Science Vs - Opioids: Kicking America's Addiction

Episode Date: March 29, 2018

America’s got an opioid problem. So where do we go from here? What can actually help people struggling with opioid addiction? We speak to Dr. Anna Lembke, Dr. Marvin Seppala, and a patient we call Mischa. UPDATE 04/17: We’ve adjusted a couple of lines of script in this episode to clarify the role of religion in Alcoholics Anonymous and Narcotics Anonymous. A previous version of this episode incorrectly implied that the 12 step philosophy considers addiction a sin and a “defect of character”. 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: http://bit.ly/2LB4kEo To find a list of our sponsors and show-related promo codes, go to gimlet.media/OurAdvertisers This episode has been produced by Rose Rimler with help from Wendy Zukerman, along with Shruti Ravindran and Romilla Karnick. Our senior producer is Kaitlyn Sawrey. We’re edited by Blythe Terrell. Additional editing help from Lulu Miller. Fact checking by Michelle Harris. Mix and sound design by Emma Munger. Music written by Bobby Lord. Recording help from Marissa Shieh and Julia Smith. For this episode we also spoke to Dr. Hilary Connery, Dr. Ben Davies, Prof. Linda Gowing, Dr. Laura Payne, Prof. Suzanne Nielsen, Prof. Tom McLellan, and Prof. Wayne Hall. Thank you so much for your help. And special thanks to the Rimler family, Devon Taylor, Sarah McVeigh Joseph Lavelle Wilson, and to everyone who spoke with us about their personal experiences with addiction and treatment. Selected readings: The White House report on combating drug addiction This study that followed about 150 people in NA This review on buprenorphine and other medicationsThis review on risk of death This survey that asked doctors what stopped them from prescribing buprenorphine Learn more about your ad choices. Visit podcastchoices.com/adchoices

Hi, I'm Wendy Zuckerman and you're listening to Science Versus from Gimlet Media. America is now deep in an opioid epidemic, with thousands dying from heroin, fentanyl and prescription opioid overdoses. If you want to know more about how we got here, go back and listen to last week's episode. On today's show, we're looking at treatment. Over almost 20 years, the number of people in the US looking for treatment for an opioid addiction jumped by more than 600%. So the pressing question of the moment is this. How can we possibly help these people? Did you grow up here in this house? Yes, I did. Oh yeah, there's the wall of pictures.

How old were you here? This was the year I graduated from college. I might have been, I'm pretty sure I had taken some Vicodin before that picture. The guy showing me pictures from his college days is Misha, not his real name. He lives in Los Angeles, and we visited him at his mum's house in the suburbs. Misha was always an anxious kid. Like, I didn't go to a lot of dances when I was a kid.

I didn't... I love having friends and love spending time with other people, but large groups of people, especially who I don't know necessarily or don't already have a relationship with, made me feel very uncomfortable generally. Misha has also struggled with depression, and there's just always been this voice in his head that was telling him to feel bad about himself. And so to quiet these voices, Misha started experimenting with drugs in high school. He tried marijuana and cocaine, and it wasn't until he went to college

that he found the drug that could turn his anxiety and depression way down. Opioids. The first time he tried them, a friend gave him this pill right before going to an event that the college was putting on. It was formal and there were going to be tons of strangers around. And I remember feeling like, oh, I don't feel weird being with all these people dressed up all nice and standing rigidly. That would normally stress me out. And I just felt okay with it. It felt good. So Misha started taking opioids every now and then, whenever he could get them.

And eventually he met this guy who could get him opioids, stuff like Vicodin, Percocet and Oxycontin more regularly. But one day the friend called him up and told him about something else that he could try. Oh, I think he was talking about how, oh, it's really cheap, I can get it whenever I want, you know, why it's the same thing as doing Oxycontin, you know, why are we doing Oxycontin?

