It’s our first ever “Ask Me Anything” episode! This week, Nzinga answers a range of listener questions. A mom wants to know if her daughter has to be ready for treatment. Another woman asks if she’s addicted to toxic relationships and emotional uproar. And what is the best way a daughter can get her 77 year old mother into a treatment program during COVID? Answers to these questions, and more, in rapid fire (Nzinga style).
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Dr. Nzinga Harrison: [00:28] Hello, I am Dr. Nzinga Harrison, and you are listening to in Recovery. If this is your first time listening, I’m your host because this is a show about addiction. And I’m a physician, a psychiatrist and addiction expert. I’ve committed my whole life to serving people with addiction, their loved ones and their communities. I am chief medical officer and co-founder of Eleanor Health where we do just that. We talk about all things addiction, not just alcohol, not just opioids, but also some things you might not think of, like toxicity or emotional upheaval. And that’s what we’re going to get into today. Recently, we’ve had a lot of guests on the show, which I love. And we will definitely keep doing that. But this week, we’re going to switch it up a little bit and take a break just to answer a bunch of your questions, rapid fire. We have called this type of show “ask me anything.” So we’ll start to do these AMA, ask me anything episodes every once in a while between our one-on-one conversations with listeners. So of course, to make AMA episodes happen, we need your questions.
Claire Jones: [02:16] OK, let’s get to the first question. This question comes from Viviana. She sent us an email that says, “My 27 year old daughter has been a heroin addict since she turned 18 and she recently graduated to fentanyl. She’s run away from just about every rehab in L.A. and has overdosed countless times. Your description of the rehab industry is very accurate. They are rapacious and irresponsible. Do you really believe that your person has to be ready to go to treatment? I wonder if my daughter ever will be.”
Dr. Nzinga Harrison: [02:50] This is a hard question, Viviana. So first of all, I know you’re super worried about your daughter. I’m definitely super worried with the graduation to fentanyl, one of the deadliest opioids we have. And so let’s think about this in kind of two different phases. So to your question: do they have to be ready to go to treatment? The answer is no. So lots of people get mandated to treatment before they’re ready to go.
Claire Jones: [03:21] Is that like a court thing?
Dr. Nzinga Harrison: [03:23] Yeah. So like, if she were to get some criminal charges or to get arrested, then they could say, you have to go to treatment instead of going to jail. And so the quick answer is no, she doesn’t have to be ready to go to treatment. But if she’s not ready to go to treatment, kind of the only way to get her to treatment would be if there was some sort of mandate from somewhere. So let’s back this up a little bit earlier in the process, because there are definitely interventions we can do to reduce the chance of an overdose death, to reduce the harm that her opioid use disorder might bring her. And it’s called harm reduction. And harm reduction interventions work even if a person does not go to treatment. And so I think, Viviana, what I want to do is kind of talk through some harm reduction strategies for use. So, number one, we want to try to look for the root cause. So maybe she’s not “ready” to go into drug treatment, but is there something else she needs? Like, does she have depression, anxiety? Is she stressed out? Does she need a friend group? Is there any other way that a professional might be able to connect with her and see if you can get, even if it’s not to residential treatment, maybe it’s to an outpatient treatment.
Claire Jones: [04:46] Right. OK. Can you just describe the difference or define inpatient versus outpatient?
Dr. Nzinga Harrison: [04:52] Yeah. So in substance use disorder treatment, there’s really a continuum that starts with education and prevention and then goes to outpatient treatment, which means you go to the office, but you don’t stay there. You go to the office or you go to the treatment program. You get your services, you go back home. And then the next level is called intensive outpatient. You still go back home, but you go to an intensive outpatient program, usually no less than three times per week. And then the next is called partial hospitalization. You still go back home on partial hospitalization, but you’re getting at least 25 hours of treatment a week. So you’re like at the hospital, it’s called a day program. You’re basically there all day, Monday through Friday, and then you go home. And then the next level after that is residential, where you actually live there. And residential is usually 30 days or longer. And then the next level beyond residential is inpatient. And so that happens in a hospital setting. This is for people that are at risk for some physical or psychiatric complication that really might need the intervention of a physician. And so it’s in a hospital setting where you will get seen multiple times a day. And those are much shorter stays, usually five days or less.
Claire Jones: [06:15] Great. Well, I definitely did not know that.
