One prescription drug is keeping some addicts from dying. So why isnt it more widespread? A story of regulation, stigma, and the potentially fatal faith in abstinence.
Listen and subscribe to our podcast at Apple Podcasts, Stitcher, or elsewhere. Below is a transcript of the episode, edited for readability. For more information on the people and ideas in the episode, see the links at the bottom of this post.
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In our previous episode, No. 402, we looked at the rise of the opioid epidemic:
Barack OBAMA: We are seeing more people killed because of opioid overdose than traffic accidents.
The tragedy seemed to come out of nowhere, but in fact it had distinctive roots in the pharmaceutical industry:
Jeanmarie PERRONE: They really somehow fooled us into thinking that pain was a vital sign, and that we needed to treat it more liberally.
In government policy:
Tomas PHILIPSON: What happened during that growth was that prices for opioids came way down due to government subsidies.
And in the highly addictive nature of a medicine that had been promoted as not being addictive:
Stephen LOYD: I was taking 500 milligrams of OxyContin a day. And so it progressed very, very quickly. And I couldnt stop.
The opioid crisis, we learned, is really a story of supply and demand. In retrospect, theres plenty of blame to go around; there was inattention and wishful thinking and almost certainly some deception, or at least greed. As a result, hundreds of thousands of people have died; countless families have been broken. And one unintended consequence of the crisis is that many people who have legitimate need for pain management and who have never abused those drugs now find it much harder to get the medicine they need.
One such person wrote to us recently. I was born with severe scoliosis, he said, and needed multiple surgeries starting as an 11-year-old. I was on fentanyl patches for over 10 years. They allowed me to not hurt every minute of the day. I did not get high. I went to a pain clinic every month and was drug-tested. A year and half ago, they stopped prescribing me because of government regulations. Now every day is a struggle to get out of bed and be productive. So as this man suggests, the prescribing protocols for opioids have changed in his case, not for the better. How have the new protocols affected potential opioid abuse?
The fact is that more than one in five Americans still gets at least one opioid prescription filled or refilled per year. And a dependence on prescription opioids often leads to a dependence on heroin or synthetic fentanyl, both of which are even deadlier. Just how many people are we talking about here? The Department of Health and Human Services estimates there are roughly 2 million people in the U.S. with what it calls opioid-use disorder. As the healthcare economist Alicia Sasser Modestino told us last week: an entire generation has been addicted at this point. So whats to be done about that?
Nicole ODONNELL: Its treatable. We dont have to overcomplicate it.
Today on Freakonomics Radio: our second of two episodes about the opioid crisis. The focus today: an addiction treatment option that some people think should be universal.
PERRONE: They can get it as part of routine medical care just like they might get their insulin for their diabetes or their blood-pressure medicine.
So is it being universally embraced?
PERRONE: Thats thats probably a no.
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Last week, in Part 1, we met Jeanmarie Perrone at the University of Pennsylvania.
PERRONE: Im an emergency-medicine physician and a medical toxicologist. Which means I was trained in poisonings and overdoses. And more recently Ive started to do addiction-medicine work.
Perrone has seen the opioid crisis up close as a researcher and a practitioner.
PERRONE: So, we have about 1,000 or 1,200 patients who visited our three hospitals last year, and about 400 of them were overdoses.
Stephen DUBNER: Have you ever used opioids of any sort?
PERRONE: No. Had a couple kids. And broke my leg and broke my wrist. I didnt have opioids for any of those three things.
DUBNER: Were you offered, in any case?
PERRONE: I broke my leg in Canada interestingly, I would say, right in the middle of the opioid crisis, and theyd said, do you need anything? And I said, You know, Im fine with ibuprofen.
PERRONE: Mountain biking. But anyway, I would
DUBNER: So you brought it on yourself.
PERRONE: I did bring it on myself. But I would definitely say that I would have a super-high threshold for anyone in my family, anyone I know. I mean, I advise against it sort of across the board.
DUBNER: Because its just too easy to
PERRONE: Just that you just dont need to go there.
DUBNER: So opioid deaths in the U.S. have leveled off, maybe started to decline a little bit. What are you seeing here in Philadelphia?
PERRONE: So they did decline a little bit. I think what is important about the national data is that the deaths that have declined the most are the oral pills. And thats probably the result of deprescribing, and a little bit of a result of prescription-drug monitoring programs preventing the co-prescribing of benzodiazepines with opioids. Maybe a little bit more public awareness, like I shouldnt drink when Im taking back-pain medication.
Another potential driver of this slight decline in deaths is the widespread availability of Narcan, an emergency nasal spray of the drug naloxone, which can stop an overdose as its happening, wherever its happening. Perrone has administered Narcan herself a few times. The most recent was riding the subway home, in Philadelphia, after a night out.