Let's do heroin. Heroin. When Misha heard that word, he thought, no, I can't do heroin. But eventually he came around. He thought about it and he didn't really see how heroin was that different to OxyContin. Plus it was cheaper and now it was easier to get. And at first it felt great. He could relax and make friends. He even fell in love for the first time. And heroin helped give him this magical feeling. It just felt amazing all the time. I don't know,

it was like I was living in fantasy land. Like it felt like living, you know those board games like Candyland? Like it felt like living in that kind of thing. All of these possibilities that I always considered I was either not interested in or it would just never happen became possibilities for me. At first, he was snorting heroin. But then he started injecting. Why did you inject? It's a very unique feeling.

It's like a warmth that... Have you ever peed in a wetsuit yeah so imagine that warm not pee but warm feeling moving throughout your veins and your body rising up to your skull it's a very gentle very serene experience but within a couple of years the magic was wearing off instead of connecting connecting him with people, drugs were isolating him more and more. He was hiding his drug use from his friends, and that was getting really hard. On top of that, college was almost over, and he didn't know what he wanted to do next. And it was then that Misha realised that he actually had no way to deal with the ups and downs of life without using drugs.

But now, like, heroin had become a complete crutch for. Right, yeah, I mean, it was how I coped. I didn't really, I didn't use those formative years to figure out other ways of coping. I just basically used drugs. And then one day he injected too much and he overdosed. I met sitting at my desk, I do the heroin and then I sort of sit back and I put some music on and I smoke a cigarette. And the next thing I know, I'm looking at the ceiling and my head is like this back. I mean, I had to like grab my hair to pull my head up because the muscles were so tired.

This actually didn't stop him from using, but eventually he started to think that he needed help. So he went home to tell his mum. He steeled himself for a tough conversation, and then he knocked on her door. I think she'd been doing something in her room, and I knocked on the door, and it's like, I have something to tell you, and I need help. I'm using heroin.

I was feeling better because I had opened up. It felt like a burden, and it felt awesome to be seen. Even if it was this horrible thing, it felt awesome. His mum was horrified. And I remember her reaction was just shock, like freeze, shock. And then I think it went to sadness and helplessness. Helplessness. They didn't know what to do next.

And the risks here are so high. Misha had already overdosed, so they felt like they had to do something and fast. But what? The problem is that that answer isn't clear. The two solutions that consistently come up seem like polar opposites. One, stopping drugs completely and heading into a 12-step program. And two, using medication, that is, using a drug to get off drugs.

What's your best bet? When we come back, it's science versus opioid addiction. What does the AI revolution mean for jobs, for getting things done? Who are the people creating this technology and what do they think? I'm Rana El-Khelyoubi, an AI scientist, entrepreneur, investor, and now host of the new podcast, Pioneers of AI. Think of it as your guide for all things AI, with the most human issues at the center. Join me every Wednesday for Pioneers of AI. And don't forget to subscribe wherever you tune in. It's season three of The Joy of Why,

and I still have a lot of questions. Like, what is this thing we call time? Why does altruism exist? And where is Jan 11? I'm here, astrophysicist and co-host, ready for anything. That's right, I'm bringing in the A-team. So brace yourselves. Get ready to learn. I'm Jana Levin. I'm Steve Strogatz. And this is Quantum Magazine's podcast, The Joy of Why. New episodes drop every other Thursday, starting February 1st. Welcome back.

We just met Misha, who told his mum that he wanted to get off heroin. And after that, they didn't know what to do or where to go. And this is becoming a bigger and bigger issue in America. There are now more than two million Americans struggling with opioid abuse problems. And for a long time, there wasn't much out there to help them, even if you went to a doctor. In fact, surveys have found that a lot of doctors don't want to or don't know how to treat opioid addiction,

making it really hard for families like Misha's. Anna Lemke, a psychiatrist at Stanford, was one of those doctors who wasn't keen to treat addicts. The way that I was trained in psychiatry was that this is not my problem. And that if patients come to me and they have alcohol or drug problems, I need to basically just send them away, tell them to get themselves together. I was into it for real mental illness. So the idea here is that like, if you're addicted to opioids, like you, that's your fault. That's your failing. Like you need the strength to get off