Dr. Nzinga Harrison: [06:17] Yeah. And so if a person — and this is kind of what’s commonly misunderstood, is like the knee-jerk thought, when people think about treatment for substance use disorder is either the three to five day detox, which happens inpatient. That’s usually hospital level, although we can do outpatient. But that’s usually people are thinking like you go somewhere to a hospital for three to five day detox and you’re done. No. Or people are like you go to a 30-day residential rehab and you’re done. And it’s like, no. Depending on what the symptoms of the illness are right now, we may be able to start at outpatient. You may never have to go inpatient. You may never have to go residential. You may have to go inpatient or residential if you’re 78 years old and have other complex morbidities and that’s what I had to do to keep you safe. But even if you go inpatient or residential, that’s not the end of treatment. This is a chronic medical condition, and so you will always have to land back at outpatient for ongoing care or else your illness is going to relapse.
Dr. Nzinga Harrison: [07:29] And so, Mom, that’s the first thing, try to get her connected among some other need that she has right now that she’s motivated to get help for. The second thing is harm reduction. So she needs a Narcan kit, period. Anybody else who is hanging out with her needs a Narcan kit, period, so that if she needs to be reversed, they have a kit to do it. If she needs to reverse somebody else that she’s using with, she has a kit to do it. Mom, you have to get a Narcan kit. You can get it in many states without a prescription. But you can also definitely ask your primary care doctor and they’ll write a prescription for you. And you can go to the pharmacy and get it and we’ll put that information in the notes. And then the third thing, Mom, for you, whether there’s another, like, pathway to get connected to your daughter, like I said, something else that she’s motivated to get help with, whether you can get her Narcan kit or not, get yourself a Narcan kit. And please go to WetheVillage.co. They have incredible resources that have been shown, one, to help you kind of just going through this journey as a mom. But also their interventions have helped moms get their kids in treatment. So number one, is there another way a professional can start the relationship with her? Number two, Narcan for everyone. Number three, WetheVillage.co For you.
Claire Jones: [08:55] One quick follow up question to this. Will treatment centers accept people over 18 who are not checking themselves in?
Dr. Nzinga Harrison: [09:05] Only if mandated from some legal body. So Over 18, the person has to sign their own consent forms for treatment. And so she would have to be the one signing up for that. But again, broaden your thinking beyond residential rehab, inpatient stay, like look for an outpatient treatment provider that might be able to start this relationship with her. And actually, let me give you a specific resource for that. HarmReduction.org has an incredible resource center by state, I’m making number four. Well, actually, this is still number one because it was like, is there a way that a professional organization can make a connection to her that’s not treatment? HarmReduction.org will help you find that resource. Number two, Narcan for everybody. Number three, WetheVillage.co for you, because just because she’s not ready right now for drug treatment doesn’t mean she’s not ready for a professional relationship of some sort. And we know that those relationships often help move people over whatever barriers are keeping them from being ready for treatment.
Claire Jones: [13:47] OK. Our next question is a voicemail from Danielle. Let’s take a listen.
Caller:: [13:55] Hello, my name is Danielle. I’ve never struggled with substance abuse or alcohol. Both my parents did, but not me personally. So I just recently kind of got out of a very toxic relationship. It’s not my first one, actually. It took a really, really hard toll on me. But at the same time, I find myself feeling like I need emotional uproar. And like, I need toxicity to feel like loved. I didn’t really grow up with a fathers, so I obviously can connect that my childhood trauma of not having a dad. I guess really my question is can people get addicted to toxic situations that they put themselves in?
Dr. Nzinga Harrison: [14:50] All right. Thank you, Danielle, for this question. And the quick answer is yes. So based on the definition of addiction that we’re using for In Recovery, which is continuing to do something despite negative consequences, absolutely. Yes. People can get addicted to toxic situations. And so, remember, we always say there is nothing as humans that we continue to do if it’s not bringing us some sort of benefit. And so what we want to look and see is when you’re in these toxic situations, what benefit are you getting from it? And so just from the little bit about your childhood that you shared with us, remember, I always say we are not born with relationship skills. We are not born with coping skills, we’re not born knowing how to interact with other people. We learn that from the experiences we have. And so you feeling like you need emotional uproar and toxicity to feel loved is somewhere rooted in those experiences and learnings that you got as a child when you were growing up. And to put this into chemical sense, it’s like coded in our DNA. Some people get a dopamine signal from very small things. Other people, just like at baseline, need a very big happening to get that dopamine serotonin signal that makes you feel loved and reinforced. And then on top of the DNA that we just inherited, the way our brains just work, our life experiences show that to us. So if your childhood was full of very frequent but small dopamine serotonin signals, then your brain can generate that response and feel loved from just like consistency and stability and because you know another one is coming.
