“With very highly addictive drugs, it’s not that there are risky people, it’s that the drug itself is inherently addictive.”
Dr. Andrew Kolodny, a leading expert on opioid addiction, spoke with KET about the opioid epidemic as part of an upcoming one-hour documentary on the crisis in Kentucky and possible solutions.
Kolodny is chief medical officer of Phoenix House, a nonprofit addiction treatment organization, and senior scientist at the Heller School for Social Policy and Management at Brandeis University. He is also the executive director and co-founder of Physicians for Responsible Opioid Prescribing (PROP). As a public health official in New York City, he helped to implement overdose prevention, medication-assisted treatment, and other intervention and referral programs.
Parts of this interview will be featured in the KET documentary directed by Justin Allen, scheduled to air in early 2017.
What are opioids and opiates? What’s the difference?
When you hear the term opiate, that’s referring to drugs that exist naturally inside opium. Inside opium, morphine exists naturally and codeine exists naturally.
When you hear people use the term opioid, that’s referring to drugs that come from opium. Heroin comes from opium. Hydrocodone and oxycodone are synthesized from opium, but they’ve been treated chemically to make them more potent.
And the effects that hydrocodone and oxycodone produce in the brain are indistinguishable from the effects produced by heroin. So, when we talk about opioid pain medicine, we’re essentially talking about heroin pills. Which doesn’t mean that you should never prescribe them.
Opioids are very important medicines for treating pain at the end of life. They play a very important role when used after a major surgery for a few days. Unfortunately, the bulk of our prescribing in the United States, and the bulk of our consumption, is for common conditions where opioids may be more likely to harm patients than help them.
Heroin epidemics are not a new thing. What is different about this one?
The opioid addiction epidemic really began in the late 1990s with the introduction of OxyContin. Purdue Pharma, when they put that drug on the market, they were interested in a drug that would bring in lots of revenue on sales. But, when they were introducing OxyContin they had a problem, which was that the medical community understood at that time that opioids are highly addictive drugs.
We knew that if you treated common conditions with long term opioids, many patients would get addicted. We knew that patients would develop a tolerance to the pain-relieving effect rapidly, meaning they’d need higher and higher doses. The medical community understood that opioids were not appropriate drugs for these common conditions.
What Purdue Pharma did when they were launching OxyContin was to reframe these very good reasons for being concerned about opioids as barriers to compassionate pain care. And they sponsored 20,000 educational programs across the country with messages for the medical community that we were allowing patients to suffer needlessly because of an overblown fear of addiction. … And as the medical community responded to this brilliant marketing campaign, and as the prescribing began to take off, it led to parallel increases in addiction and overdose deaths that led to a public health crisis. Since 1997, we’ve had a 900 percent increase in opioid addiction in the United States from exposure to opioid pain medicine.
What groups are at risk for opioid addiction? Do you see any general characteristics?
We have two groups of Americans who have become addicted, an older group and a younger group. The younger group are people who are getting addicted either through medical use of opioid pain medicines or from recreational use, or sometimes from both. That young group, when they get addicted, even if their addiction developed through medical treatment, they have a hard time getting enough pills from doctors to maintain their addiction. So they have turned to the black market, once addicted, to maintain their supply. And the pills are very expensive on the black market.
So, if the young person was in a region of the country where heroin was available, they switched, because the heroin produced the same effect and cost much less. And what we’ve seen happen over the past 15 years is that heroin has spread across the country into places it was never previously available to meet the demand for it by these young people who first became addicted to prescription opioids.
But what’s really important to understand, and which doesn’t really get reported on very much, is that there’s this older group – people over 40 who developed opioid addiction, usually through medical treatment for a chronic pain problem. When that older group gets addicted, they don’t need to switch to the black market. They can usually find a doctor who will prescribe them all of the opioid pain medicine that they would want.
What’s not well known is that the overdose death rate is actually significantly higher in the older group than it is in the younger group that’s been switching to heroin. The age group with the highest rate of overdose death in the United States is 45 to 54 years old. Yet, many of us think of the opioid crisis as something that’s exclusive to young adults.