them. You messed up. It's not a mental illness and you need to go somewhere outside of my office. I don't know where, maybe Alcoholics Anonymous, Narcotics Anonymous, but somewhere where I'm not because I have no idea how to help you. But Anna saw more and more people coming to her for help with addiction, and she ultimately realized that she did want to help them, but she didn't know how. And that was really, yeah, that was really a horrible moment for me as a, you know, health care provider and a psychiatrist

because I realised I'm a bad psychiatrist. A lot of her patients told her that they were interested in going to Narcotics Anonymous, or NA. And this is actually one of the most common ways that people try to get clean. It's the first thing that Misha tried too. But these kinds of programs have come under fire recently, so much so that Anna says... We're in an era of AA and NA bashing.

Yeah, NA and AA bashing. There's been a bunch of articles written over the last few years saying that AA is irrational and not evidence based. And I was sceptical too. And that's because of NA and AA's very unscientific and religious roots. It's even inspired mockery from comedians like Doug Stanhope. AA is so splattershot and made up on the fly, AA makes Scientology look credible. Basically, the AA model was invented by a couple of guys in the 1930s who got a lot of inspo from Christian traditions. They said a spiritual awakening helped them overcome their drinking problems and they endorsed total abstinence.

That is, if you're an alcoholic, no cheeky beer on the weekend. If you're a heroin addict, no cheeky oxys to relax after a tough day. And because this can be so difficult, there are 12 steps to help you along. Steps like admitting that you're powerless over your addiction and asking God to remove defects from your character. In fact, seven of the 12 steps refer to God, spirituality or a higher power. And right off the bat, AA was pretty popular. AA offers help freely to any alcoholic anywhere who is willing to admit his own inability to help himself. So I wanted you to know I'm sorry I tried to sock you.

I acted like a heel. So two blokes just invented these steps and then God is supposed to help you accomplish them. Is there any science here? That is, do these 12-step programs actually work? Well, Anna Lemke, our psychiatrist, says yes. And she says she's tired of people bashing NA. And you know, there are a lot of like quiet AA and NAs who aren't going to like speak up and say you're wrong. AA and NA saved my life. But they're out there by the millions. By the millions. Anna says that these programs can give people support,

encouragement and role models because they see people who have successfully quit and found a way to live without drugs. I'd say, you know, it's not that AA is perfect and it's not that AA and NA are for everybody, but there's an incredible amount of collective wisdom in those organisations which cannot and should not be denied. And when we look at the research, there is evidence that 12-step meetings help people stay clean.

For example, one study followed about 150 opioid addicts for several years after they went to rehab. And it found that those who went to NA or similar groups were more likely to stay off opioids compared to those who hadn't gone to any meetings. We do know that NA can help some people. But we don't know overall how good these programs are. That is, we can't say the likelihood that you'll get clean if you try them. And that's partly because these studies that we have on NA and AA often don't follow people who drop out. Say they don't like the meetings, say they stop going to them. Despite the fact that we don't have evidence that NA works for everyone. Many addiction specialists insist that 12-step rehab is the only way to go. And this brings us back to Misha. He and his mum

started seeing this counsellor that insisted he try 12 steps. So he went. It was a rehab centre in this big old house covered in vines. What are you feeling as you walk through this place? It was mostly, I think it was excitement. It was, yes, I'm doing this. I'm doing something about this. I'm getting it addressed. Going into treatment, I was so desperate for help

and I was so motivated to change. What happened after? Did it work? Well, no, it didn't work. Nothing in the 12-step program rang true. It just felt like one giant guilt trip. All this focus on being powerless and asking a higher power for help. It didn't feel like the treatment that he needed. It felt more like Catholic confession. One night, he snuck out of the treatment center and went to downtown LA to buy heroin. He smoked it on the way back. And when he returned to rehab...

