Here’s an alarming number: in recent years the use of oxycodone has risen by 500% in the US. In fact, America consumed more opiates than any other country.
But it’s not because we’re suffering from more pain or accidents than anywhere else. These drugs are simply overprescribed.
Drs. Eike Blohm and Maria Steiner talk to Jesse about the legitimate medical uses of opiates and why they’re so easy to abuse.
Opiates and Pain Management
Opiates are great at treating pain, at a time when doctors are focusing more concerned with pain than ever before.
Pain is often treated as a “fifth vital sign” and emergency room doctors’ salaries are sometimes based on client satisfaction, which often hinges on significantly reducing pain.
Opiates are very good are alleviating pain temporarily, although can make pain worse over the long run via opiate-induced hyperalgesia.
Doctors are then faced with the choice of doing the “right” thing or the easy thing.
The Opiate Epidemic
The current opiate addiction epidemic is killing more people per year than AIDS at the height of the crisis. And it affects people across socioeconomic lines.
Addiction is not a choice; it’s a disease that affects brain chemistry. Nobody wakes up and says, “I want to be an addict.”
Opiates are highly addictive, and prescribed more frequently than ever, creating a deadly cycle. Opiate addicts often first become addicted from a prescription but move to heroin because it’s cheaper and easier to get.
Just how serious is the addiction crisis? According to some estimates, a typical heroin user will overdose between one and ten times each year. Deaths from overdose have overtaken deaths from car accidents in the US.
Treating Opiate Addiction
Whatever you think of addicts, reducing overdoses makes financial sense. Treating addiction before addicts need to be admitted to a hospital due to overdose cuts health care costs and enables some people to get clean and return to being functional members of society.
There’s still a stigma to addiction; we associate drug use with a moral failing but that’s not the case. Addiction is caused by a change in brain anatomy that changes our reward circuit in a way that’s hard to get out of.
PS: Our weekly emails aren’t physically addictive, but they will reward your brain.
Eike: Right now, we have a huge opioid crisis in the entire United States and that is the amount of opioid use, both therapeutic and abusive has gone up dramatically. Since 1999, our use of just oxycodone alone has risen by 500%. If you take a look at the opioids that are consumed worldwide, the United States are far ahead of any other country. And of course you could make the argument that if you live in Sub-Saharan Africa maybe you simply don't have access to opioid so that's why they don't consume opioids. But multiple other civilized countries including Japan, France, Germany that have access to these drugs don't consume nearly as much as the people in the United States. Now, the question is why does this happen? Do we experience more painful events over here? Do we have more accidents? Do we have high rates of cancer that require all those drug usages? Really, the answer to that is no. You're more likely to get shot in the United States but pretty much everything else is the same.
Maria: I mean, something that should be realize is there's lots of people who are actually taking Opioids for medical reasons, for chronic pain management. When your body is regulated to do so, you can actually function very well in the world. It's not illegal to drive a car if you're taking opiates -- if you are doing so in a prescribed, safe manner. You actually maybe interacting with people on opiate pain medicine often and have no idea that's the case. One reason why, you know I got the chance to work with Eike and he was so passionate about this topic is how often do you see it in an emergency room. If you're trained up as a highly specialize physician in a different field, again, you just never see it so you're not aware of the size of the problem. Once I begin to work with it and also did some work with the Western Public Health Council combined with the budget cuts that are put to state with the epidemic, it's an unbelievable problem that needs to be solved and people needs to address it.
Eike: Something happened in the United States a couple of years ago where the pharmaceutical industry had these products that they wanted to sell and they needed to convince physicians that this is actually a safe drug. A lot of physicians were reluctant to prescribe opioids even to people that had significant pain from cancer for example just because these drugs were known to be so addictive. So along came something called oxycontin. An oxycontin is the same as oxycodone. It's just in a pill that's designed to dissolve very slowly. So the idea was if it’s a slow release, it won't get you high and it won't get you addicted. Turns out that's not true at all and the pharmaceutical industry actually had to settle because of false advertisement to the country.
But, this set into motion a new approach to pain, pain perceived by patients. The first step was that pain was introduced as what they call the fifth vital sign. Now when you come to the emergency room or to your doctor you will always be ask to rate your pain on a scale from one through ten. One being almost no pain. Ten being the worst pain that you could possibly imagine. That has become the standard now. The fact that it's considered a vital sign is somewhat of a misnomer because medically speaking a sign is something that the clinician observes. A symptom is something that the patient experiences. So by default it can be a vital sign because I don't appreciate it from the outside. You appreciate it as the patient.
