Science Vs - Opioids: How America Got Hooked

Episode Date: March 23, 2018

More people in the U.S. died from opioids in 2016 than the peak year of the AIDS epidemic. So how did we get here? We speak to Prof. June Dahl, pain specialist Dr. David Tauben, and emergency physician Dr. Jeanmarie Perrone. If you or someone you love is struggling with an opioid addiction, in the US you can call the Substance Abuse and Mental Health Services Administration's National Helpline: 1-800-662-HELP or visit their website. Check out our full transcript here: http://bit.ly/2Pq1bZk Credits:This episode was produced by Wendy Zukerman with help from Rose Rimler, Heather Rogers, and Shruti Ravindran. Our senior producer is Kaitlyn Sawrey. We’re edited by Blythe Terrell. Additional editing help from Alex Blumberg and Sruthi Pinnamaneni. Fact checking by Michelle Harris. Sound design by Emma Munger. Music written by Bobby Lord. Recording help from Amber Cortes. And a huge thank you to all the researchers and doctors who spent time with us. We really appreciate it. Dr Andrew Chang, Dr Michael Vagg, Dr Andrew Kolodny, Dr Michael Von Korff, Dr Mary Lynch, Prof Gary Franklin, Prof David J. Clark, Dr Andrew Rosenblum, Frank Lopez, the Zukerman family, and Joseph Lavelle Wilson. Selected Readings: The National Academies of Sciences report on the epidemic This government report on the marketing of Oxycontin The Danish study on chronic pain This review of opioids and hyperalgesia For a list of our sponsors and show related offer codes, go to gimlet.media/OurAdvertisers Learn more about your ad choices. Visit podcastchoices.com/adchoices

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Yes, we're back with a new season. And over the next few months, we're going to be tackling sex addiction, UFOs, the ketogenic diet and serial killers. But on today's show, the opioid epidemic. More people in the US died from opioids in 2016 than those who died of AIDS in the US in its deadliest year. Another way to look at it? It has claimed more lives in 12 months than all 19 years of the Vietnam War. Opioids are now the biggest drug epidemic in American history. If you break the law and illegally peddle these deadly poisons,

we will find you, we will arrest you, and we will hold you accountable. This week, Trump said that to stop this epidemic, he wants to pursue the death penalty for drug traffickers and to tighten up border control to stop opioids coming in the country. But Trump wants to cut back on legal prescriptions too. That's the stuff coming from doctors. And this is the piece of the puzzle that we're focusing on today.

40% of opioid deaths in 2016 involved prescription opioids. That's painkillers like OxyContin, Percocet and Vicodin. And that 40% figure comes from the Centers for Disease Control. Now, in the last decade, doctors have been prescribing opioids by the bucket load. So, how did we get here? Why did so many doctors start prescribing so many opioids? After all, it shouldn't be a surprise to anyone that opioids can be addictive.

We've known this for ages. Morphine created all of these substance abuse problems during the American Civil War, and then heroin came. That was supposed to be a less addictive opioid. Yeah, heroin was developed as a legitimate drug. And yet, surveys from the mid-2000s showed that around one in four doctors were not concerned about prescription opioids causing addiction. So how on earth did these doctors think that opioids were going to be safe this time?

Well, it seems it all started with pain. Are you all mic'd up and everything? I guess I am. Great. Excellent. OK, I think we can just get started. OK. This is June Dahl. She's at the University of Wisconsin Medical School in Madison.

And June reminds me of Betty White. Betty White with a PhD. She has poofy white hair and getting her grammar right is something that she fusses over. Boy, that was a sentence ending with a preposition. Bad, bad, bad, bad, bad. June isn't a medical doctor. She started out as a scientist, a chemist, in fact. And she wasn't studying opioids, nothing like it. I was working on the surface tension of molten salts. Totally unrelated. But then in the 1970s, she was asked to teach a course

at her university on drugs. And June wasn't that excited or passionate about it, but with her background in chemistry, she knew the material, someone asked her to do it, and so she said yes. And it was this class, this seemingly nothing thing, that would lead to something really big for June. It would change the course of her life and end up playing a role in the opioid epidemic. So June had taught this random uni course in the late 1970s, which led her to being appointed to Wisconsin's Controlled Substances Board, which looked at how painkillers, like opioids, were being regulated.