Everybody knew that this had happened. One morning, we had a group where it was like me, and then they went around a circle, and each person told me how fucked up. I mean, it was to share their feelings, but each person's feelings were like, you're a piece of s***, we hate you, you really f***ed up, you need to admit what you've done. Because these meetings are anonymous, we couldn't confirm what happened that day. But what's important is that this is how Misha felt.

12 steps didn't work for him. Yet his mum thought that he needed to go to rehab. In fact, as Misha tells it, the addiction counsellor that she was talking to told her that if Misha didn't go to a rehab centre, then she should kick him out of the house. So she put him in a couple more rehabs and none of them helped. By the time his mum was driving him to the fourth rehab, he asked her to pull the car over. I told her that in a very calm, very collected way, making it very clear that I was not going to rehab.

So that was it. I ended up leaving from there and walking to Venice. Where did you sleep? Eventually I found out how comfortable cardboard is and slept on the boardwalk, the concrete part of the boardwalk in Venice Beach. Ultimately, Misha would rather sleep on the street than go to another 12-step program. After the break, maybe the solution to Misha's opioid addiction is, well, taking opioids. That's coming up. Welcome back.

We just found out that the 12-step program, one of the most popular ways that people try to get off opioids, can help some people. But it doesn't work for everyone and the evidence can't tell us who it will work for and who it won't. If NA or 12-step programs don't work, there is another option, and that's staying on opioids. Yeah, there's a group of medications out there for opioid addiction that actually are opioids. One is pretty well known. It's called methadone. But there's another drug that's getting a lot of buzz,

despite its name being pretty hard to pronounce. It's called buprenorphine. It's sold under the brand name Suboxone or Subutex. If you're not a regular opioid user and you pop it, you'll probably get high. In fact, when Misha started experimenting with opioids, he took buprenorphine and he loved how it made him feel. This is a huge reason why these drugs are pretty controversial. And that's even for our psychiatrist Anna Lemke. When she first heard about this drug, buprenorphine, she wasn't too excited. Why were you so worried about prescribing it? I worried that if I started prescribing buprenorphine, that somehow word would get out and I would be like this go-to doctor for all these people who just wanted to get drugs from me

and weren't really interested in getting better. Despite her initial hesitation, Anna started looking into these drugs to see if they really could help her patients. And she was impressed by what she saw. Because if you look at what these drugs do to our brains, it makes sense that they should work. So for a chemical like buprenorphine to have an effect in the brain, it needs to have a special receptor. So that's a little protein that fits this chemical just right. All opioids latch onto these very specific opioid receptors.

Heroin, Oxycontin and, yeah, Buprenorphine. And this is why these drugs can give you a high. But Buprenorphine also has a few special qualities that make it very different to heroin. For one, it latches onto that special receptor for much longer than heroin, say, more than a day. So it gives people a steady supply of opioids which can prevent their cravings.

Buprenorphine also does this other really cool thing. Because it's latching onto that receptor, it blocks other opioids, like heroin, from getting in and getting you high. That's exactly right. If you want to believe in something in medicine that's evidence-based, believe in buprenorphine. Anna told us about the first patient that she prescribed buprenorphine to.

He was a Stanford student who came to her asking for help after he dropped out of school because of his heroin addiction. And Anna says that buprenorphine really worked for him. Gosh, he graduated with honors and I just couldn't be prouder. Taking buprenorphine to him was like a light switch. He feels like he was chemically lacking something that buprenorphine replaced and it gave him his life back. So it actually works? Oh, yeah. I mean, like any intervention, it doesn't work all the time for all the people, but for the people for whom it works, it's really a miracle drug.

Anna says that because she's seen it do wonders in some of her patients. But in the realm of miracles, buprenorphine is more like Hanukkah than Easter. That's all to say, it's way less impressive. A big study that followed hundreds of opioid addicts treated with buprenorphine for more than three years found that 60% of them stayed off the drugs. 60%. Which is pretty great when you consider that the vast majority of people who try to quit on their own will relapse.