So that was the first step. Then the next step was that patient satisfaction was tied to physician compensation. This is done through surveys. One of the most well-known services is Press Ganey. Press Ganey is sent only to patients that see an emergency medicine doctor and get discharged, which means if you come in and you're gravely injured or really, really sick and I really save your life and you end up in the intensive care unit, you will not get a survey. If however you had an ankle sprain and I sent you home from the emergency room, you might get a survey.
On that survey it will say, this is paraphrasing from the actual survey, “But did the clinical team do everything in their power to control your pain?” and I can do a lot to control your pain. I can make you stop breathing. So people that were hoping to get pain medication or people that simply can't handle pain very well are more likely to say yes, they tried to control my pain if you give them opioids rather than seeing that pain is while uncomfortable also necessary because well, you sprained your ankle and your ankle hurting tells you to not put weight on it and allowing it to heal. But this set-up a culture where now physicians were very prone to prescribe opioids because it was directly tied to patients satisfaction and the patient's satisfaction was directly tied to their bonuses at the end of the year. So you now incentivize an entire generation of physicians to prescribe opioids.
Jesse: Was this a change in the laws that this is like an unforeseen consequence or what actually transpired to make this change happen again?
Eike: Well it's not a change in the laws. Congress didn't get together and said this is how it has to be done now. This was a change in medical culture that was influenced by the pharmaceutical industry. Now you have a patient that has chronic back pain, for example, and we know very well that treatment with opioids alleviates pain temporarily but over the long term will make the patient's pain worse. This is something called opioid-induced hyperalgesia. We know this from animal studies as well as from human studies and observational studies, yet in order for me to create patient satisfaction I can only do this by giving you prescription for oxycodone. In addition to that, think of the time restraints that I have as an emergency medicine physician. I have several unseen patients. Some of them might be dying. I don't know because I haven't been able to see them yet and I have a choice of either writing a prescription for oxycodone and not a have a discussion with the patient or sitting down and explaining to the patient why I'm not comfortable prescribing them oxycodone because maybe they are already on different opioids or maybe they have a significant alcoholism, and alcohol with opioids does not mix very well. It’s actually a lethal combination. Then these patients get upset and they ties up more of my time. And if they complain then I need to go to my boss's office and I need to explain myself. They may even complain to the Board of Medicine. So this can escalate and soak up so much of my time so now the question is, do I want to do the right thing or do I want a fast and easy thing? There's a lot of physician that will go for the fast and easy thing.
Jesse: Listening to you talk, I was reminded of the AIDS crisis in the late 1980's probably it was, when they kind of started talking to the public about AIDS education in a way that would have been probably unthinkable before because they were sending kids home with little pamphlets for their parents to read it, and talk about drug use and anal sex and stuff like that that would have just been unthinkable a decade before. Even have a public discourse around this but they figured there was a problem that had become so severe and was growing so fast that they needed to pull-out all the stops because it was a growing public health crisis. Do you feel like the current opioid crisis is near a watershed moment like that where people say “Hey we got to educate the public in a more proactive aggressive way?”
Maria: Yes. I do think it does. I think you're picking up on something pretty nuance there because I've noticed in my medical education that the way we address sex and safe sex practices is incredibly different than the way physicians were trained prior to the epidemic. That was I think a pivotal point in the way that medical professionals interact with the public and realizing that the dynamic between the physicians and patients need to change to become vastly more comfortable.
I think you're correct because opioid epidemic is now killing more people each year than the AIDS epidemic was at it’s height. You were talking about that opioids seem to affect different parts of the population more than other parts but that is less so that it was for the AIDS epidemic. I mean, I'll tell you every single patient I talked to in Western regardless of how they appear or whatever, I make certain to ask about illicit substances because it is far more common than you think. I'm not certain that older physicians do that.
Eike: So now there is a movement of foot to really reverse that cause. In Massachusetts for example, I am now required to look up a patient in something called the Prescription Monitoring Program which records all schedule to a medication that are potentially abusable that patients fill at pharmacies in Massachusetts and surrounding states. So I am by law required to look that up no matter who the patient is and you'd be surprise what this does to physicians. (A) this is a lot of work. You have to type in a name. You have to type in the date of birth. You have to make sure you get the correct patient. You have to look for the history. Being a little bit work avoidant, you may rethink “Does this patient really need the oxycodone for the ankle sprain or maybe motrin tab will cut it. I found myself to be prescribe a lot less simply because under time constraints I didn't want to look it up. That sounds horrible but that's how it is. Interestingly, nobody came back and said "You know what. I need a stronger pain medication because the motrin tab just didn't cut it." I was probably unconsciously overprescribing to begin with.
In addition to that, once in awhile you find out that the sweet little 80 year-old lady has been to five different of these in the last week in different state and has collected opiate prescriptions. And all of them in patients that you would not suspect would be doctor-shopping or drug-seeking. All of a sudden you discover that pattern then you have to have a very candid conversation with that patient.
