Ira Minot (IM): We are honored to have this opportunity to speak with you Dr. Kolodny. Our readers are anxious to learn about the current opioid epidemic.
Andrew Kolodny (AK): I am very pleased that Behavioral Health News is devoting this issue to the current opioid epidemic. Opioid addiction is the most urgent public health crisis facing the country. The CDC would agree with that and are calling this the worst drug epidemic in our country’s history, and have placed this issue on their top five priority health challenges for the country. The Obama administration has finally recognized the seriousness of this problem and the President is proposing $133 Million in the 2016 budget to target the opioid crisis. As you and your readers may know, governors around the country have been talking more about the opioid addiction epidemics in their states. Last year for instance, Governor Peter Shumlin of Vermont devoted his entire State of The State Address to the crisis they are dealing with (www.governor.vermont.gov/newsroom-state-of-state-speech-2013). Many other state’s elected officials have come out to proclaim the opioid epidemic as a signature issue in their state. With that background I am again so glad your publication is focusing on this because frankly, I am amazed by how little attention this problem gets considering how serious it is.
When we talk about the problem, you’ll hear it described in different ways. You will hear it described as a problem with prescription drug abuse, or Heroin abuse. However, I think that’s the wrong way to describe the problem. It’s the wrong language, and I believe the language we use to describe it is important. I don’t believe we have an epidemic of people abusing opioids – which sort of makes you think of it as teenagers taking pills for fun and then overdosing on the pills, or people using Heroin because it feels so good. That’s not the problem.
The problem we have in this country is an epidemic of opioid addiction. Some of the people who have this disease of opioid addiction develop the disease through abuse of painkillers, but many people develop this disease through medical use of painkillers. It’s both medical and non-medical use of painkillers which lead to opioid addiction.
What we’ve seen over the past 15 years is a very sharp increase in the prevalence of opioid addiction. The number of Americans who are now struggling with opioid addiction has skyrocketed since the late 1990’s. The reason we’re seeing overdose deaths at historically high levels, and why it has become the leading cause of accidental death in the United States, even surpassing deaths from motor vehicle accidents, is because we have so many people who are opioid addicted. The incredibly high amount of overdose deaths we now see is due to the fact that the prevalence of opioid addiction has increased dramatically and overdose death is a common outcome for people with the disease of opioid addiction.
When we talk about people who are using Heroin one of the things that we know is that those who have become users over the past 15 years (to separate them from those who have been using Heroin since the 1970’s) is that at least 4 out of 5 of them (or more than 90%) began their opioid addiction using painkillers. When you look at the population of people struggling with the disease of opioid addiction there are roughly three different groups:
(1) Those who developed opioid addiction in the mid 1960’s and 70’s and have struggled with their addiction for the past 40-50 years. From that cohort, many people died from overdoses and many people also died of AIDS as the use of needles increased the spread of that disease. So we have a cohort of survivors from that epidemic who are aging. These are mostly men (as we see at Phoenix House) who are now in their sixties and who are disproportionately African American and Latino from inner-city communities.
Then we have the group I was speaking about that developed opioid addiction during the past fifteen years. Among these people who have become more recently addicted we have two different groups:
(2) One group of people who are young – perhaps in the range of 18 to 34 years of age who developed opioid addiction from medical or non-medical (recreational) use of painkillers. Some of them may have had a medical exposure (wisdom teeth or a sports injury) and they kind of liked the effect of the drug. So, they were using the drug recreationally and probably didn’t realize that they were essentially using Heroin pills – because Hydrocodone which is in Vicodin and Oxycodone which is in OxyContin and Percocet are opioids derived from Opium, the same as Heroin is. The effects they produce are indistinguishable from Heroin. For many, they probably thought they were playing around with a “soft drug” that was safe because it was prescribed by a doctor and not “cut” with anything – and it wasn’t until they got addicted that they may ultimately figure out that this is basically the same thing as Heroin. Because they are young and typically do not have serious medical problems, they have a hard time getting a large enough supply of pills from doctors so many of them have been switching to Heroin.
There is a common media narrative that our current Heroin problem is brand new was caused by government efforts to crack down on painkillers. But that’s not true. There hasn’t really been a government crackdown on pills and young people who became addicted to opioids from painkiller use have been switching to Heroin since the early 2000’s, especially if they were in areas where Heroin was readily available. That’s because when you compare a pill that cost $30 to a $10 bag of Heroin that would do pretty much the same thing, it boils down to a matter of cost.