That's according to a report from the National Academy of Sciences that came out this week. And even though there are still some unknowns about buprenorphine, like we don't know its long-term effects, the World Health Organization, the National Institute on Drug Abuse and the White House have all come out in support of using buprenorphine to treat opioid addiction.

So these drugs really can work. Still, they are opioids. So is it a problem that we're giving opioids to an opioid addict? As Anna and I were talking, it was pretty clear that she's thought a lot about this. I asked her about that student, the Stanford student, who did so well on buprenorphine because he's been on it for several years now. Periodically, I raised the topic with him, you know, hey, you've been on it now for, I don't know, six, seven years doing really well. Maybe, you know, we should think about slowly

going off of it. And he says, absolutely not. I'm not remotely interested in going off of buprenorphine. It saved my life. And why would I want to stop taking it? So then I say, okay, let's keep going. There is this concern, I think, that you're substituting one addiction for another. Who cares? I mean, if it works, right? You know, in some ideal world, in my ideal world, no one would smoke cigarettes and no one would drink too much alcohol and, you know, no one would use opioids, but that's just not the world we live in. So given the world we live in, if you have somebody who's lying and cheating and stealing and prostituting themselves to score the next hit, and you can give them a medicine like

buprenorphine and give them back their lives, who cares if they're going to be on opioids for the rest of their life? I don't care. I mean, that doesn't make any sense. Here's how Ana and other experts think about it. Just because a person is dependent on a drug, it doesn't mean that this is a problem. One of the key features of addiction

is that the drug they're addicted to harms the person. So if an opioid addict is taking a particular kind of opioid and it's not harming them, then maybe that's okay. It's like you're just treating them for any kind of chronic condition that they need medicine for. Another way to look at it? A diabetic is dependent on insulin, but not addicted to it, because using insulin has good consequences for them. It helps keep them alive. And this brings us to perhaps the strongest case that you can make for buprenorphine, that it can save lives. To understand more about this, we spoke to Marvin Seppeler. He's the chief medical officer at Hazelden Betty Ford. Yes, Betty Ford, the place

where Hollywood celebrities go to dry out and the largest non-profit addiction treatment provider in the US. Now, Marv has been an addiction specialist for decades, and he says that he rarely had patients die after going to treatment. But as the opioid epidemic ramped up and more and more people with opioid problems came to his clinic, that all changed. Now the deaths were really regular. So it's a different sort of picture entirely. Sudden death for all these young people and some of them dying right after

treatment. And here's a big reason why opioid addicts are dying after rehab. If you stop taking an opioid altogether, your tolerance for this drug drops. It's just like if you don't drink alcohol for a while, you might get drunk on just one glass of champagne. But with heroin, if your tolerance drops and then you shoot up, it becomes easier to overdose and to possibly die. And here's where buprenorphine can help. Because it controls opioid cravings, it means that people are less likely to go back to heroin. And studies do suggest that buprenorphine cuts down the risk of death.

Now, when Marvin found this out, he was like, great, I want to prescribe this drug. There was just one problem. Hazelden Betty Ford, where Marv works, is famous for telling people that abstinence is the only path out of addiction. Marv actually got sent there for alcohol addiction when he was a teenager, and this is what he was told. They told us you can't even take aspirin because, you know, you might...

Oh, whoa. Yeah, it might trigger you to go back to use of the substances you really like. Marv tells us that Hazelden Betty Ford is now A-OK with aspirin. Still, it's a clue as to the philosophy of this group. If there are questions about recovering addicts taking aspirin, there's definitely no buprenorphine. So, at first, Marv did not want to be the guy bringing drugs into Hazelden Betty Ford. But after seeing his patients dying... It became imperative to me to be the guy who did all that, and I did.