Jesse: It sounds like the current opioid crisis started based on legitimate medicine. This wasn't like heroin dealers getting together and saying, "Hey, let's make street heroin cheaper for everybody," but it's more the people who are at least getting their initial exposure to these opioids in a fully above the board context, and then things devolving from there.
Eike: Yeah, I mean we really dropped the ball on this as physicians. Nobody wakes up one morning and says, "You know what. I want to try heroin today" Because heroin is a big and scary thing, but to get started on a pill that my doctor prescribed me and then just never stopping, that's a different issue. That doesn't mean you're a bad person. It just means your brain is wired in a way that the reward you get from taking this medication creates really neurological pathways that make it difficult to stop.
Maria: Something I remember a mentor once told me was that nobody wakes up and says “I want to be an addict.” The problem is they have a disease that's affected their brain anatomy, brain chemistry and they can't help it. When you talk to these patients or when you see them in the office, you're given an opportunity to help them. I think physicians in the public still thinks that addiction is a choice and I have heard of numerous patient-physician interactions and I witness it myself where a physician squanders that opportunity to have a real effect.
We actually get a lot of training now in medical school on how to counsel patients and assess their level of readiness for change and what sort of therapy or intervention is appropriate that time. It's important if the patient is in your office or you're having some chance to interact with them, you really have to treat it like an opportunity. You may not get everything done that you want to get done. Patient may say, "It's for you. I'm going to do whatever what I'm going to do and walk out door.” but who's the physician to do the best they can? I think that the mindset that you're talking about, the switch that occurred is helping us do that better.
Eike: So now the question is, what do we do with all these people who are on opioids? One of the things is we need to reduce the prescriptions and we need to provide a way out of people who are addicted to opioids. The problem is that mental health is horribly underfunded in this country. I have people that come to the emergency room and they say, "I'm here because I want to quit." All I can say is, "Well, good luck. Here's the list of phone numbers. Maybe somebody will have a bed for you in a week." Whereas the right thing to do by the patient would be, "I'm so glad you want to quit. Let me mobilize all those resources that I have available to help you do so." But we simply don't have the resources because it's not funded well.
Maria: I think PSA's aren't necessary with how much the media is sort of covering this but just a continued hope that people will maintain awareness and realize how much it's affecting our community and how much being in sort of active participant in your local government politics can make a difference.
Jesse: If somebody wants to write their congressman and say support X. What should they be supporting at this point?
Maria: I think that they should be supporting programs that provide naloxone or that provide addiction services. I think communities now have frameworks for these programs. The reality is funding. I'm sure you realize there's always an issue. So encouraging local governments to divert funds to those programs or making grassroots effort yourself can make a huge difference. The most successful programs come out of small communities. That's what I would say to somebody who wants to get involved.
Jesse: You have to think that an economist somewhere has already run these numbers. For every dollar spent on a treatment program, they can get somebody back to being functional member of the society who can be taxed and things like that. He's going to pay for himself hundred times over, right?
Maria: Yes. There's many politicians who had attempted to run on this policy that why are we throwing money on addicts. If they want to overdose and kill themselves, let them do so. Economists address that and look at it. I can send you the citation, there’s multiple studies that are shown. It makes financial sense in the community to reverse overdoses. It makes sense on multiple levels. The first is that you're stopping people from needing to be admitted to the hospital. Naloxone programs actually reduce immediate health care cost.
If you're an opiate addict, the chance that you will have at least one overdose in your length of addiction is very high especially once you move to heroin. It's not as controlled a habit. The chance that you will overdose is very high. If you stop those overdoses from leading to mortality, a certain percentage of people are going to become clean, and as you said become functional members of society again. There's an economic benefit there. There are multiple analysis showing it makes sense in the community to have these types of programs in place financially and socially.
Jesse: Probably most of us have seen a movie like Trainspotting that shows somebody trying to get off of heroin and locking oneself in a room and crapping your pants, and basically feeling like you're going to die for several days. Is there any real difference between breaking an addiction to something like heroin and breaking an addiction to something like oxycodone?
Eike: Well, they're both medications in the same class, so the withdrawal is essentially the same. The good thing about it is that opioid withdrawal doesn't kill. Alcohol withdrawal can. Opioid withdrawal does not. It makes you wish you were dead because you have horrible diarrhea and horrible vomiting and sweatiness, but unless you get injured from the dehydration that comes with the diarrhea, it's not lethal.
Some people quit using Opioids by themselves at home and they do so successful. Other people do much better when they are on a replacement therapy such as Methadone and Suboxone. Both these medications go to the same receptors as heroin does for example but there are something called partial agonist, meaning they're bind to it, they activate that receptor a little bit but not to the same degree as heroin. It's enough to take away the craving but not enough to get you high and that allows these people to be functional and go to work and find a job and become functional members of society again.