And it was in this role that June starts reading about pain. Because I was thinking very seriously of the patients who had agonizing pain. And frankly, pain is not good for you. It doesn't build character. So it makes sense to treat it effectively. And June said that throughout the 80s and 90s, people weren't getting treated for pain effectively. Some doctors and nurses weren't actually trying to get rid of pain completely. Many just wanted to relieve some of it. And surveys of patients showed that many would still have a lot of pain from surgery. June says that even people who were suffering at the end of their lives

would still be left in pain. Even in people who were suffering at the end of their lives would still be left in pain. Even in people who were dying. Even in people who really had horrendous pain which wrecked their quality of life. And so some researchers started calling for better pain treatment. And June joined them. I asked her why this pain issue became so important to her. Oh, goodness, what a question. I don't know.

It just came to me as something that was critically important and there were opportunities to do something. By the mid-1980s, June started working with doctors in cancer wards, encouraging them to treat pain more aggressively. And so we started with cancer pain, but eventually we decided that all pain needed to be addressed. Chronic pain, pain after surgery, pain from a broken leg, June wanted everyone's pain treated better.

And when she looked around, one group of drugs that seemed to treat cancer pain really well was opioids. Yeah. So June and other researchers started to think that if opioids worked so well for cancer pain, then they should be used for other kinds of pain too. As June saw it, though, there was one big obstacle,

one thing stopping doctors from prescribing more opioids. And that was this. They were worried about addiction. People thought that, boy, if you took any amount of these drugs, you automatically became addicted. It was just such an excessive concern. At that time, June wrote that opioids weren't that addictive. And that's because a few articles were published in the 1980s

saying just this. One found that less than 1% of people who were given opioids at a hospital got addicted to them. Less than 1%. And June went on to study this too, finding pretty much the same thing. And from there, she and others just figured that opioids were safe for all kinds of pain. These results were just so exciting

because it meant that we now had a safe painkiller. The problem was that there were other studies at the time showing just the opposite, that opioids were addictive. But if you go back and look at the research, some scientists just discounted those cautionary studies. And we don't know why. Maybe they just got too swept up in the excitement over a possible solution to people's suffering. Of course, today, we now know that they were wrong.

A recent review of almost 40 studies found that opioids are more addictive than June and the other scientists thought they were. Around one in every 10 or 11 people who take opioids for chronic pain get addicted. And it's now understood that the longer you take the drugs for, the more likely it is that you'll become addicted. With the question of addiction, back in the early 2000s, there were quite a lot of booklets that you wrote. One of them says sort of addiction very rarely occurs in patients who receive opioids for pain control. Do you still agree with that? Oh boy, I would not agree with that statement just out of context. I think it has to be described in maybe a lot of ifs and buts and

whatever. And so these are from things that you wrote in the early 2000s. Do you wish that you hadn't written them? I had no idea at that point in time. I was working from the evidence that was available at that point in time. I guess you can say I was naive. My response was simplified, very simple, and it certainly doesn't reflect today's world. That's the tricky thing here. It's a lot easier to see where things went wrong when you've got hindsight. And back in the 90s and 2000s, when June and others were on this anti-pain mission, the idea that opioids were safe really caught on. In the mid-1990s, new drugs also hit the market, like the FDA-approved OxyContin,

which was slow-release opioids, supposed to last 12 hours instead of four to six. And their manufacturer, Purdue Pharma, said that this meant they were less addictive. So it all seemed to fit together. Opioids were safe now. One doctor remembers what it was like when opioids seemed like a miracle drug. Hello, Brooklyn, New York.