Marv and a few others started pushing this idea to bring in medication for opioid addicts. And it all came to a head at this presentation that he did. It was in a big hall in front of all of his Hazelden colleagues. We joked before we went in that we needed flak jackets for all the rotten tomatoes and eggs and things that would be tossed at us. Oh, no! And we had people publicly, you know, making really derogatory statements about me personally and about our treatment program, that we were ruining alcoholics and us, that I was Dr. Death, you know, all kinds of things like that.

That you were Dr. Death? Yeah, yeah. Unfortunately. But eventually Marv, and the evidence, won them over. And in 2012, Hazelden announced that it would start using buprenorphine to treat people with opioid addiction. But the battle for buprenorphine is far from over. Many doctors in the US still aren't prescribing this drug.

A recent review paper found that just about every US state had way more people with opioid abuse problems than doctors who prescribe buprenorphine. And this is for a few reasons. It can suck up a lot of time for a doctor to prescribe buprenorphine and manage patients with addiction. But also, some doctors aren't confident using this drug. And some doctors just don't think buprenorphine is a good idea. So, the bottom line here is that medication for opioid addiction can work. But right now, even if a lot of people need it,

and it could save their life, it could be hard for them to get it. Misha eventually found a doctor that would prescribe him buprenorphine. Later, he tried methadone. He said they both helped him. They both reduced cravings and cleared up some mental headspace so that he could figure out what he really wanted to do with his life. I feel like everything, even if it's not perfect, everything is totally fine the way it is. He joined a

mindfulness and meditation group and eventually he went back to school. He's studying to be an interfaith chaplain and thinks he'll work at hospitals comforting the sick and dying. It's a whole world that opened up after he reined in his illegal opioid use. I mean I never ever would have imagined that I would end up working as a like interspiritual chaplain in a hospital or teaching mindfulness or like wanting to work in a neonatal intensive care unit with like parents and their newborn infants. After a while, Misha was doing pretty well and he even stopped taking the medications. But then last year, when he was back living with his mum, for some reason that he can't

fully explain. He went downtown, bought some heroin, and went into the bathroom to inject it. The last memory before coming to the hospital was opening the front door, going in the bathroom, drawing the bath. I don't remember injecting the shot. And apparently I, like, collapsed onto the floor and eventually my mum heard the water running and running and running and so she came in.

His mum revived him with Narcan, a drug that blocks the effects of heroin. And Misha's story is pretty common for opioid addicts. Things are going well, treatment is working, and then maybe something happens and it's back. And studies can't fully explain what's going on here, why it's so hard to kick an opioid habit. But many scientists now think of addiction as a chronic disease, something that needs to be managed. And just like a diabetic needs to keep their insulin in check, addicts like Misha need to keep working through their addiction,

sometimes with medication, sometimes with perhaps a group therapy like 12-step, if that's what's working for them, and sometimes with both. Like many chronic diseases, this one is a tricky beast and there is no one answer. That's science versus opioid addiction. This episode has been produced by Rose Rimler

with help from me, Wendy Zuckerman, along with Shruti Ravindran and Ramila Karnik. Our senior producer is Caitlin Sori. We're edited by Blythe Terrell. Additional editing help from Lulu Miller. Fact-checking by Michelle Harris. Mix and sound design by Emma Munger. Music written by Bobby Lord. Recording help from Marissa Shea and Julia Smith. For this episode, we also spoke to Dr Hilary Connery, Dr Ben Davies, Professor Linda Gowing, Dr Laura Payne, Professor Susan Nielsen, Professor Tom McClellan and Professor Wayne Hall. Thank you so much for your help.

And an extra special thanks to the Rimla family, Devin Taylor, Sarah McVie, Joseph Lavelle-Wilson and to everyone who spoke to us about their personal experiences with addiction and treatment. 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 1-800-662-HELP.

That's 1-800-662-HELP. And we'll link to their website on the show notes so you can find counselling and treatment options in your state. Next week, we're tackling a different kind of addiction. If you take away sex from a sex addict, nothing happens. Nobody ever died in the history of the world from blue balls. Sex addiction. Does it exist? I'm Wendy Zuckerman.

Back to you next time.