Like, you're a bad person. People don't get better. You know, 75% of people recover from substance use disorders. We only hear about the 25% that don't recover. Right. And so like undo the stigma that talking about addiction makes people use. We used to believe that about suicide and then uncover the conversation.
Dr. Nzinga Harrison: [00:36:26] So the way the book is structured is in six parts and it is based in this concept. We have in medicine that every chronic condition has biological, psychological and social inputs. You know, it the bio psychosocial concept of medicine, right? I extend that to include cultural/political because we know marginalization, discrimination, oppression causes health disparities and kills people. And so it's the bio psychosocial, environmental, cultural view. And it's split into two parts. It's what you're born with or what you get in early childhood. So biologically that's your DNA. What's the conversation we need to be able to have around your biological risk that you're born with? It's around psychological. That's adverse childhood experiences and positive childhood experiences. What are the conversations we need to be able to have around those experiences you had as a child? And how do we empower you with information to mitigate whatever risk that is conferring to developing a substance use disorder environmentally. ZNA, the ZIP code you are born in predicts your lifespan and health conditions more than your DNA. It's a body of research called ZNA and so like, what zip code were you born into and what risks does that confer for developing a substance use disorder? And how do we empower you with information to mitigate that risk? So that's all childhood. And then the second half of the book is all adulthood. So right now biologically the way you acquire risk is getting injured and getting prescribed. Norco. My 16 year old just got his wisdom teeth out yesterday. God bless his heart. And so that came with the Norco.
Dr. Tyler Johnson: [00:38:16] Deal with it.
Dr. Nzinga Harrison: [00:38:17] Here's your Tylenol and your ibuprofen. But that came with a Norco prescription. I already told you, our DNA is stacked. We already know adolescents psychologically is a high risk time. We already know he's in a school. Literally. I was at the lacrosse sitting next to one of the lacrosse players that just finished playing and overhear him telling his girl, yeah, so-and-so told me he's going to get me some phenergan so I can see what it's like, right? So like social, environmentally high risk times. Psychologically, Adolescents, high risk time. Biologically, already stacked. And so I am on it.
Dr. Nzinga Harrison: [00:38:51] Now. His pain was like eight. He got all four out. It was a tragic thing. So like, we're going to do some Norco, but how do we have that information going in so we can put safety boundaries around the Norco? How do we empower people to understand the conversations they need to be having, identifying those risks and giving them the information they need to mitigate that risk? That's the book.
Dr. Tyler Johnson: [00:39:17] You heard it here first, guys. Okay. But here's my like existential question. You mentioned earlier that the reason that people use substances that they then become addicted to, and I agree with you that I think we can extend that from smartphones to cocaine to calorie dense foods to whatever. But the reason that they do that is because the substance or the thing offers them something. And a great deal has been written that in the Western developed world. We live in this era of unprecedented affluence. It's not to say that there isn't poverty, but it's just to say that, you know, if you just look at the number of dollars and the living conditions of most people, certainly, at least in the United States, again, there is real poverty. I'm not questioning that, but I'm just saying if you look at like a per capita average level of subsistence for someone now versus 100 years ago or 150 years ago or whatever, we live in an era of unprecedented affluence.
Dr. Tyler Johnson: [00:40:18] That is true in a general sense, and yet much has been made of the fact that, for all of that, we also live in an era of unprecedented meaninglessness. Right? Like there is just this sense that there's this kind of gaping void where the heart of life is supposed to be. Right? And I would argue that in a sense, and I don't mean that like every time somebody goes to drink alcohol or whatever, that they're like, I am now going to fill the gaping void at the heart of my life by drinking alcohol.But unlike some subconscious level, you can make an argument like we talk about deaths of despair and everything. Like you can make an argument that what's happening is that people, even if subconsciously sense that there is this hole where meaning is supposed to be, and then they try to fill the hole with this like endless IV drip of whatever the stuff is, right?