PERRONE: And somebody called and said Does anyone have Narcan? Theres a man down. And I do carry Narcan and so I ran five or six subway cars up and there was a man on the ground getting CPR, was blue cyanotic was pulseless, really on the brink of death or defined as dead already, maybe. And so we continued CPR, I got my Narcan out, I gave him one dose and he didnt really respond. And then I gave him another dose and then I thought, you know, we need to do mouth-to-mouth. And then I thought, maybe some of the Narcan was still stuck in his nose and so I sort of scribbled his nose a little bit and kind of irritated it a little bit more and then he took like one teeny, tiny breath and over the course of the next 90 seconds he started to wake up. And then about 10 minutes later E.M.S. came. I was like, You guys just saved this guys life.
DUBNER: Youre saying, You guys, but you were the one that gave him the Narcan
PERRONE: Well no, but they had started CPR. They had called someone for help, they had called 911. I mean, theyd done so much. You know, we simulate resuscitations like that in the hospital and this group of people just got it all together. Did all the right things. So it was really impressive. I mean, it was probably 25 or 30 people at the end of it all, and it was like this amazing I call it my Philly moment because it was like winning the Super Bowl, when everyone was in the streets and everyone just had this amazing bond. And it was just incredible. It brought tears to my eyes then, it brings tears to my eyes when I talk about it.
So that story had a happy ending. Many overdose stories do not. And Narcan can only do so much. It doesnt treat the underlying addiction.
PERRONE: The patients who come to the emergency department after receiving Narcan from an overdose, about 6 percent of them are dead at the end of one year. And 10 percent of them are dead at the end of two years. So there is no other medical condition that we currently treat in the emergency department that has that kind of mortality.
DUBNER: So from your perspective, Im curious: youre an E.R. doc and people come in for help when theyre in a desperate state already. Right? Theyre not typically coming to you to say, Ive been thinking long and hard about my life and I want to make a graduated change, right? So what can you do for them? What was the treatment, lets say, five years ago when the problem was starting to really turn into a horror, and how does the treatment differ now?
PERRONE: So thats a great question. Five years ago, an overdose patient hopefully got some compassion in the emergency department, and a little bit of a conversation about why they may have overdosed that day, or what we can do to help them. Maybe as of four or three years ago, they wouldve been discharged with a box of Narcan or naloxone so that if they were exposed to another overdose, somebody could use that on them, or they could use it on a friend or a colleague. I think fast-forwarding from there, what weve realized is that giving them kind of a crumpled piece of paper that said, You should stop using drugs doesnt really work. Theyre in a cycle of using and fighting withdrawal every three or four hours. And so that doesnt lend itself to getting your phone out and making an appointment for Monday morning to see an addiction specialist.
This appointment model was failing in other hospitals too.
DONOFRIO: We were on the frontlines, just seeing patients being brought in sometimes being just dropped off at the door and thrown at the emergency personnel.
Thats Gail DOnofrio.
DONOFRIO: I am professor and chair of emergency medicine at the Yale School of Medicine.
She is also chief of emergency services at Yale-New Haven Health. So, like Perrone, DOnofrio is a practitioner and a researcher.
DONOFRIO: So our study in JAMA in 2015 was looking at different models of care for opiate-use disorder.
JAMA is the Journal of the American Medical Association. And in 2015, E.R. practitioners like DOnofrio werent having much success treating the many opioid addicts theyd started to see. So she and her team set up a study. It included 300 patients, divided into three treatment groups. In the first group:
DONOFRIO: Well try to motivate them to get care and then well refer them to the centers of care that we had here at Yale, or in the community.
This was the standard treatment at the time the crumpled piece of paper model that Jeanmarie Perrone mentioned. The second group of DOnofrios patients got a bit extra.
DONOFRIO: They got motivational enhancement, which we call the brief negotiation interview.
That was a 15-minute conversation, talking about their addiction and the circumstances that led to it.
DONOFRIO: And then those people got a facilitator referral.
Not just a crumpled piece of paper.
DONOFRIO: So we actually called the place ourselves, and if it was at night wed call them in the morning and said we referred this person to you.
And then the third group:
DONOFRIO: They got also a motivational enhancement, brief intervention. But then they were started on buprenorphine.
PERRONE: So buprenorphine is an opioid agonist, which means it activates the opioid receptor just like heroin and oxycodone.
Jeanmarie Perrone again.
PERRONE: I think everyone knows methadone, and methadone is our historically opioid-agonist treatment that we use for patients with opioid-use disorder. And the only treatment we really had for a long time.
But methadone has issues.