The other people who are opioid addicted right now are individuals in their 40’s, 50’s, 60’s, 70’s and 80’s. These are people who have mostly become addicted though medical use of opioids – in particular opioids prescribed to them for chronic non-cancer pain. This is a group that doesn’t need to turn to Heroin because they generally don’t have any problem finding doctors who will prescribe them all the pills that they need. One of the interesting things that observers and the media do not really capture is this older group that is addicted to legitimately prescribed medication. One of the more interesting findings is that the overdose death rates are much higher in that older group getting pills from doctors than the younger group that’s been switching over to Heroin. The age group with the highest rate of drug overdose death in the United States is 45 to 54 years old. A recent Utah study where they looked at everybody that had died of painkiller overdoses found that 92% were having them prescribed to them by legitimate doctors for documented chronic pain.
I began by saying that there has been a very sharp increase in opioid addiction and overdose deaths are at an all-time high. But we are also seeing skyrocketing rates of infants born with neo-natal abstinence syndrome who are born dependent on opioids. We are also seeing a significant rise in Hepatitis C and a rise in Heroin flooding into communities where Heroin has never really been seen before.
The question you might ask is what caused this increase in the disease of opioid addiction? Why are so many Americans addicted to opioids today than there were 20 years ago? The CDC has done a pretty good job of answering these questions. (see graph)
What the CDC is saying is that this epidemic has essentially been caused by the medical community. Doctors began prescribing opioids in the 1990’s more aggressively than they had ever done before (other than the 1800’s another era when opioids were overprescribed). As prescriptions soared it led to parallel increases in opioid addiction and overdose deaths.
There are situations when opioids are essential medicines such as in end-of-life care and they are also very important for easing suffering of someone who has just come out of surgery or had a very serious accident.
What’s so disturbing about the vast over-consumption of opioids in the United States is that it is not for these conditions where opioid use is appropriate or essential. On the contrary, the vast over-prescribing of opioids are for conditions where opioids are much more likely to hurt patients then help them. I am talking about conditions like lower-back pain in a patient with a normal spine, fibromyalgia, and chronic headache. These are conditions where the experts that study them have made clear that opioids are not safe or effective.
IM: How do addictions actually begin? Are there bodily thresholds that must be met, or certain parts of the brain that differ in each person that are involved?
AK: That’s a very good question. Addiction doesn’t happen from a single exposure and is very different depending on the drug. For example, some drugs like alcohol are inherently less addictive. About 90% of the people who drink alcohol do not become addicted to it. When you look at who becomes addicted to alcohol you will often see a very strong genetic component suggesting that alcohol addiction runs in families.
When it comes to highly addictive drugs such as nicotine, opioids (both Heroin and painkillers), and meth-amphetamine, genetics play much less a role, and the inherent addictive property of the drug plays a much more important role.
Environmental factors or the person’s psycho-social state can also play an important role. If you are depressed for example and you are taking opioids and they not only relieve your pain but improve your mood, that’s going to put you at greater risk of becoming addicted. For the most part it’s mostly repeated exposure to the addictive drug that leads to addiction.
One exposure to an addictive drug is unlikely enough to cause an addiction. Let’s say I offered you one cigarette, you would not develop a nicotine addiction. However, if I gave you a few packs and told you to smoke 5 cigarettes a day for an entire month, it’s very possible that you would develop a nicotine addiction. Generally, if you begin taking an opioid over and over again regardless if it’s a recreational user who starts off doing it on week-ends or at parties because it’s fun, it can easily lead to an addiction. Similarly, when someone is prescribed long-term opioids, taking them every day, they can easily become addicted.
We now know a fair amount about the neuro-biology of opioid addiction as well and we understand that with repeated exposure to an opioid there are structural changes that occur in the brain that may even be irreversible.
IM: In your opinion, is there a solution to the current opioid epidemic in this country?
AK: I think the way out of this is to first think of this as a disease epidemic not an epidemic of people using drugs. We need to face this epidemic as you would any other disease epidemic such as an HIV epidemic, Measles, or Ebola epidemic, by which I mean we need to contain the disease by preventing new cases and we have to treat people with the disease so that it doesn’t kill them. The first thing we have to do is prevent new cases of opioid addiction from occurring and the second thing is that we must see that people with opioid addiction receive effective treatment. That’s really it.
Number 1: Preventing new cases of opioid addiction boils down to getting doctors and dentists to prescribe more cautiously. By doing so they won’t directly addict their patients or indirectly cause addiction by stocking medicine cabinets with pills that become an attractive hazard for their teenagers.
Number 2: We have to get better at improving access to treatment for people who already have this disease. If it’s easier to get pills or Heroin than it is to access treatment, we’re going to have no chance of reducing overdose deaths.