Ah, hello. David Taubin is a physician and specialist in pain medicine at the University of Washington in Seattle. And as a pain specialist, David sees a lot of people in pain every day. So a patient would come in very, very distressed, eyes closed, often tearful, leaning forward, clutching painful body parts. And like June, he wanted to stop their suffering. And when David started reading and hearing about how opioids were safe, he really wanted that to be true. Well, wouldn't it be nice if we could just give someone a pill and their pain would be gone

and they could lead the life that we all wish for ourselves? Wouldn't that be nice and easy? That's seductive. And David got really seduced. He was so convinced that these drugs were safe that he was prescribing some patients over 30 pills of opioids a day. I remember one patient saying to me, boy, the number of pills I'm taking, I can't even eat

because my stomach is so full of pills. Wow. It really is a lot of pills. And then this happened. David had a patient who had been taking opioids for a while and wanted to get off them. So David prescribed him a different type of opioid, one that he thought maybe would help the patient taper off the drugs easier.

And it turned out that the dose he prescribed ended up being too high. The patient actually died. It was an overdose. The patient's wife called David and said that he died in his sleep. This is something that my prescription did. I'm responsible. Oh my goodness. And how awful.

I still feel awful just telling this story. David told us that he'd actually prescribed the recommended dose. And when he got that call, he checked it again. I went back to the books. I studied it. I'd done it exactly as the textbooks told me to do it. And I said, the textbooks are wrong. What I've been taught is wrong, and I'm responsible. And I said, the textbooks are wrong. What I've been taught is wrong. And I'm responsible. And I said, I'm done. So that was the straw. And this is, I'm not going to let this happen ever

again. Now, it's actually very rare for someone who's prescribed an opioid from a doctor to die from it. In fact, one study estimated that it's way less than 1%. But when doctors prescribed so many of these drugs, that less than 1% can lead to thousands of deaths. And for David, the death of his patient was really a turning point. He started thinking about how he was prescribing opioids and he started to think about something else that had really been nagging him. He wasn't sure if the opioids that he was

prescribing were actually working, because some of his patients, they didn't seem to be getting better. What's going on here? Why do I feel so bad about this person's condition? Or is it the meds I'm giving them? Am I responsible for the fact that they're worse? So David starts looking at the data for chronic pain, and particularly back and neck pain, which is a lot of what he treats. Now, in the 2000s, it's estimated that doctors in the US were putting hundreds of thousands of patients on opioids

for more than a year. And as we talked about, taking opioids for a long time increases your risk of getting addicted to them. So was there evidence that all these opioids were helping people with their chronic pain? Well, here's what's bonkers. What is the evidence around chronic pain and opioids? Like, do opioids treat chronic pain?

What was the data? The data is still awful for the benefits of opiates for chronic pain. Awful. There were very few studies looking at this. So doctors were giving opioids to patients for months, sometimes more than a year, without good evidence that they would work. In 2006, one of the first studies came out looking at whether opioids could treat chronic pain. It was a Danish study that looked at almost 2,000 pain sufferers, comparing those who had been on opioids for more than six months

to those who hadn't. And there was no improvement in pain? No improvement in pain. Oh, yes. Probably the most widely used, inappropriately used opioid is for chronic back pain. So there's no good evidence that opioids can help people with back pain? This is not a condition where opioids are going to do anything good long term,

and we see worsened outcomes. Because I thought like, oh, well, I mean, I assumed opioids were addictive, but I also just assumed they're just really good at treating pain. Isn't that what opioids do? It is completely counterintuitive. And what you're saying is what many patients say. These are pain medicines. They help pain. And that was part of the seduction. So this one study made David suspicious about the use of opioids in treating chronic pain. But he also started to see another, totally different problem.