Dr. Nzinga Harrison: [16:40] But if your childhood was pretty devoid and the point at which you got seen was in a really toxic, high volatility, high emotion experience. and that was the time you felt seen and connected to the adults around you, then your brain lays that down psychologically but also chemically. And so smaller interactions of love won’t be able to generate that dopamine and serotonin signal for you to actually be able to feel it and recognize it. It has to be huge. And so that might be part of what you’re experiencing in these relationships. And so how to move forward from that? It’s always the same answer. Therapy. The way you start to get to this is you literally want to get a therapist that can help walk you back to your earliest relationship experiences, those are with the kids and the adults that were around you growing up, and figure out how to get that dopamine and serotonin signal that leads to a feeling of you being cared for and reinforced without the negative emotional valence. And so it still may have to be like a big gesture, but learning how to get that dopamine and serotonin from a big positive gesture and decoupling that from the toxic gesture.
Claire Jones: [18:35] OK. So going back to the DNA part of it, you’re saying that some people can get a dopamine signal from something really small, like a hug or something. And then other people won’t necessarily get a dopamine signal from a hug. It might take something more.
Dr. Nzinga Harrison: [18:54] Like throwing you in the air. You know, when you’re a little kid and your uncle throws you in the air and you’re like, whee! And you get a big dopamine signal.
Claire Jones: [19:01] Is that something that you can, like, change? I mean, that’s sort of it’s mind blowing to me.
Dr. Nzinga Harrison: [19:08] The answer is yes. In fact, all of our life experiences are constantly changing the way our brains and bodies are responding to the environment. But those developmental years, your early childhood years, where you’re literally still forming your brain and your brain is still forming its electrical and chemical processes, the answer to your question is not yes, can you change that? The answer to your question is there is no way not to change that by virtue of your life experiences. That is what development is.
Claire Jones: [19:51] Let’s go to our next question. This is from Jennifer, who asks, “what is a trauma bond? I’d really like to understand why my daughter, who has a substance use disorder, is also involved in a very unhealthy relationship. She describes it as a trauma bond.”
Dr. Nzinga Harrison: [20:08] So thank you, Jennifer, for your question. I’m not sure how your daughter is using the term trauma bond, but I’m going to talk about it from two different angles. So a lot of times when we have people who are in abusive relationships, this is actually right along the same lines as what we were talking about with Danielle. So when we talk about the development of a trauma bond, we’re actually talking about in childhood, as you are learning what it means for another human being to love you and see you and hear you and affirm you that those childhood experiences are happening within the context of some sort of trauma, whether that’s abuse, whether that’s neglect, whether that’s physical, verbal, whether that is social trauma. So housing insecurity, food insecurity. And so like to give a very simple example, we come out of the womb knowing that being swaddled equals love and protection and safety, like biologically, just neurobiologically, we know that. But say you grow up with significant food insecurity. You may experience love as a person cooking a meal for you more deeply than a person who hasn’t because it’s filling in that which is transmitting to your brain danger.
Dr. Nzinga Harrison: [21:26] And so as we grow up as kids, if you are mostly invisible, but the time you get seen is when Mom is yelling at you, or if you are scared most of the time and the time you feel strong is when you’re fighting back against your dad, then your brain starts to lay down, ‘this is what it means to be loved. This is what it means to be seen. This is where you have your most power, when you can yell louder than the next person.’ We’re constantly learning these things from our environment as we’re growing up that is bonding the experience of being loved and cared about with the experience of trauma. That’s the first way I’m gonna talk about trauma bonding. And so I would look at your daughter’s early life experiences and see if you see any parallels to the relationship she’s currently in to the earliest relationship she had with you, with dad, with siblings, with friends, with other family members, with other adults and kids that were in your lives.
Dr. Nzinga Harrison: [22:30] The other way I’m gonna talk about trauma bonding is literally when you are in a traumatic situation with other human beings and you survive that situation together. That trauma bond runs, as they say, deeper than blood. So any veteran will tell you, the people that they were in combat with, that bond runs deeper than blood. Any person who has survived a natural disaster will tell you the people that they were with, people that would have never, ever crossed their lives any other way now becomes some of the closest people to them. And so that is another way of trauma bonding that can often keep us in relationships that are not necessarily healthy, because having survived something awful together is such a strong human connector.
Claire Jones: [23:20] So what do you tell somebody who is in an unhealthy relationship but they don’t necessarily want to end that relationship because they have this bond and that other person is the only person that understands the trauma that they went through?