IM: What’s the first line of defense in terms of treatment options available today?
AK: Buprenorphine therapy, also called Suboxone, when administered and monitored properly is one of the more effective treatments.
IM: Is Buprenorphine similar to Methadone?
AK: It’s similar to Methadone. Methadone is a full opioid which is potentially dangerous when taken outside of Methadone clinics. Buprenorphine is a safer medicine that has fewer side effects, but the main advantage is that doctors can prescribe if from their offices, but it still must be done responsibly. By that I mean urine test should be done to verify that the patient is taking it, and you would want patients to receive psycho-social support. When it’s done well, patients can have excellent outcomes. This is a very treatable condition.
IM: Is Buprenorphine used to wean the patient off opioids or is it used as a life-long substitute for opioid addiction.
AK: That depends on the patient, but many people do need to stay on Buprenorphine long-term. Just like diabetes or high blood pressure, patients can be able to get off pills or insulin if they lose enough weight, eat right and exercise regularly- but if they can’t do these things, we still give them the medicines they need.
IM: Does the Buprenorphine give the patient a euphoric effect when taken?
AK: Patients who take it regularly do not feel high from it. Some patients describe it feeling similar to having a cup of coffee. Patients look and feel alert on it.
IM: Is there a down side to taking it?
AK: The down side is that Buprenorphine is an opioid which means that if a patient runs out of it or loses their prescription while on vacation, they are going to feel ill. It’s not fun to be dependent on a medicine and need to worry about running out. But unfortunately, not many opioid addicted patients are able to do well without Buprenorphine or Methadone.
IM: What are current attitudes towards using Buprenorphine by the treatment community?
AK: That’s a good question. Unfortunately, Buprenorphine isn’t as widely accessible as it could be. This may be due to ideological differences at treatment facilities where some centers feel they do not believe in mediated assisted treatment. What we end up with is people dying of overdoses who might have lived had they been prescribed Buprenorphine.
IM: We are deeply grateful for this opportunity to speak with you. Do you have a message you’d like to leave with our readers?
AK: Yes, first I would like to thank Behavioral Health News for providing a much-needed forum for information and collaboration among professionals in the field of chemical dependency and for providing a roadmap to resources in the community for individuals struggling with substance use disorders and their families.
My second message is to tell everyone that there is hope for people with serious chemical dependency issues.
Andrew Kolodny, M.D., Phoenix House’s chief medical officer, started his career with a keen interest in public health and a passion for helping those who are suffering from addiction.
Prior to joining Phoenix House, Andrew served as Chair of Psychiatry at Maimonides Medical Center in Brooklyn, New York. In that role, he provided clinical and administrative oversight of psychiatric services and a residency-training program for one of the largest community teaching hospitals in the country. During his tenure, Andrew demonstrated a hands-on approach to improving quality of care, integrating health and mental health services, and developing new services and programs to meet changing community needs.
Andrew received his medical degree from Temple University School of Medicine. After completing his residency in psychiatry at Mount Sinai School of Medicine, he pursued his interest in public health with a public psychiatry fellowship at Columbia University and a Congressional Health Policy fellowship in the United States Senate.
Andrew then worked as Medical Director for Special Projects in the Office of the Executive Deputy Commissioner for the New York City Department of Health and Mental Hygiene. Tasked with decreasing overdose deaths, Andrew helped expand access to opioid addiction treatment. He also developed and implemented citywide programs to improve New Yorkers’ health and save lives, including naloxone overdose prevention programs and emergency room-based screening, brief intervention, and referral to treatment (SBIRT) programs for drug and alcohol misuse.
When Andrew began a clinical practice, he encountered the type of patient who has become the new face of the worst drug crisis in U.S. history—young adults and middle-aged pain patients from suburbs who were addicted to prescription opioids. Andrew realized a new drug epidemic was emerging. People were dying in greater numbers every day, and no one seemed to be paying attention.
To combat this crisis, Andrew co-founded “Physicians for Responsible Opioid Prescribing” (www.supportprop.org), now a program of Phoenix House. Through his advocacy, he met and worked with people who have lost loved ones to prescription opioids—people he considers heroes because they have the courage to speak out despite stigma and work to make something meaningful come from their loss. Their advocacy with FDA led the rescheduling of Hydrocodone products such as Vicodin, correcting a mistake in federal law that had led to inappropriate availability and hundreds of thousands of cases of addiction.
When it comes to his role at Phoenix House, Andrew is most excited about the opportunity to close the treatment gap in addiction, and states, “There are millions of people in this country suffering from this disease of addiction who are unable to access effective and affordable care.”