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PRE Interviews: Dr. Stephen Loyd

Dr. Stephen Lloyd is the chief medical officer at Cedar Recovery in Nashville. He treats people with substance use disorder and specializes in those who also happen to be pregnant. Under Tennessee Governor Bill Haslam, Loyd served as the state's 'Opioid Czar,' and he's currently vice-president of the state's board of medical examiners. He's been in recovery from opioid use disorder since 2004, and his story with addiction inspired the main character of the Hulu miniseries Dopesick. He visited Goldsboro on Oct. 13 for a drug recovery conference at Wayne Community College. There he sat for an interview with PRE.


RYAN SHAFFER, PRE: This is PRE, Public Radio East, I'm Ryan Shaffer. Joining me at Wayne Community College is Dr. Stephen Lloyd. He's the chief medical officer at Cedar Recovery in Nashville. But you may know him, or at least his story, from the Hulu miniseries Dopesick, whose main character is largely based off of Lloyd. Loyd has also served as Tennessee’s Drug Tsar and currently sits on the state’s medical board. Doctor Stephen Lloyd, it's great to be speaking with you.

DR. STEPHEN LOYD: Thank you for having me.

SHAFFER: You spoke today at a conference about substance use disorder and recovery. I listened to your talk, and it was very frank and open. You've been in recovery for almost two decades after a very long battle, if you don't mind, how did it start and when did you realize that it was perhaps a problem?

LOYD: It started in my last year of residency in internal medicine. I'd been out of medical school for almost three years, and it started with just taking 1/2 of a pain pill on the way home from work one day. And really thinking that I'd found a cure for my ills, for lack of a better term. It progressed very quickly, and so inside of two and a half years, I was using nearly 100 hundred pain pills a day and adding stuff to it because I couldn't sleep. Xanax came along, and that became how I slept. So, my life was falling apart personally, but professionally, it was still great. I got intervened on by my dad. I've been into it for coming up on four years at that point. And then Dad just put it in front of me, and I knew that I was in trouble. I actually knew I was in trouble for a while. I remember the day that I went from taking one at a time to two at a time. I remember specifically where I was, and I remember looking at myself in the mirror thinking “This is bad.”

I couldn't tell anybody. I was afraid of what I would lose. I was afraid people would know. I was ashamed, and I really just thought that I would just keep doing it until I died. Luckily for me, I didn't. I got help, and as a professional, as a doctor, I had access to the best care, and it changed my life. Not only personally, but professionally and more importantly for me it changed the atmosphere that my kids grew up in, who are now grown.

SHAFFER: You have this flashbulb memory of going from one to two. And you say you remember precisely where it was. Where were you?

LOYD: I was in my aunt's bathroom. She lived out in the out in the country, and she was always a good source of pills. She didn't know I was taking them, but she had always had issues and so she always left her medicine in the cabinet. So, I went to her house and went into her bathroom, and I remember needing two at a time rather than one. I was standing in her bathroom. I remember it very vividly, and I remember putting it in my mouth and I looked at myself in the mirror and said “Steve, this is a problem. And what are you going to do about it?” Then immediately, it just went away, and I just put it out of my mind.

SHAFFER: You shared a story with the audience. You're in Alabama. Your kids are at the beach, and you're in a pharmacy parking lot. Would you mind sharing that story and what's going through your mind?

LOYD: I had at that time it was near the end of my addiction and I was only a few months away from getting help but didn't know it at the time. I was using about 100 pain pills a day. So, we're going to the beach for a week, so I need 700 pills, and I actually got my hands on 700. It's pretty hard. And I took them all by Thursday and we're staying until Sunday, so I knew I was going to get sick. I went around to different doctor's offices, looking for one that I thought was a pill mill, and I couldn't find any. So, on the way back to our condominium, I stopped in front of a Rite Aid pharmacy and pulled in the parking lot. I'm a country boy, so back then, I had guns on me. I carry a permit and all that. Don't do that stuff anymore. But I was younger, and I pulled a gun out and laid it in my lap. In the parking lot and I said “You know, I could write myself a prescription. I have a DEA number, but they track that. I could rob this pharmacy.” I sat in that parking lot for a long time and contemplated strong arm robbing it. Keep in mind, at the time, I was a professor in medical school. I was seeing patients in my community. I was a doctor in the hometown I grew up in, and I had what's called in recovery terms as a moment of clarity. I'm very grateful for that moment of clarity. The thing I thought was I couldn't come back from that. Right. That's a strong-armed robbery. That's a felony. I'm not a criminal. I've never done anything like that, so the chances of me getting away with it were pretty low. So, I actually had a couple of clear thoughts there and wound up being sick for the next three days. But, luckily for me, I did not rob the pharmacy.

SHAFFER: What about substance use disorder puts people in that position?