Dr. Nzinga Harrison: [23:34] One, that person is not the only person who can understand, but two, like I always say, what are the benefits? Like, it’s the same being emotionally at least safe and setting healthy boundaries in any relationship. And so it may not be that you have to end that relationship, but you do have to end that relationship the way it currently is. Because the way it currently is, it’s not emotionally safe for you or maybe physically safe for you or for the other person. And when you truly love and care about a person, yourself included, what you aim to do is create a safe emotional and a safe physical space for that person. And some people can do that work. Everybody cannot do that work before yourself. You say like, how much pain am I experiencing in this relationship? Is there a way to experience the love and compassion in this relationship without experiencing that pain? And if yes, can me and my partner make the commitment to try to walk towards a more nourishing relationship? And then you just have to define your boundary for yourself. Jennifer, if you’re approaching your daughter about this relationship in an antagonistic way, you’re not helping her decisional balance. Because what we’re looking for is for her to get love and compassion in a way that’s not antagonistic so that she can see that exists and move her along the stage for wanting to make that decision in the existing relationship. So you just want to approach her love, compassion, “I understand. Tell me, what’s what’s this relationship bringing you? Do you see the pain?” Sometimes that will help her to see your pain. But just trying to be there as a support person who understands she’s in a hard position.
Claire Jones: [25:35] Our next question is from Sarah, who is from Utah. She says, “is self care basically getting ourselves some dopamine? I’m an academic and totally feel the things that you were saying in the episode on work addiction. When you talked about how you have to identify sources of dopamine to replace the dopamine you get from work or whatever it is that you’re addicted to. It just struck me: is engaging self care basically getting ourselves some dopamine?
Dr. Nzinga Harrison: [26:07] The answer is yes. And so I’m going to add serotonin in there also. And it obviously is more neurobiologically complicated than that. But that is literally what self care is, is turning down the norepinephrine. You know the everyday where we use for norepinephrine is adrenaline. So it’s turning down the adrenaline and it’s turning up the dopamine and the serotonin. Spot on. I’d try to give a longer answer, but you were right. That’s all I got.
Claire Jones: [31:01] Okay, next one, Mike. “What is the medical opinion on CBD and recovery? I am a person in long-term recovery and I’m also a recovery coach. I’ve been hearing more about CBD products, including ads on your show. What is the medical opinion of CBD and recovery?”
Dr. Nzinga Harrison: [31:24] Hey, Mike, congratulations on long-term recovery. That’s what’s up. Woop, woop. Just like in recovery, there’s a spectrum from people who believe in complete and utter abstinence, period. No nothing ever at all. At all. All the way over to what I would say the other end of the spectrum, which is harm reduction, which is like even if you’re using, how do we keep you alive? And everything in the middle. You can think of this on the same spectrum. And so the way I, Nzinga Harrison, so I’m not speaking on the whole medical opinion of all the doctors in the world, ok, Mike? This is the way I use CBD for my people in recovery. You know I practice harm reduction and abstinence based depending on the autonomy of the person who I’m taking care of. So the person I’m taking care of makes that decision. And then we work together within that framework. For a person who is benchmarking to complete and utter abstinence, CBD is not a psychoactive compound.
Dr. Nzinga Harrison: [32:24] So you can use CBD products and that is not increasing your risk for relapse to whatever substance or behavior that you’re in recovery from. I would much rather — now, this is swinging over to a harm reduction — for my people with any substance use disorder, even if it’s not marijuana, I don’t want those folks smoking marijuana. Because shared brain chemistry — so even though you’re not “addicted” to marijuana, you’re tapping that pathway and that puts you at risk for relapse to whatever substance or behavior you are addicted to. And so my people who are smoking marijuana, I always talk to them about the option. The harm reduction pathway is like smoking the whole plant, to vaping, to edibles, to CBD only products, to nothing. That’s kind of like the harm reduction cascade. And so I’ve definitely helped a lot of people move from marijuana smoking to edibles, to CBD only so that I can get the therapeutic parts of CBD without the addictive parts of THC.
Dr. Nzinga Harrison: [33:37] In a nutshell, Mike, the answer is that every medical professional you talk to is probably going to have a different opinion on this and will be able to find a medical study that supports their opinion. And so CBD can be used safely. I have found it to be a good strategy for reducing marijuana use. I have found it to be a good strategy for managing pain and anxiety without using other more addictive meds like pain medications or anxiety medications. I have found it to be a good strategy and there’s data for it to be a good supplement for sleep. Now, make sure you get a regulated brand, because all CBD is not created equal and we don’t regulate CBD products in this country, although they do in Canada and they do in Europe. And so I use PureKana. PureKana has not given us an ad and they have not told us to say that. But PureKana has like excellent quality control. You know, it’s not adulterated. It has the amount of CBD in it that it has and it has good safety data. That’s the main thing. It’s not addictive. It’s not psychoactive. It is not going to bounce you out of your recovery and be considered a relapse. And it can be a good strategy to stay away from some other substances even prescribed. That absolutely can do that.