Dr. Tyler Johnson: [00:41:12] So here's my question. If you were talking to a person and let's say that they had been addicted to some thing or some set of things, and then you work with them using all of your expertise and experience and know how to help them overcome their addiction to the thing. And then let's say that they were a particularly perceptive or articulate whatever person. And once they had done that, they were like, 'Well, okay, doc, but now what? Like, okay, that's not there. And I'm glad that that thing I was addicted to is not there. But I still feel like there's this like emptiness. There's this like existential void. So if I'm not going to fill it with the stuff that I was addicted to, which I don't want to be addicted to anymore, but what do I fill it with instead?' I know now I'm like turning you into, you know, like pastor or something, but like. But I think it's an important question, right. Like, and it's not so far out of the bounds of psychiatry to talk about something like that.
Dr. Nzinga Harrison: [00:42:08] It is the most important question. So not only is it not outside the bounds, it has to be at the core. And it's not only for psychiatry. So the evidence base is irrefutable about the impact of life, meaning and purpose on health period physical health, mental health, social health, psychological health. And so there is not. An effective. Plan for substance use disorder that does not start with life, meaning and purpose. So I always cringe when people are like the gold standard for opioid use disorder is Buprenorphine. And no.
Dr. Tyler Johnson: [00:42:50] No.
Dr. Nzinga Harrison: [00:42:51] The gold standard is Buprenorphine, plus psychosocial support, plus life meaning and purpose, plus co-occurring management of any other mental health conditions, plus navigation of social drivers of health, plus care coordination for physical health conditions. That's the gold standard. At least it's.
Dr. Tyler Johnson: [00:43:11] Easy.
Dr. Nzinga Harrison: [00:43:12] Yeah. You know, along with all the cushion we have in all of our appointments to see people right to do all of that. But that's what the gold standard is. And so any plan that does not account for life, meaning and purpose from the beginning cannot be sustainably successful. It may be that you're successful in no longer drinking alcohol, but abstinence is not the goal. Thriving is the goal, right? There is no thriving without life, meaning and purpose. And so when we start from the very beginning and this thread goes through the book as well, that is different for everyone.
Dr. Nzinga Harrison: [00:43:50] So like let's identify one thing that you're very passionate about that can bring you some meaning in your purpose. And that has to be part of your plan. The same is true. Say it was an addiction that we were talking about. I had a colleague and friend who was a runner and broke her foot, and running was how she managed her stress, and she had an identity as a runner. And so when you break your foot and you can't run, okay, you can't run. And that's how you are getting your endorphins. So let's make a plan for that. But we also have to make a plan for the identity loss and the meaning and the sense of purpose that running brought to your life. So yeah, spot on in the middle core most important segment of the podcast today period. Dot as the kids say.
Dr. Tyler Johnson: [00:44:37] Period Dot. Which is especially funny because I just saw this New York Times article about how kids get mad if you include punctuation with your text messages, because apparently it's overly.
Dr. Nzinga Harrison: [00:44:47] So old, like, stop being old and out of touch.
Dr. Tyler Johnson: [00:44:50] Sorry, I'm just, you know. What can I say?
Dr. Nzinga Harrison: [00:44:53] I just learned 'lol' is like not a thing anymore for people who are still cool, but I can't let it go just yet.
Dr. Tyler Johnson: [00:45:01] But I do think back to what we were talking about, right? That this is kind of, I mean, the impetus for this podcast. The whole reason we're doing the podcast is because Henry and I sensed that there is a loss of a shared sense of meaning in medicine. Right. And in a sense, I think that it's a little surprising, except that then it's actually not surprising when you think about it. Right? Because, I mean, medicine has its own problem with substance use, and then that has its own very complicated ramifications about how do you identify it and deal with it and everything else. But even aside from what we traditionally think about the surgeon who has a problem with alcohol use disorder or whatever, I just think on a broader scale, I feel like there is this sense in which modern life has become so, even for people who have their basic needs met, it has become so busy and it has become so, like, 'addictive' almost feels like one of the defining traits of modern life, right? Like it's like there is just addiction sort of everywhere around you, ever present, that it is almost as if we have traded meaning for addiction.