It became more and more apparent that for the majority of the patients I was prescribing the opioids for, they were actually getting worse, the majority of the patients at the high doses. People on opioids, sometimes their pain got worse? Yes. Some people will do worse. This idea that opioids could make some people's pain more painful started showing up in rat studies in the 1980s, but it wasn't clear that it happened to humans

until actually quite recently. Now it's accepted that it can. And here's how. Opioids basically kill pain by blocking a pain signal that sends an ouch message to your brain. But when opioids block some of these signals, it can actually make us more sensitive to the pain signals that do make it through. We can really botch the whole balance off. So even if there's less ouch messages, they can feel worse. Now, the research here is pretty new, so it's hard to say how many people have worse pain after taking the drugs. But it is being taken seriously enough that the FDA is now requiring pharmaceutical

companies to test this. The first results should be out next year. Given that there wasn't a lot of data, or no good data, on the long-term use of opioids, how did the medical community feel so confident in giving them out long-term? Well, that's a great question. So how did the medical community feel so confident in giving them out long term? Well, that's a great question. So how did the medical community feel confident that it was going to be effective and safe without any evidence? I don't know the answer. Did everyone just sort of get sucked in by the allure of opioids? Getting duped is too strong a word.

I think it's multiple gentle persuasions help move the pendulum over to why not. And now we've got compelling evidence this is why not. Looking back, David says it was just really complicated at the time, because for some of his patients, opioids actually did help their pain. Well, some patients did do well. Of the few studies that we do have, some find that maybe 10 to 25% of chronic pain patients will benefit from taking opioids in the long term, which isn't nothing.

And also, opioids do work to treat other kinds of pain as well. Like, David says there's good evidence that opioids can treat pain from a broken bone or when you get a tooth pulled out. Opioids work and opioids are very effective. What's interesting here is that even when opioids do work, they might not be the best painkillers around. Like when it comes to treating pain from broken bones, a study came out last year which found that after two hours,

one high dose of Tylenol and Advil worked just as well as Percocet, Vicodin or Codeine. But of course, David didn't know any of this. He just kept hearing that opioids were safe and were effective. And somewhere else that he heard that from was pharmaceutical companies. Back in the 1990s, David used to have regular meetings with people working for pharma. It was something that many doctors did back then, he said.

No biggie. They'd give David some samples, tell him about some new products. And frankly, the person who was pitching it were typically very attractive people. They came beautifully clothed and clothed, and the women would market to the male physicians, and the males would market to the male physicians and the males would market to the female physicians. Really? Oh, yeah. Why be astounded? Advertising is advertising.

Do you think it, I mean, when you think back at how it all happened for you, do you think that was a part of it, the pretty ladies in the lab coats selling the stuff? They didn't wear lab coats. Okay, that was good of them. It's seductive. And I use the word intentionally because it's seductive to be able to do something so difficult so simply. It's seductive to be given the product that you're going to be using, so it was there ready at hand.

It was seductive when you get pens and coffee mugs that market the product. And it's seductive when they pick super attractive people. So I'm not suggesting that I was not influenced. The question of how significant that influence was on my subsequent practice would be worth a separate conversation. And maybe laying down on the couch with a psychologist. So for David, multiple gentle persuasions pushed him to prescribe more and more opioids.

After the break, the persuasions become less gentle. Welcome back. So we've just heard that through gentle persuasions, doctors around America became convinced that opioids could treat people's pain safely and effectively. And they got a bit too excited. A lot too excited about it. In 2013, doctors wrote so many prescriptions

that every American adult could have had a bottle of pills. That's according to the CDC. Now, the majority of those pills came from doctors' offices, doctors like David. But to fully understand how the epidemic unfolded, we have to look somewhere else, at hospitals, because something weird was going on there. Hello. Sorry, I just washed my hands.