Claire Jones: [35:02] OK, so our next question comes from Tara. She says, “My mother is 77 years old and has been waiting to go into some kind of recovery program since last fall. She was supposed to go into treatment earlier this year and then, of course, COVID came, and now that’s been really difficult. She’s been waiting for treatment for so long and is so desperate to get these drugs out of her system and to not be dependent on them that she’s tried to wean herself off. I don’t know what I can do, especially because I live 400 miles away. She wants to help fight this so badly and has no real medical support or resources right now. There needs to be accessible treatment plans for the elderly. They are more fragile and at-risk than ever and cannot be forgotten.
Dr. Nzinga Harrison: [35:40] Tara, you are preaching to the choir. And I am so frustrated by the lack of care and support continuum for our older community members. So I think the first thing I’ll say to you is that I want you to broaden your thinking beyond she has to go to treatment somewhere. As in like it’s a residential treatment program or go there everyday type of program. It is more difficult to take care of older people as an outpatient, but I would rather her have an outpatient addiction doctor and therapists involved in her care helping her wean than having her over there trying to wean herself and trying to do this just on her own right now. Geriatric doctors are the doctors who specialize in older adults, internal medicine doctors who are primary care doctors also do. So if she does not have a primary care doctor or if it is her primary care doctor maybe who’s prescribing the opioid and she doesn’t feel like she can have this conversation, I would say find a geriatric psychiatrist. Or a geriatrician, which is a geriatric, usually internal medicine, trained doctor who will also have the data waver to be able to prescribe Suboxone, the MAT waiver.
Dr. Nzinga Harrison: [37:12] And this is hard. I’m telling you, you are looking for a sliver of people. But go to American Geriatric Society. Google that and the state that you live in. They should have a provider directory. But even if they don’t, you can contact them and say, I’m looking for a geriatric doctor that can help my mom with addiction. And they should be able to give you some options. American Geriatric Society. And then I want you to do the same thing with American Association for Geriatric Psychiatry. Call both of those local chapters in your state and ask them to identify doctors who have the ability to help with addiction in older adults. And let’s get your mom connected for some outpatient care, at least to get us started so she can have the evaluation, be connected, start getting some therapy, start getting the other support, help with weaning off whatever she’s on and help with the decision does she actually need to go somewhere for treatment program or can this be done as an outpatient?
Claire Jones: [38:18] Why is outpatient harder with elderly people?
Dr. Nzinga Harrison: [38:21] One, your physiology is different. So as we age, all of our physiological processes get less flexible and so a smaller insult can make an older adult way more sicker. One small thing can have big consequences in a person who’s not otherwise healthy or younger. And so we have to be very much more in tune to that. And it’s higher risk. And so if you haven’t had that training, it’s easier to have you in a program where I can put eyes on you every single day to make sure that the decisions I’m making are not leading down a whole bunch of different pathways I’m not intending for them to lead down. Whereas I just have more latitude and that with a younger person without medically complex conditions. And most outpatient substance abuse treatment programs are not designed to see you everyday because the idea of outpatient is that your illness is more stable. You don’t have to be seen every day.
Claire Jones: [39:23] Right. That makes sense. Great. Our first AMA.
Dr. Nzinga Harrison: [39:27] I loved it. That was so fun.
Claire Jones: [39:30] I guess this whole show is kind of an AMA, though. And in order for us to keep doing these, we need questions from all of you. And like you saw here, some of them are really short, like, hey, what is the trauma bond? And some of them are longer. There are no bad questions. We want all of your questions.
Dr. Nzinga Harrison: [40:13] Thanks. Talk to you next week.
Dr. Nzinga Harrison: [40:21] In Recovery is a Lemonada Media original. The show is produced by Claire Jones and edited by Ivan Kuraev. Music is by Dan Molad. Jessica Cordova Kramer and Stephanie Wittels Wachs are our executive producers. Rate and review us and say nice things. And follow us @LemonadaMedia across all social platforms, or find me on Twitter @naharrisonmd. If you’ve learned from us, share the show with your others. Let’s help destigmatize addiction together.