PERRONE: Methadone is dispensed from federal treatment programs and the patient has to go there every single day to get their dose. And the opioid-agonist methadone works by being a very long-acting opioid and acting at the opioid receptor. And in high-enough doses, it thwarts the use of other opioid agonists. Buprenorphine is different. First of all, it can be prescribed from a doctors office. So the patient doesnt have to go to a methadone clinic every day. They can get it as part of routine medical care, just like they might get their insulin for their diabetes or their blood-pressure medicine. And its intended to be less stigmatizing to get it as part of routine medical care. The other thing is that its a partial agonist at the opioid receptors, so it doesnt continue to activate it the way methadone does. So that is what we call a ceiling effect, which makes it much safer, so that there isnt as much respiratory depression and there isnt as much risk of opioid overdose and death.
DONOFRIO: Its really hard to overdose on it. Its hard, even if a child takes a pill of their adult familys or friend, off a table, that they will die from it. Because it does eventually just reach that ceiling effect.
So buprenorphine, which is itself an opioid, would seem to offer a safer and more flexible treatment for opioid addiction. But how effective is it? Thats what DOnofrio was really looking for her in her study at Yale.
DONOFRIO: And so what we found was that those patients that were in the buprenorphine group were two times more likely to be in formal treatment at 30 days, one month.
That was a huge improvement over the two other groups in the study.
DONOFRIO: So about 37 percent of patients in the referral group were in treatment and about 45 percent in the brief-intervention group and then almost 80 percent in the buprenorphine group.
PERRONE: So they were able to double the rate of engagement of patients who showed up for a follow-up meeting.
When Jeanmarie Perrone of Penn saw the Yale study, she was impressed, and excited.
PERRONE: And that is so critical to getting people into treatment. And that medication stabilizes the cycle of withdrawal that patients are experiencing. So its really important to not say, You can come in tomorrow for your first appointment, but Heres a medication, the next twelve hours wont be the hell you think its going to be if you start on this medication now.
DUBNER: So that sounds like a wildly useful drug that Im sure every hospital and medical board and state legislature must be in favor of dispensing more of this antidote, yes?
PERRONE: Thats thats probably a no. I think theres a lot of good people in theory who do want to do this and expand our treatment. I think the logistics of learning how to administer buprenorphine sounds more complicated than it might be, and that is a barrier.
DUBNER: What do you mean by the logistics of administering it?
PERRONE: So first of all, in order to write a prescription for buprenorphine, you have to get something called an X-waiver, which means that you have to take an eight-hour training program and you have to apply to the D.E.A. to get a special waiver.
DUBNER: Does the same sort of waiver-licensing process apply to prescribing medical opioids in the first place?
PERRONE: It does not. So I can in fact treat your opioid-use disorder with oxycodone or hydromorphone if I wanted to. And that would be not regulated at all.
DUBNER: So why the extra level of regulation for buprenorphine?
PERRONE: Its complicated, but when we went from the late 60s, when we started methadone and we had people who needed treatment, but we werent going to let just any doctor prescribe it. And so thats why methadone was restricted to these federal treatment programs. But then when we said, well, in 2000 buprenorphine became available and was approved in the United States, but we werent just going to let every doctor put out a shingle and start administering buprenorphine.
Buprenorphine is most commonly administered in a name-brand drug called Suboxone, which also contains naloxone. Buprenorphine was invented by the pharma firm Reckitt Benckiser in 1966, one of many synthetic opioids designed in the 20th century. They were meant to treat pain but be less addictive than opium itself; but as it turned out, most of them were addictive. That is the foundational problem of the prescription-opioid crisis.
In the 1990s, Reckitt Benckiser recognized buprenorphines potential for treating opioid-use disorder, and it spun off its buprenorphine division into what is now a subsidiary company, called Indivior. Several years ago, another drug company thought about getting into the buprenorphine market: Purdue Pharma, which makes OxyContin, one of the most widely abused prescription opioids. A Purdue memo at the time called buprenorphine an attractive market but they never did jump in.
Today Purdue is the target of thousands of lawsuits, charged with having downplayed the addictive nature of OxyContin. Just how influential was Purdue in the opioid universe? Consider this startling development: The World Health Organization recently retracted its two main guidelines for using opioids to treat pain. Why? Because the guidelines, it has now been discovered, were unduly influenced by opioid manufacturers, including Purdues international subsidiary. And yet, at this moment, OxyContin is still legally and widely dispensed, as a useful painkiller that is also easily subject to abuse. Suboxone, meanwhile, is much harder to abuse but is also harder to get.
What do medical professionals who treat opioid addiction think of this? Heres what one doctor wrote on the HealthAffairs blog: Buprenorphine has the potential to be a transformative tool in healthcare practitioners fight to reduce deaths from opioid overdose but that the X-waivering process is onerous, outdated, and hampers our ability to help patients manage and recover from opioid addiction. An editorial in JAMA Psychiatry made the same complaint, and noted that easing the restrictions on buprenorphine in France helped drive down deaths from opioid overdose there by nearly 80 percent. If extrapolated to the United States, the authors wrote, this translates to more than 30,000 fewer annual deaths from opioid overdoses.