Dr. Tyler Johnson: [00:46:08] And even there's a sense in which there are elements of practicing medicine that almost... Addictive is not quite the right word, but they become so rote, so busy, so just sort of formulaic that it feels as though the meaning has been sucked out of it in a way that, you know, addiction, that's one of the things, as you mentioned, is that it becomes a thing that you do by rote that has sort of, by definition, lost much of its meaning, but you keep doing it anyway, right? It feels like there is some overlap there where there's something to be said for stripping away that sort of rote. I'm just going to keep doing the thing, keep doing the thing, even though it's hard to do that, to get back to a place where we see what actually made it meaningful at the outset.
Dr. Nzinga Harrison: [00:46:51] Yeah, I think that is so spot on. And really what you're describing is like moving. If we talk about the different parts of the brain, you know, we have our deep brains, our dopamine pathway, which is motivation for survival. And then your amygdala where you have fear and hippocampus and where you have memory underneath your temporal lobes there, and then forward to the prefrontal cortex and the rest of our cortex, which is quote unquote, what sets us apart from the rest of animals. The fact is that we're animals. And what you're describing is that medicine swims around in this culture that is in the rote automatic, like, you don't have to think about breathing mindlessly. You can breathe because that is in your deep brain that does not require your prefrontal cortex, that does not require any of your associated cerebral areas. Right? Like no mindfulness required.
Dr. Nzinga Harrison: [00:47:39] Medicine is swimming around in this high paced, high pressure, very intense. Reduce the emotions so that you can do the hard work without being affected. Deep brain survival culture. And it's turned way up in medicine and it's a culture of mindlessness. We are being trained to deliver health care in that rote, repeatable way, which is important, right? Like there's evidence and you want to do it that way so you get good outcomes, I get it, but we're being programed to deliver in this rote, repeatable, mindless way health care, rather than connecting to the life meaning and purpose that actually contributes to people's health, it has become about the services and the tasks. And like, get that blood pressure down. Well, I can get that blood pressure down. But what if this person is still languishing? Doesn't matter. The blood pressure is down, right? Get that cataract out. Right. And so... The more we can... Medicine will be super hard... The rest of our institutions will be super hard. We start this training the moment you come out of the womb, and especially now, like we're putting kids in front of screens very early, right? Like all of that is dopamine pathway, deep brain. The more we can start training mindfulness and the more we can start valuing meaning and purpose over productivity. Then we'll get on the right path. We're not quite there yet. Slowly, you see it slowly building, but we're not quite there.
Henry Bair: [00:49:17] Well, Dr. Harrison, on that hopeful note, we want to thank you again for taking the time to join us. We appreciate your openness in talking about these difficult issues and hearing your stories. And it's been a true pleasure.
Dr. Nzinga Harrison: [00:49:31] It has been a pleasure talking to both of you. I love that you all do this podcast. That is so awesome.
Speaker4: [00:49:36] Thank you so.
Dr. Tyler Johnson: [00:49:37] Much and we wish you all the best with your new podcast and your new book.
Speaker4: [00:49:41] Thank you very much.
Henry Bair: [00:49:47] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the www.doctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Dr. Tyler Johnson: [00:50:05] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:50:19] I'm Henry Bair
Dr. Tyler Johnson: [00:50:21] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
You can follow Dr. Harrison on Twitter @NzingaMD.
Visit Dr. Harrison’s website at: www.nzingaharrisonmd.com.
We want to take this opportunity to spotlight National Addiction Treatment Week from October 16th to the 22nd, 2023. This is a week for us all to learn more about addiction and evidence based approaches to care, and to tackle the stigma surrounding addiction within the medical community. To get involved, visit www.TreatAddictionSaveLives.org.