Great, so did I. Yeah. This is Jean-Marie Perrone. She's an emergency physician at the Hospital of the University of Pennsylvania in Philadelphia. And Jean-Marie said that she started prescribing more and more opioids after these new guidelines came in for her hospital. And they came in from a group called

the Joint Commission. And I don't know who started it or, you know, who they answer to, but we all answer to them. And for you, that commission was one of the key players in this? Definitely. The Joint Commission is an independent not-for-profit that regulates the vast majority of hospitals in the US. So if you want to run a hospital in the US and the Joint Commission says jump, chances are you have to say how high.

And in 2001, the Joint Commission said doctors and nurses now had to jump. That is, they had to start asking every patient about their pain. And specifically, to give it a score from 1 to 10. So, you know when you go to the hospital and the doctor might ask you, out of 10, how much pain are you in? Well, that came from these new guidelines. And right away, this changed how Jean-Marie did her job.

Now, along with checking every patient's heart rate and temperature and blood pressure, she was also asking them to rate their pain on a scale. Every single patient, no matter why they were admitted. So on every nursing, every floor in the hospital, not just the emergency department, post-op, pre-op, everywhere, they asked you about how is your pain. First of all, they asked you, do you have any pain? You know, so that like, you know, somebody might come in because they, you know, had a fever. And now they're being asked about pain for every single visit. And people could say, yeah, you know, I always have back pain.

So now she might give painkillers for the back pain and then treat whatever they actually came to the hospital for. And this emphasis on pain? Well, it all just got a little out of control. People were asked after they left the hospital, how was your pain treated and was your pain treated adequately and did they do everything they could to treat your pain? Oh, wait, so your boss would be saying, like like your patients aren't happy with what you're doing,

you're not being a good doctor. Yes. And so there was a big push to just start treating everyone who said they had pain, pain equaled opioids. We really just started treating everybody's discomfort with opioids. Everybody's discomfort. Every type of pain, every type of condition, if there was pain involved, it got treated with an opioid. Jean-Marie told us that the push wasn't to use more Tylenol or Advil to treat people's pain, but to use opioids. And it wasn't really clear why that happened, but it was partly because doctors thought that opioids were the strongest and best kind of pain relievers. It was mostly just you couldn't get the IV in fast enough to give them something to make them more comfortable. And I used to pride myself on the idea that we can, you know, take your pain away very quickly and make sure you were comfortable.

So you had this big focus on pain and doctors who were treating that pain with opioids. And then money entered the mix. Here's how. The US government cared about those pain surveys that patients were filling out. And hospitals that treated patients with government insurance, like Medicare, would be financially penalised if they got bad pain scores. So, ultimately, hospitals needed to do well on these surveys. And to help that along, Jean-Marie said that some hospitals would reward their doctors for getting good reviews. One way or another, whether it was your salary and they were withholding it and you were

getting some part of it back to meet these incentives or not. There was money held on the table. So it's fair to say there was financial incentives for doctors to give opioids? I would say it's fair to say that there were financial incentives for doctors to treat pain aggressively with opioids. Jean-Marie said that this didn't happen at her hospital. And actually, it's not clear how many hospitals had financial incentives tied to pain treatment. Just generally, when we look at

the research, there's not good evidence about how much these pain surveys affected doctors' practices. Still, as of this year, the US government will no longer penalise hospitals for bad pain scores. And the Joint Commission brought in new guidelines this year encouraging hospitals to decrease opioid use. And from what doctors like Jean-Marie told us, it seems that these pain surveys were just another gentle persuasion encouraging them to use opioids. So I, you know, for a long time, I just gave everyone what they wanted because it was, you know, it was what they wanted.

It was what we were told to do. It was, you know, the way I could then spend more time on patients who really needed my ability to think through their problems. Did you have a bit of a come to Jesus moment about how bad opioids were? You know, it was just this pattern of people who weren't being particularly helped by them, who were coming in with escalating doses. And it just sort of dawned on you at some point that it was like, this is just bad. It's bad.