PERRONE: So globally, the statistics are tremendous. No doubt in the evidence there.
DUBNER: Do you see the the waiver requirement for buprenorphine as a sort of overcorrection, over-response, to the medical communitys own embrace of opioids in the first place? Like, We messed up big-time and at the very least, what were not going to do now is mess up in the same direction, even though this might be a different direction?
PERRONE: I think it lingers because of some of those concerns. But if we go back to 2000, we didnt really have any kind of opioid crisis in 2000. So it was really approved in the absence of a big surge in opioid use at the time. I think not repealing it at this point is probably multifactorial. People are worried about Suboxone diversion. So the same substance that we want to prescribe is also available on the street and we acknowledge that. But its not used on the street to get high. Its used for patients to treat their own withdrawal symptoms when theyre unable to get other medications. So I think thats part of why theres been some resistance to taking away the X-waiver. I think it also is going to take an Act of Congress, which is fairly hard to accomplish. And I think that repealing the X-waiver isnt entirely going to open the floodgates for prescribers who want to prescribe buprenorphine. Theres still some education and some stigma that needs to be addressed before more people are going to be willing to prescribe.
DUBNER: How would you describe the weirdness, or the paradox, or whatever, of the fact that buprenorphine is so difficult to prescribe versus I mean, if Im a medical resident, lets say, can I prescribe OxyContin?
PERRONE: Yes. Prescribe is different. So prescribe is writing a prescription. So in order for them to order OxyContin in the hospital, there are no requirements. In order for them to write a prescription for OxyContin, they would of course need their D.E.A. number. But in order for them to prescribe Suboxone or buprenorphine, they would need to take that eight-hour training.
DUBNER: On the other hand, if a drug is as valuable as buprenorphine sounds it may be, is an eight-hour training program such a big barrier or even shouldnt it be something that we should applaud as proving the worth of being able to prescribe it?
PERRONE: I think that theres some value to training. I think our original activism around opioids, we thought all doctors should learn a little bit more about any opioid that they prescribe, because there was clearly a lack of education about the addictive nature. The problem is in primary care, if youre going to prescribe buprenorphine and you need to take an eight-hour training, thats okay if you plan to treat a lot of patients. But if youre only going to treat five or six patients, just sort of as part of their other medical problems, it becomes a much bigger barrier. In the cases of the emergency department, we had to get all of our doctors X-waivered just to be able to write the occasional prescription for somebody who has opioid-use disorder. I can understand the historical evolution of this, but I cannot understand the modern response.
DUBNER: Modern response meaning?
PERRONE: Modern lack of response. Modern ways of addressing some repeal of the waiver or modifying the waiver.
DUBNER: I see that some hospital chains and some state and local governments are moving in the direction that you advocate. But I see that others are moving in the opposite direction including the state of Pennsylvania, which has kind of pinballed. Can you describe that?
PERRONE: So the state of Pennsylvania, despite everything we thought, was moving in the right direction, the state legislature introduced a bill that would add an additional layer to the X-waiver. So even if you were already X-waivered like myself, you would have to pay $500 a year to get an additional X-waiver license in order to prescribe in Pennsylvania. I think that it came out of perhaps some well-intended sense that they needed to decrease the amount of buprenorphine prescribing that wasnt being as tightly administered as they might wish.
That bill passed the Pennsylvania state Senate, by a vote of 41-9, and is now in the House. But the X-waiver and training requirement and extra fees arent the only things holding buprenorphine back from widespread use.
LOYD: If you look at residential treatment programs across the country, most of them, over 70 percent of them, are still abstinence, 12-Step-based programs.
Thats Stephen Loyd, a physician in Tennessee who specializes in addiction. In last weeks episode, we heard how Loyd himself was for years addicted to prescription painkillers.
LOYD: Basically, I took pills all day long. When I got out of bed in the morning, I had withdrawn during the night, so I was sweating. I felt like an 80-year-old man, and I was in my early 30s.
Loyd went into a detox program and then a 30-day residential rehab facility, which got him turned around. Today, hes the medical director for a network of addiction-treatment centers.
LOYD: Im a big believer in medication-assisted treatment. And we know that the most effective thing that we can do for opioid addiction is actually medication-assisted treatment with the use of drugs like buprenorphine, methadone, and naltrexone. And Ive taken heat from this in the local treatment community as well as the treatment community statewide, and even nationally.
DUBNER: Can you just describe where that pushback and that reluctance is coming from?
LOYD: Well, unfortunately Stephen, the pushback comes from people in the recovery community. And one of the problems with addiction medicine is that most of the people that work in the field, or a lot of the people that work in the field, had the issue themselves. Thats how they got in the field. Like myself. But they believe that the only way to get healthy is how they got healthy. So its totally anecdotal.