LOYD: It’s the thing we talked about with the audience today. It’s that the part of our brain that the drug takes over, hijacks pretty much, is the part of our brain that's responsible for our will and our desire to live. That will and desire to live is replaced by whatever the substance is, so that part of the brain's goal, instead of being the will and desire to live, changes to I have to have this – and not only do I have to I have this, I have to have this or I'm going to die. So, I tell people, what would you do to get your hands on the thing you thought you would die without, and the answer to that, as you well know, is anything and that's where I was. Now, did I know that at the time? No. But as I've gone on in this journey of learning about addiction and I start to have those insights, it's really pretty neat, going “Oh, that's what happened.” Because at the time I looked at it as just something that happened, but there's actually a reason behind it. I think when people start to understand that, they start to get a little bit better feel for what people are up against, and I think it helps their empathy.

SHAFFER: There's a scene in Dopesick where the main character Dr. Samuel Finnix, played by Michael Keaton, visits one of his own patients to secure some pills. That was based on a true depiction of something from your life.

LOYD: I had a patient that I'd seen on and off that I knew, you know, was in that, you know, in that field. And so I went, you know, drove down there to see him.

SHAFFER: And you got a call.

LOYD: If you watch the scene, the Keaton character is buying drugs from one of his patients late at night and two people walked by in the background, almost unnoticeable unless you're looking for it. For me, that was the important part of the story because a few weeks later I got a call from one of those people that were walking behind that night and saw me -- I don't know if they're walking, but they definitely saw me -- and it was a high school friend and he said, “Hey, Steve, I love you, but people are starting to recognize your vehicle.” I knew what he meant, and I remember I can't have that. Right. I can't. I can't have my vehicle being known in a place that everybody knows what's going on. I knew it was under surveillance, or probably was, and it was just a really ominous warning sign for me. Honestly, because that happened kind of towards the end, it was one of the things that pushed me in that direction, like knowing “OK, I'm not going to be able to keep doing this.” But he was calling me out of friendship and love going. “Hey, man, you got out of here and we don't want you coming back.” Right. That's kind of the message. That’s not what he said, but that's what he meant. I got to thinking about it with you, I don't think I’d ever gone back. Now to think about it, I never really thought about it before, but I don't think I did it again.

SHAFFER: You never went back to the patient?

LOYD: Right, never went back to that house.

SHAFFER: This was in your . . . where was it?

LOYD: Hometown. That's where I was practicing medicine at the time, Johnson City, Tenn.

SHAFFER: I'm curious about how you've refined that story to connect with audiences over the decades, so what's changed in your presentation?

LOYD: Well, at the core of my story, it has always remained the same – even from the first time that I started using it. It has been refined through the years as I have grown more comfortable with certain aspects of it, mainly the abuse component. The genetics has always been there, the dirty underbelly, as everybody likes to hear about has always been there, but the abuse component of it is something that's grown with time, and I have changed it basically as a result of interaction with my patients and seeing things that they were struggling with and having a hard time finding connection. So, I just got more comfortable over time with sharing those aspects to try to make connections with people who maybe had some of the same experiences by abuse.

SHAFFER: We're talking about more than substance abuse?

LOYD: Absolutely. When I talk about abuse, I'm talking about the three core adverse childhood experiences, which are physical, sexual and emotional abuse. I started pretty early talking about the physical abuse – and I don't want to give degrees of badness to anything here, they're all not good – but the sexual abuse was a little harder to talk about. As I got more and more help with it going forward, the term I use is it became less of the bogeyman in the closet. So, I became more comfortable with sharing when in front of audiences.

SHAFFER: You talked about how it's helping you connect with patients. Why is that important? You talk about adverse childhood experiences aces.

LOYD: I think it's really the core of people getting better long term. Adverse childhood experiences put you at risk for a lot of things health wise: diabetes, hypertension, all different kinds of cancers, substance use disorder as well as mental health issues. I know, in my personal experience and treating patients, that if we address those underlying drivers as the abuse, things get easier going forward. They don’t go away. It doesn't change it, but the reaction to it changes, and I think that's really important in recovery going forward.

SHAFFER: You spend a lot of time nowadays educating on substance use disorder. What we know about substance use disorder and how to treat it has come a long way. Substance use disorder is a mixture of biology, psychology and the social environment. You call it the biopsychosocial model. Could you share that model with our listeners?