What we're doing is bad. It's bad. What we're doing is bad. So given that doctors like Jean Marie thought that these pain guidelines were persuading them to prescribe more and more opioids, what do the people who actually wrote those guidelines think about their influence? We went back to one of the architects of the guidelines. You might remember her. Oh, boy. June Dahl, the Wisconsin scientist who was on a mission to treat pain. Well, June's team actually wrote the guidelines for the Joint Commission.

But I want to emphasize that nothing in the standards indicated how pain should be treated. That was not, there wasn't anything in the standards that said, thou shalt give every patient morphine. There were no words about that. There was no mention of how to treat, no mention of what drugs to use. And that is true, except that something else was going on as well. In June's story, there are fingerprints of everyone's favourite villain, Big Pharma. In an interview in 2006 with the University of Wisconsin, she said, quote, we're blessed that Purdue Pharma gave us a significant amount of money to keep things operational here, end quote.

And that's Purdue Pharmaceuticals, the makers of OxyContin. And so I have to ask, June, what was your relationship like with Purdue Pharmaceuticals? So what was my relation with Purdue Pharma? I suspect that I spoke at meetings that they probably sponsored. I did not get paid by them for anything. She was involved in making a book that was, quote, supported by an unrestricted grant, end quote, from Purdue Pharma. What did that mean? That mean they gave the money, but they didn't have anything to do with the content. Nobody reviewed it. I don't know if anybody even read it. But if anybody had tried to tell me what to write, I would have told them to go you know where.

And do you think that just by the fact that they paid for it, it might have affected or influenced your work in some way? No. No, I can't. How would you think that would influence my work? Tell me seriously because I certainly am extremely independent and I would hate to have somebody tell me what to write. It's so, I mean, from the outside you can see how it looks, right, June?

I mean, you're writing these booklets that are saying that opioids are safe and addiction rarely happens and they can be used for all sorts of pain. That was the evidence at that point in time. Yes. And then that's also very much in the interests of the people who are paying for these booklets. I guess you're right. I don't think at that point in time that at least I didn't think of this in terms of bad, bad, bad stuff. But I never looked at it in that context. I just don't recall being influenced by them that much. Because there was, I was on this, I don't know what the right word is, mission. Mission to really stop people from hurting so much. And when June looks around now at all the problems that have been caused by opioids, she just can't believe it.

It makes me feel pretty bad. I don't know what the right word is. Discouraged, disgusted, because that was never the intent. I mean, what would you class your role in this as? Oh, dear. I don't know. Obviously, I am responsible for this current opioid crisis, I guess. Anyway, I'm being silly.

What is my role? I don't know. A trivial role, that's for sure. Now, June is being sarcastic here. She's not claiming to have single-handedly orchestrated the opioid crisis. And throughout the 90s and 2000s, she was far from the only person suggesting that opioids were safe. And there were plenty of other academics

who were involved with pharmaceutical companies and even big organisations, like the Joint Commission, the group that brought in the pain standards for hospitals. Purdue paid for programs which trained doctors and nurses on how to treat pain better. Last year, the Joint Commission defended themselves, saying that a lot of other organizations got money for education too. We reached out to Purdue and they said that they've stopped their speakers programs and directly promoting

opioids to doctors. As soon as you try to wade into this to understand how the medical community seemingly all of a sudden felt comfortable and confident prescribing opioids, it just gets more and more complicated. But a few things are clear. Doctors who are prescribing opioids should have been more sceptical of these drugs and of the pharmaceutical companies. But they weren't, and here we are today, where roughly 40% of the people dying in the opioid epidemic,

that's almost 17,000 people in 2016, are dying from prescription opioids. Now, it's not necessarily that the patient gets the pill from the doctor and then dies. While, yes, that can happen. For many of these overdoses, these people got their hands on someone else's pills. And that's because these days there's just a ton of opioids sitting around in medicine cabinets all over the country. And teenage kids can find them, they get shared with their friends, they get sold on the street, and then people can overdose. The point of all this is to say that if doctors hadn't gone on an opioid prescription binge over the last couple of decades,