As Loyd noted, most addiction-treatment programs do stress total abstinence including 12-step programs like Alcoholics Anonymous and Narcotics Anonymous. How successful are such programs? That is a famously difficult question. Solid data are hard to come by; after all, anonymity is a feature of such programs, and there are all kinds of possible selection biases. Alcoholics Anonymous claims that 75 percent of its participants stay sober. But academic studies put the success rate closer to 10 percent or even less. That said, one Stanford study compared addicts who quit with the help of A.A. versus those who quit on their own, and found that A.A. nearly doubled the success rate. Stephen Loyds argument is that abstinence is the chosen path for the recovery community but that medical professionals embrace M.A.T., medication-assisted treatment.
That is the National Institute on Drug Abuse.
LOYD: Everybody who looks at this says the role of medication is paramount, it should be the cornerstone. Yet its so hard to get people into those programs because of the stigma associated with it. A lot of times, itll be from parents. Ive had numerous parents talk their kids out of medication because they said they were trading one drug for another, and then a few months down the road, I get the call that theyve overdosed and died. And I cant tell you how heartbreaking those calls are.
DUBNER: If I say to you, I dont like the idea of the pharmaceutical industry being able to be the chief beneficiary of medication-assisted treatment because they helped drive this problem in the first place. Its a little bit like I set a house on fire, then Im the hero who calls in the fire to the fire department. I dont like the optics of that. I dont like the economics of that. What do you say to that argument?
LOYD: I have to say I agree with you a million percent. It makes me choke every time I think about it. But I dont have a better option. I dont have anything else thats going to stop my patients dying at the rate that M.A.T. does. I cant stand it. I read somewhere recently that, several years back, Purdue Pharma tried to acquire the marketing rights to buprenorphine, which just absolutely is unconscionable to me, and so I would agree with you one thousand percent. I wish there was a better option. But right now, theres not. And so I cant let my feelings get in the way of trying to help my patients and help them stay alive.
DUBNER: Could you describe for me the underlying causes of opioid addiction? I guess what Im looking for is if you could break it down between a physiological addiction or craving, as well as the psychological and environmental drivers.
LOYD: Well, I dont know how much more I need to break it down, you just did. You know, thats the classic model, psychosocial model that you just described. So thats really the three big components of developing any addiction, in this case opioids. So youve got the I teach it in terms of a slot machine, you know, when the three sevens come down on the pay line, thats when the money comes out. So the first seven is the bio component, and thats simply genetics. Do you have a family history of any addiction? If you do, then that first seven comes down on the pay line. And addiction is about 60 percent genetic, for the most part.
The second part is the psychological component. What kind of household were you raised in? Do you have a high ACE score adverse childhood experiences. Were you physically, sexually, or emotionally abused? Do you have that chronic trauma, maybe even later in your life? If you do, then that second seven is down on the pay line. And then the third seven is the social component, and thats just the availability. You know, what is widely available? And the thing thats most widely available and accepted is alcohol, and thats still mostly what we see people abusing and addicted to. But in the late 1980s, early 90s, and into the 2000s, opioids became much more widespread.
DUBNER: You and many others call addiction, generally, a disease, and it sounds like the factors that may determine your likelihood for the disease are pretty much everywhere. So do you see this as a different sort of disease than we typically think about with epidemiology?
LOYD: Lets take a disease that everybody agrees on. Type 2 Diabetes mellitus. You know, nobody has a problem with Type 2 Diabetes being a disease. Right? I never hear any discussion about that. Yet for the most part its behavioral, right? Why do people get Type 2 Diabetes? Well, they dont eat right, and they dont exercise correctly. And so we treat that widely with medication to try to decrease the bad outcomes with diabetes. So I look at addiction as being much the same.
DONOFRIO: If you know about addiction addiction is a brain disease.
Gail DOnofrio again, from Yale.
DONOFRIO: And we know by looking at scans of the brain that even though I maybe have had treatment and Im no longer physically dependent, the minute you show me something whether its a syringe or it could be just a place that I used parts of my brain, my amygdala will light up, showing that I still have this craving. I still have this possibility to use if I get back in that situation. I cant pray myself out of it. I cant will myself out of it.
LOYD: So it doesnt matter if I call it a disease or a learning disorder. It is a rewiring of the brain, the reward system in the frontal-lobe interaction, and to where the primary focus becomes acquisition of this substance for me to be okay. And so when I look at it in those terms, it looks a lot like diabetes to me.
DUBNER: Can you talk for a minute about federal policy toward medication-assisted treatment and perhaps buprenorphine specifically? From what Ive read, the policy recommendations during the Trump administration have been evolving very rapidly.