LOYD: Well, traditionally when we learned about addiction, that's how it's taught. They call it the BPS, the biopsychosocial model. For me that always sounded like psychobabble, right? If you want to put somebody to sleep, tell ‘em you’re going to have an hour lecture on the biopsychosocial model. So, I just turned it into a slot machine. The slot machine is when the three sevens come on the pay line, and that's when the money comes out. So, I teach addiction that way: the genetics, then trauma and then opportunity. Basically, everything we're going to talk about the rest of the day when it comes to abatement and spending this money, help is going to fall in one of those three categories. People understand it better. They don't hear biopsychosocial, like “Oh, the slot machine.” So, I've got a genetic predisposition – mom, dad, and relatives with some kind of substance use disorder. Then the trauma: This happened in my life early on and it was an adverse childhood experience. It put me at increased risk. Then really, all you're waiting on is the social opportunity. For a lot of people and looking at young folks that I take care of, a lot of them got started when they had their wisdom teeth removed, they experimented at a party, r they had a surgery from a sports injury, an injury that they had suffered some other place, or they had a friend who had that happen to him and then shared it and it went from there. So, it's a really common pathway, and I think when people understand that, they can start to see what the risks are and start to have a better understanding about how to address it,

SHAFFER: My last question has to do with how we train doctors. Your doctor and you speak a lot with those who develop medical curriculums, and every doctor has to. Every school has a curriculum, and every doctor has to be certified. In these conversations, what are you talking to them about and what needs to change?

LOYD: This needs to be in the formal curriculum, and I think the only way to ever get that to happen, or at least the easiest way to get that to happen, is to have questions on the national board exam that we all have to pass before we can get a medical license in every state in the country. I think that there's a lot to cover in medical school and residency and they've gotten a lot better about it. Your generation is wonderful. Right. The classroom is not the typical classroom and the most ineffective way to teach is an hour-long lecture. Everybody knows that. So, it's got a lot more innovative through the years. But the curriculum is still packed. But if you look at addiction and the ramifications of addiction, it's the second biggest health problem in the United States, outside of COVID. People always bat an eye at that and I'm like “No. Don’t bat an eye at it.” Nicotine addiction is the number one preventable cause of death worldwide. So, it's a huge issue, but we learn almost nothing about it. I think some of the things that you see in how people are treated with addiction very poorly, it's really out of a lack of education for the providers because they get frustrated, don't know what to do and the easiest thing to do is kick them out or say “I don't want you” or “you did this and so you can't come here anymore” rather than educate them and get them to help these folks. Because when you kick people out, you drive them to the street and that's where street value comes from. That's where the market gets filled by drugs like heroin and fentanyl. So really, we need questions on the national board exams because I don't think that there are medical educators out there that don't realize this is important. Matter of fact, the accrediting body for all the residency programs in the country, it's called the Accreditation Council for Graduate Medical Education, the ACGME – terrible name – but they are now putting this in the formal curriculum and residency programs, and that's a good thing. That's a really good thing.

SHAFFER: You were caught up in substance use disorder in the late ’90s and early ’00s, but the opioid epidemic continues to this day. We have these settlements from opioid manufacturers and distributors, so there is an urge to say it's over and that we've closed that chapter, but we know it's not over. Where are we now and what concerns you most?

LOYD: It's actually still getting worse. Some of the things that we've talked about already were well-intentioned, but they actually led to more overdose deaths. North Carolina Attorney General Josh Stein was here earlier today, and he talked about 11 North Carolinians dying a day right now – highest it's ever been – and a lot of that is due to unintended consequences. Whenever you start to restrict something that people are addicted to and you don't get them help, then they're going to continue and they're going to replace it with whatever fills the market void. In our case, the market void was initially filled by heroin, which was bad, but not nearly as bad as fentanyl. So, overdose deaths have continued to skyrocket because the fentanyl is more and more potent, and more and more deadly. We just haven't made progress fast enough on the treatment and prevention end, and I think we'll get there. I'm really hoping that this year or next year is the peak and that we start to see a plateau. I think that's possible with the opioid abatement money.

The conversation going forward is what we are discussing, which is the abatement: how do we make the most effective use of these dollars? There's a treatment system out there that probably doesn't want to change. They want to take these dollars and fund more of what they're doing right now, and I would argue that while what they're doing right now is not a bad thing, it certainly hasn't made a dent in our issue. I think we've got to be open-minded enough and willing enough and you're going to take the leaders that are going to be able to do that to allow us to direct our money to things that are going to make a difference and to measure it. And if it's not making a difference, having the courage to change path. I think that's the key because if we get locked into this and say we're going to do this come hell or high water, then what we'll do is distribute the money – and we're good at distributing money. I think our challenge is to make effective use of this money, and the only way to do that is to have goals, to measure those goals, and be willing to move resources to achieve those goals.

SHAFFER: That was Doctor Stephen Lloyd. He's the chief medical officer at Cedar Recovery in Nashville. Tennessee. Thank you, doctor.

LOYD: Thank you.

Ryan is an Arkansas native and podcast junkie. He was first introduced to public radio during an internship with his hometown NPR station, KUAF. Ryan is a graduate of Tufts University in Somerville, Mass., where he studied political science and led the Tufts Daily, the nation’s smallest independent daily college newspaper. In his spare time, Ryan likes to embroider, attend musicals, and spend time with his fiancée.