then some people who are dead probably wouldn't be. Now something else is going on. People are dying from non-prescription opioids. It's stuff like heroin or illicit fentanyl. And that's becoming a bigger deal. Now, there are lots of reasons as to why this is happening, but are doctors part of it too? Well, it's very murky tracing a person's path to a heroin overdose,

but some studies at treatment centres have found that maybe a quarter or more than a third of heroin users started with prescription drugs before graduating to heroin. And Jean-Marie, our ER doc, she's seeing what's happening firsthand. In Philadelphia, where she lives, paramedic teams are getting called out to fentanyl and heroin overdoses pretty much every day. You know, we're finding people with needles in their arms

because they're dying so quickly. Immediately upon injection, it's someone who becomes immediately unconscious and dies in five minutes. Pennsylvania, the state where Jean Marie lives, is one of the hardest hit in the country. So we have to take some responsibility for how we got here. You know, I think I've heard some prominent leaders say that, you know, when we build the wall, we'll, you know, we won't have all these drugs in this country. I don't think that's true. And that's where obviously the physicians come into play. We were writing the prescriptions. How does that make you feel like now that you see the real pointy end and the kids who are overdosing because you're at the front line of

that and then seeing that you're you have a role to play in what's happening no it's absolutely terrible and i feel you know tremendously sad um we we had a patient who died in his own home with his family he had gone to shower and clean up and they, you know, heard a fall and went to check on him. And he was, you know, in the bathroom. How old was he? So there was, I mean, they're generally often in their 20s. And those are, you know, just so sad. They had family.

They had people who cared about them. And then do you have to talk to their parents? We do have to talk to their parents. And it's just devastating. And then do you have to talk to their parents? We do have to talk to their parents. And it's just devastating. It never gets easy to talk to a mom who had a baby 16 or 25 years ago, and now that baby's gone, and it's the same every single time. I have kids who are like 20 and 19.

But I think it's just the moms are moms everywhere. And it's just a terrible, terrible, terrible sad. And, you know, if they've been aware, most of them have been aware that the kids have been in trouble and that they've gotten them into rehab. They've done everything they could, you know, hoped that they were doing better and thought that they were doing better. And just that, you know, it sort of creeps back up. You know, there's really no words. And often the parents found them or in the cases I can think of, so they knew that it was going to be bad. And this is the part of the story

that we're going to talk about next week. The people who are caught up in this epidemic. If you're dealing with an addiction, what should you do? Should you go cold turkey and tough it out? Should you work your way through 12 steps? Or are drugs for addiction your best shot? That is, are we looking to Big Pharma for the solution again? You know, who cares if they're going to be on opioids for the rest of their life? You know, I don't care. I mean, that doesn't make any sense to deny them that

just because, you know, you have some kind of moral compunction against that. And if you or someone you love is struggling with an opioid addiction, in the US, you can get in touch with the Substance Abuse and Mental Health Services Administration's National Helpline. They're at 1800 662 HELP. That's 1800 662 HELP. And we'll link to their website in the show notes so you can find counselling and treatment options in your state. This episode has been produced by me, Wendy Zuckerman, with help from Rose Wimler,

Heather Rogers and Truti Ravindran. Our senior producer is Caitlin Sorey. We're edited by Blythe Terrell. Additional editing help from Alex Bloomberg and Shruti Pinamaneni. Fact-checking by Michelle Harris. Sound design by Emma Munger. Music written by Bobby Lord. Recording help from Amber Cortez. And a huge thank you to all of the researchers and doctors who spent time speaking with us. We really appreciate it. That's Dr. Andrew Chang, Dr. Michael Vagg, Dr Andrew Kolodny, Dr Michael von Korff. Thank you for all of your notes. Dr Mary Lynch, Professor Gary Franklin, Professor David J. Clark, Dr Andrew Rosenblum, Frank Lopez, the Zuckerman family, and Joseph Lavelle Wilson.

I'm Wendy Zuckerman. Back to you next time.