LOYD: If you look at President Trumps first appointment to the Head of Department of Health and Human Services, was Dr. Tom Price. He came out early on and said, Well, you know, this is simply switching one drug for another. And those of us in the addiction field had serious angst about that. But you have folks in H.H.S. right now that are giving really good direction with regards to medication-assisted treatment and making it more widely available.
It is evolving quickly, and I think were to the point now that some of the stigma is being decreased simply because so many people have died. Instead of defining recovery as total abstinence from any medication, I want to define recovery in those parameters of, is your life getting better? Are you still going to jail? Do you have your kids back? Do you have a job? Are you a member of the tax-paying citizenship in the United States? To me, those are much more reflective of effective treatment than whether or not somebody is totally abstinent from all drugs because some 12-step group says they have to be.
Stephen Loyds philosophy, as well as that of Gail DOnofrio and Jeanmarie Perrone, falls under the umbrella of what is called harm reduction. Its the idea that you treat risk not as something that must be driven to zero. In a recent episode called The Truth About the Vaping Crisis, we talked about the battle between smoking abstentionists people who argue that nobody should be consuming any nicotine, in any form and harm reductionists, who argue that vaping may carry risks but theyre almost certainly smaller than the risks from smoking cigarettes. When it comes to opioid abuse, the gap between the abstentionists and the harm reductionists seems to be even wider. Why is that? Whats different about opioids?
PERRONE: Its always been stigmatized. I dont know why.
LOYD: So I think anytime you lessen the stigma associated with addiction, you increase peoples opportunity to step out of the shadows and ask for help.
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As weve been hearing, treating opioid addiction with another opioid, like buprenorphine, is not a concept that is universally embraced. But a lot of smart and dedicated people are in favor including Jeanmarie Perrone, a medical researcher and E.R. doctor at the University of Pennsylvania. She and her team have been creating a new treatment protocol for opioid addiction that includes buprenorphine or Suboxone but more than just that. They are changing the way addicts are treated from the moment they wind up in the E.R. This treatment includes what they call a warm handoff.
PERRONE: So a warm handoff is a new-ish term. Its the idea that a patient at a hospital, or a clinic is going to be discharged having already met a peer or someone whos going to either accompany them to an appointment or theyve met the doctor or clinician who will take care of them. So theres a close connection between the patient and the patients next step in recovery.
And theres another member of the warm-handoff team: a peer counselor.
PERRONE: Our peer counselors are people who are in recovery themselves and who can start the dialogue right there about what it would look like if they tried medication, or tried to get into a treatment program, or tried to engage in care right then. Its all about engagement.
These peer counselors are on staff at the hospital; theyve gone through certification training, and theyve got firsthand experience as opioid addicts.
PERRONE: I think theyre the some of the most, not just dedicated, but you know, people who have been through more than Ive ever been in my super-easy life, and who have come to the other side and who want to help other people, and who are successful at helping other people. Theyre special.
DUBNER: People like Nicole.
PERRONE: People like Nicole. Absolutely.
ODONNELL: I am Nicole ODonnell and Im a certified recovery specialist in emergency rooms at Penn.
DUBNER: So Nicole, whats your story? How do you get to be in this position?
ODONNELL: So from using to here? It was a lot of work. So my first love was benzos which was Xanax. Thats what I became addicted to. I went to rehab, I was 21. My first time I went to treatment, in-patient treatment, and it worked. It worked for about two years. And then there was opioid painkillers around. So thats, you know, why not, right? And then OxyContins werent really as readily available then. So it was like Perc 30s and opiates that were someones prescription that we got. And then they are very expensive. So it was easier to get heroin.
DUBNER: And then what happened? Howd you finally get clean?
ODONNELL: I was tired of stalling withdrawal. Because thats all I was doing in the end, was using so I wasnt in withdrawal, right? So I came to this realization that Im going to continue to be in withdrawal every single time until I do something idiotic, because the withdrawal is awful. And nobody wants to be in it, and I realized my life was trying to figure out how I was getting drugs just to stop withdrawal. Its not fun in the end, its not a party, nobodys happy. Youre just really trying not to be sick and barely functioning.
DUBNER: You had a sister, yes?
ODONNELL: Yes. Three years younger than me. Jessica.
DUBNER: Yeah. And I understand she died of an overdose?
ODONNELL: She did. In it was December 14th of 14.
DUBNER: Okay. And what was what were her drugs? Or drug?
DUBNER: And what was your relationship like with her then?
ODONNELL: We used together. She gave me heroin for the first time. So I was doing restaurant management for the first seven years of my recovery, and then I lost my sister. And thats when I started doing outreach. I needed to give her death purpose. And I needed to maybe be the person for people that she probably didnt encounter in her active addiction.
ODonnell introduced me to one of the people that shes been helping.
Eileen RICHARDSON: My names Eileen Richardson. I am a restaurant manager. Im also an alcoholic and an addict. Im from the Jersey Shore originally. New to Philadelphia. Ive been here a little over a year now. Im married. I have a wife. I have a son. He just turned three.