Why are opioids not recommended for long-term use?
The problem with using opioids long-term is that tolerance to the pain-relieving effect develops very quickly. So, in order for a patient to continue getting pain relief, the dose has to start going up. And as the dose gets higher and higher, what you often see is that the patient’s functioning begins to decline, and patients who may have had all sorts of interests and activities that they had been engaged in, they stop engaging in them.
What we now know, especially with data that has come from workers’ comp – if you treat an injured worker’s chronic pain with long-term opioids, that worker is far less likely to ever go back to work again compared to any other intervention you could have offered them. What we know is that, for most patients with a chronic pain problem, taking opioids on a daily basis for weeks and months and years not only does not help them, it can even make pain worse. It’s a phenomenon called hyperalgesia. At the leading pain centers in the United States, at the Cleveland Clinic, at the Mayo Clinic, they treat people who suffer with chronic pain by getting them off of their opioids.
How should we treat chronic pain? Are there alternatives?
There’s a tendency to think about chronic pain as a single problem, or to think about chronic pain even as a disease – in fact, the pharmaceutical companies would like us to think about all sorts of common conditions as diseases.
Chronic pain isn’t a disease, it’s a symptom. It can be a sign of a serious disease, and it can be a sign of an underlying problem that needs medical treatment. So, if a patient has a chronic pain problem, the first thing that a clinician should do is try to identify the cause of that pain and treat the underlying condition.
The approach really depends on the patient. For some patients, it’s necessary to prescribe medicine. And medications that can be just as effective as – or even more effective than opioids, depending on the pain – would be a combination of drugs like Advil and Tylenol. Advil and Tylenol work differently, so it’s safe to take them together. It’s not as though Advil and Tylenol don’t have their own risks – they do. All medicines have risks. But they’re sold over the counter for a reason: They really are safer than opioids, and we sometimes forget how helpful they can be.
It’s almost a rite of passage in the United States to take out wisdom teeth, and dentists prescribe Vicodin to teenagers every time they take out their wisdom teeth. In other parts of the world, in Western Europe, dentists don’t give out Vicodin. They give out drugs similar to Advil when they remove wisdom teeth. And drugs like Advil can work just as well, if not better, because they’re anti-inflammatory.
We’ve gotten ourselves into this as a country and as a culture. How do we treat this epidemic?
The way that we should handle this disease epidemic is very similar to the way you would handle other disease epidemics – even an infectious disease epidemic. Think about how you would tackle an Ebola outbreak or a measles epidemic.
There are really two things you have to do if you’re tackling a disease epidemic. First, you have to contain it, meaning prevent new cases of the disease. And then, you have to see that the people who already have the disease are accessing effective treatment so the disease doesn’t kill them. And that’s basically the approach for the opioid addiction epidemic.
We have to prevent new people from getting addicted, and to do that there are different strategies, but the most important are those that will lead to more cautious prescribing. But for the millions of Americans now who are already addicted, we have to see that they can access effective treatments. If we don’t, if we just focus on curtailing the overprescribing, we’ll succeed in reducing new cases of addiction. But the generation of people who have already developed addiction will continue to suffer a very high rate of overdose deaths, and heroin will continue to flood the market to meet the demand for it. So, we’ve got to see that those individuals are accessing the right treatment.
Talk about prescription drug monitoring programs. How do they fit into preventing new cases?
Kentucky was at the forefront in mandating that their doctors use a database before writing controlled substance prescriptions. So these prescription drug monitoring programs, or PDMPs, are fantastic tools in addressing our opioid crisis, and they are underutilized. In states where the doctors haven’t been made to use the PDMP, very few doctors actually bother to check. Many doctors think they can tell by looking at a patient who may or may not have a problem or who may or may not be visiting multiple prescribers to get pills. And of course they can’t.