DUBNER: Congratulations. Whats his name?
RICHARDSON: His name is Henrik. Or Henrik Matthew Richardson, as he likes to say.
On the day we spoke, Richardson had been in recovery for 93 days. She had come into the Penn E.R. after overdosing.
RICHARDSON: And Nicole came to meet me in the hospital. I believe it was the physician that I saw, asked me if I was interested in getting help. And he said he had somebody he knew that I could talk to. And Nicole showed up to talk to me.
DUBNER: Yeah. You overdosed on what?
RICHARDSON: On heroin and fentanyl.
Nicole helped Eileen get on Suboxone.
RICHARDSON: Im still doing the Suboxone. You know, I take it every day. The Suboxone helps. I dont have cravings. And right away that started. When I went back in the second time to the Suboxone clinic, the recent time, they upped my dose. And from that day on, I havent had a single craving for any opiate since.
DUBNER: Whats that feel like?
RICHARDSON: Pretty awesome. Pretty amazing.
DUBNER: So how much of your success would you attribute to working with Nicole, and having a peer who understands it; the drug itself; and then any other third or fourth reason.
RICHARDSON: I mean, they all play a big part. I wouldnt want to break it into percentages or graphs or anything like that, because for me its all intertwined.
DUBNER: But do you think that Nicole without the Suboxone would do it?
RICHARDSON: No, the Suboxone is definitely something I needed. But if I was just doing the Suboxone and nothing else, I would stop taking the Suboxone. It wouldnt I wouldnt keep taking it. You know, the drug helps the physical part, and then everything else I do helps me become a new person a new human being, which is my goal.
DUBNER: So the Suboxone helps you get back to the level that Nicole can work with.
RICHARDSON: Exactly. Yeah. In my belief. Yeah.
DUBNER: So Nicole, Suboxone sounds like a really good solution at least for some of the people, some of the time, right? Can you talk about I guess the problem, or the barrier of being able to use it as widely as it might ought to be used.
ODONNELL: So from my perspective, aside from the X-waivering and the medical barriers that the doctors experience, from our experience too, is there is a big stigma with it in the recovery community. The recovery community traditionally has been abstinence-based. And that means nothing no medications, no illicit drug use, nothing.
DUBNER: How come?
RICHARDSON: Its just this, its this deep-seated thing. The 12-step programs theres a lot of tradition and stuff like that. And theres not a lot of change. And Im not going to lie I love the twelve steps and I love the program and its done so much for me. But I dont talk about the fact that I use Suboxone. My sponsor knows. You know, my close friends know, but I dont bring it up in meetings. And theres different twelve-step programs obviously, and one of them specifically states that M.A.T. is not considered clean.
DUBNER: Eileen, right before we started recording, you told us that a friend of yours just died. Just now. I dont know how much you want to say about those circumstances its a friend you knew for how long? And howd they die?
RICHARDSON: I have known him since I started going to the 12-step group that I go to what we call our home group back in February. He was coming up on a year sober in 18 days. He would have had a year. And he this is how it happens, is that people stop and then they go back out and they think they can use the same amount that they were using once before, and you just cant anymore. Youre pretty much killing yourself if you go back out. Not people always close to me, but I know someone thats dying every week. But I mean, this one, I was with him yesterday. And we were talking and joking about the fishing trip that were going on next week. And his mom was just talking to him on Facebook about how proud she was of him and its just, its a horrible disease. You know.
DUBNER: It was heroin?
RICHARDSON: Probably heroin and fentanyl everythings fentanyl now.
The opioid crisis really began with prescription pills, then moved into heroin, and now synthetic fentanyl, which presents a particularly high risk of overdose. To that end, theres another idea currently under consideration in Philadelphia:
ODONNELL: Were all harm reductionists here.
Nicole ODonnell again, the certified recovery specialist.
ODONNELL: So we advocate for safe-injection practices, the needle exchange. But theres this Safehouse that were all advocating for, and its a place to go for people to safely not overdose. They go use, drugs get tested, they have medical staff, they have peers, hopefully, there to navigate them into treatment the same way we do in the emergency room.
The legal, official kind of safe-drug-use site that ODonnell is describing doesnt exist yet, at least not in Philadelphia or elsewhere in the U.S., though its been proposed in several cities. It does exist in several Canadian cities. In the U.S., Philadelphia is at the leading edge. The Safehouse non-profit is backed by many local and state officials but the U.S. Justice Department sued, saying it would be illegal to provide a facility to consume illegal drugs, even in the interest of preventing overdoses. A federal judge recently ruled in favor of Safehouse, but there will be more legal action before any such facility can open.
ODONNELL: My point of advocacy for Safehouse is for people like your friend that just passed, because hes in recovery, right? If I use, Im going to die. Fortunately through my years, of this advocacy, I have a person. I have a safe house. I have a person that I would call if I didnt want to die to make sure I didnt overdose if I used. I have that. Thats a safety net, right? Not everyone has that. So this is a place that we want people to be able to go. Like your friend, if he was at this place, he wouldnt have died.
LOYD: The opposite of addiction is not recovery. The opposite of addiction is community and relationship.You cant have community if youre dead.
Dr. Stephen Loyd again.
LOYD: So the first thing is to keep patients alive. Now, the longer that we keep them alive, the more that we need to be able to engage them in supportive environments around really everything.
DUBNER: And whats your position on, I guess, legal dispensaries of illegal drugs? And Im curious if theres any movement toward that in Tennessee?
LOYD: Youre really putting me in a position to get in trouble. I think we have to look, at this point, at all harm-reduction strategies. So I think anytime you lessen the stigma associated with addiction, you increase peoples opportunity to step out of the shadows and ask for help. And Im for any modality that gets people to that point.
The warm-handoff program at UPenn is still relatively new. I asked Nicole ODonnell, the recovery specialist, how many patients she will see in a given day.
ODONNELL: In an average day, we could see up to six people. I mean, whether theyre inpatient for a medical reason, inpatient in our inpatient drug and alcohol treatment, or theyre through the emergency room.
DUBNER: And of those six, how many are willing to at least have a conversation with you about medication-assisted therapy?
ODONNELL: Honestly, theres not many that say they dont want to talk. Whether they want things or not is a different story. You know, then we have a harm-reduction conversation. But nobody really throws you out of the room and says, I dont want to talk about anything.
DUBNER: So if theres one misperception about opioids about use, abuse, whatever that many people like public-radio nerds, who are going to listen to this if theres one thing they really dont know, what would you want to tell people?
ODONNELL: That opiate-use disorder is treatable. Its not a death sentence. Its not its a medical condition and its treatable.
DUBNER: It sounds so simple when you say it that way. But theres all this conversation going on around the topic now. In the political community and its never said that simply. Why not?
ODONNELL: Because we like to overcomplicate things. And it really doesnt need to be overcomplicated. Eileen takes her medication, she engages, and she goes to meetings. And shes doing amazing. And shes a mom to her son, right? Its treatable. We dont have to overcomplicate it.
* * *
Freakonomics Radio is produced by Stitcher and Dubner Productions. This episode was produced by Zack Lapinski, with help from Miles Bryan. Our staff also includes Alison Craiglow, Greg Rippin, Harry Huggins, Matt Hickey, Daphne Chen, and Corinne Wallace. Our theme song is Mr. Fortune, by the Hitchhikers; all the other music was composed by Luis Guerra. You can subscribe to Freakonomics Radio on Apple Podcasts, Stitcher, or wherever you get your podcasts.
Heres where you can learn more about the people and ideas in this episode:
- Dr. Jeanmarie Perrone, Professor of Emergency Medicine at the Hospital of the University of Pennsylvania and director of the Division of Medical Toxicology and Addiction Medicine Initiatives at the University of Pennsylvania.
- Gail DOnofrio, Professor and the Inaugural Chair of the Department of Emergency Medicine at the Yale School of Medicine.
- Stephen Loyd, Chief Medical Officer at JourneyPure.
- Nicole ODonnell, certified recovery specialist at Penn Medicines Center of Excellence.
- Toward Healthy Drug Policy in the United States The Case of Safehouse, by Evan D. Anderson, Leo Beletsky, Scott Burris, and Corey S. Davis (The New England Journal of Medicine, 2020).
- Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder, by Leo Beletsky, Kevin Fiscella, and Sarah E. Wakeman (JAMA Psychiatry, 2018).
- Emergency DepartmentInitiated Buprenorphine/Naloxone Treatment for Opioid Dependence, byGail DOnofrio, Patrick G. OConnor, Michael V. Pantalon, Marek C. Chawarski, Susan H. Busch, Patricia H. Owens, Steven L. Bernstein, and David A. Fiellin (JAMA, 2015).
- Buprenorphine-Naloxone Therapy In Pain Management, by Lucy Chen, Kelly Yan Chen, and Jianren Mao (National Institutes of Health, 2014).
- Prevalence and Correlates of Street-Obtained Buprenorphine Use Among Current and Former Injectors In Baltimore, Maryland, by Jacquie Astemborski, Becky L. Genberg, Mirinda Gillespie, Chris-Ellyn Johanson, Gregory D. Kirk, Shruti H. Mehta, Charles R. Schuster, and David Vlahov (U.S. National Library of Medicine National Institutes of Health, 2014).
- The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy, by Art Van Zee (U.S. National Library of Medicine National Institutes of Health, 2009).
- The Truth About the Vaping Crisis, Freakonomics Radio, 2019.
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