Being able to identify a patient who is visiting multiple prescribers is really important, because if the patient is addicted and you don’t know that, your prescription could wind up leading to a loss of life. It’s also important to see if the patients are visiting multiple doctors, because they could be somebody who is out there selling the pills on the black market. So, mandatory use of PDMP is one very helpful intervention. After Kentucky mandated that their doctors use the PDMP, Tennessee and New York state also passed similar laws and they’ve been very helpful.
Are there ways that doctors can identify a person as being at risk for transitioning from an opioid to heroin, or for developing an addiction of any kind?
As the opioid addiction epidemic has gotten worse, some states are making their doctors take educational programs on opioids, and unfortunately the content in many of these educational programs is not good. What doctors are not being taught is that opioids are lousy drugs for chronic pain. Instead of being taught not to use opioids for low back pain, chronic headache, fibromyalgia, etc., they’re being taught how to use opioids for these conditions. And that teaching is seriously flawed.
The idea behind these programs is that these aren’t really risky drugs, it’s that there’s just a subset of our population that’s prone to addiction, and we should figure out who they are and be careful with them, and everybody else we don’t have to worry about. And that’s not true with highly addictive drugs. … With very highly addictive drugs, it’s not that there are risky people, it’s that the drug itself is inherently addictive.
“When most people get an opportunity for treatment, what we often provide them with is detox. We give them tapering doses of methadone over a few days and send them home. And that doesn’t work. That’s treating the acute withdrawal, and most individuals will relapse and they’ll relapse pretty quickly.”
We’ve heard a lot about addiction being a disease, however, there are still people who aren’t getting that message. Could you clarify why addiction is classified as a disease, or why it should be in people’s minds? How does that change the way we treat it?
I think there is a tendency to think about our opioid crisis as a drug abuse problem. I think that suggests that the problem is, we’ve got a group of people out there behaving badly, taking dangerous drugs because it feels good to take those drugs, and some of them are accidentally killing themselves in the process. That’s not what’s going on. What we have is a very large increase in the number of people who’ve developed addiction.
Once you’ve developed addiction – either because you made bad choices or because you were following a doctor’s recommendation – once you have that condition, you’re not just taking a drug to get a high from it. Without using the drug you’re feeling very sick, and it’s not just a flu-like illness. When you’re going into withdrawal, it’s also very, very severe anxiety. It feels like a panic attack. There’s this sense of impending doom. People feel like they’re truly going to die, like they’re losing their mind. It’s why they will do very desperate things to maintain their opioid supply. So the idea that people are out there having a good time with these drugs isn’t true. The people who are opioid-addicted have a horrible quality of life.
Unfortunately, when most people get an opportunity for treatment, what we often provide them with is detox. We give them tapering doses of methadone over a few days and send them home. And that doesn’t work. That’s treating the acute withdrawal, and most individuals will relapse and they’ll relapse pretty quickly.
Talk about medication-assisted treatment for opioid addiction. What is the difference between what methadone does and what buprenorphine and Suboxone do?
Buprenorphine and methadone are similar in that they’re both opioids. Methadone is more like the opioid pain medicines that are prescribed in that if you take too much of it, you’ll stop breathing and you can die of an overdose. So, it’s a dangerous drug, which is why when you’re using it to treat opioid addiction, it is almost always given to a patient who’s visiting the clinic. In general, it’s not prescribed.
Buprenorphine is much safer, and works a little differently. It’s very hard to overdose on it – it has what we would call a ceiling on its effect. It doesn’t slow breathing the way methadone or other opioids will. Buprenorphine has this other unique property, in that it blocks the brain’s opiate receptor, so if a patient is taking their buprenorphine or Suboxone – which is another name for it – if they’re taking their buprenorphine and they run into a friend who offers them heroin and they try to use the heroin, they won’t feel the effect of the heroin, it’s blocked. This is very nice when you’re treating a condition where people are prone to relapsing.
There’s very good evidence supporting the use of methadone and buprenorphine. And with buprenorphine, we also have evidence from France that when the drug was released and widely prescribed without the same restrictions we have in the United States, within six years of the release the overdose death rate in France dropped by 80 percent. So, there’s good reason to believe that with better access to buprenorphine we could reduce overdose deaths in the United States.