Sometimes they're able to be titrated off. This replacement therapy sometimes they stay on for the rest of their life. Then there is a group that wants to self-treat. Self-treatment can occur with things like craydon for example which is a tree that grows in Southeast Asia that contains microgynon which is a chemical that also binds to the opioid receptors in our body. You can just buy this over the counter. It's legal. You can order them on the internet. So people try to treat themselves that way. Other people use loperamide which is a medication that is used against diarrhea. loperamide is also an opioid that you can buy over the counter but the big difference between loperamide and oxycodone is that loperamide has a lot of difficulty entering the body. It stays mostly in the bowel which is where it’s supposed to work as an antidiarrheal agent. But if you take enough of it, you overcome the inability to cross into the bloodstream just by sheer force because you're taking so much that it actually starts to work against withdrawal. Then last but not the least, there are people who abuse loperamide in order to get high. These people of course expose themselves to all the risks of opioids but also other associated risks that come with the toxicity of loperamide in these high doses.
Jesse: Even horrible things tend to find an equilibrium point somewhere. I'm wondering if you look at the sigmoidal curve of new cases of people becoming opiate addicts. Have we reached a plateau stage or is this still continuing to grow?
Maria: It's not plateaued yet. The rate is still increasing but it is not as increasing at the same rate that it was say five years ago. When you look at how people get addicted to opioids, initially it was largely due to prescriptions and now it's so easy to get access to heroin on the streets that people can get addicted to those methods. We don't have as much data or knowledge about how people are getting addicted now but the problem is growing.
Jesse: What are the estimates in a country of 300 million people? How many of them are currently struggling with some level of opioid addiction?
Eike: Well, we know that deaths from overdoses have now exceeded the death from motor vehicles. We have cross that line a couple of years ago where more people die from overdose than car accidents.
Jesse: Wow, that's unbelievable. If you get tangled up in opiates, what's your chance of actually dying of an overdose?
Eike: It's really hard to estimate those things. Because of the social stigma that comes with drug use, people are not well supervised in medical care which means the only people that I encounter are the people that did overdose. So I see a bias subsection of the population. I have no idea how many people are out there that are, and I use quotation marks on this, “are using heroin responsibly”. Big quotation marks. But the ones that never overdose, I will never see. We simply don't know how many people are out there but the estimate is that everybody who uses heroin will overdose anywhere between one and ten times per year. There are people in my emergency department that I know by first name because I see them all the time.
Jesse: In that case what defines an overdose? Like are there none life-threatening overdoses? What sort is the tripwire for that term?
Eike: All opioids whether that'd be oxycodone or heroin, they bind to something called the mu-receptor. They bind to other receptors as well but the mu-receptor is the one that gives you the high. That's the one that makes you euphoric and feel good. However, the mu-receptor also sits in the part of your brain called the medulla oblongata. The medulla oblongata is your breathing center. What the medulla does is it maintains the automaticity of breathing. Right now as you and I are talking you're not thinking to take a breath, it just happens.
When you sleep for example it just happens automatically. The problem is that it drop binding the mu-receptor will deactivate it automaticity. Now you get high on say Vicodin and you fall asleep because that's what opioids do to you, make you sleepy. Once you fall asleep, now your breathing automaticity is disabled and usually it's going to slow down your breathing and eventually it's going to stop and that's what kills you. You simply stop breathing. No matter how much CO2 builds up in your bloodstream and high low your oxygen saturation drops, it cannot kick back in unless you get the antidote or unless somebody's breathing for you. That's why we have now started to distribute the antidote to all opioids widely in the community. It’s a medication called Naloxone, also known as Narcan. There's a big movement right now to get this in the hands of people that are most likely to need it.
So first we only had it in hospitals. So you were brought in by an ambulance. We give you the antidote and hopefully it wasn't too late. But think about how long it takes for an ambulance to come to your house and then they lift you up, and then they bring you to the hospital. That's a long time to hold your breath. Sure, the medics can bag you a little bit and kind of breathe for you but even if you just need to wait 10 minutes for an ambulance that's a long time to wait if you're not breathing.
We decided to distribute the antidote to police officers who typically respond much earlier than an ambulance just because they're more mobile. They drive a small car and not a big truck. They work pretty well. Then the next step was, well, if we have people who are known to use drugs, they are around other people who also use drugs. Why don't we give the antidote to people who use drugs? We are trying to bring it up into the community. So far that actually had pretty decent results.
There was of course some concern especially from the more conservative elements of society that if we give drug users the antidote, won’t that just escalate their drug use which was the same argument as if we put seatbelts in car, won’t people drive more riskily which didn't pan out. It also didn't pan out that people that got the HPV vaccine all of a sudden sleep with everybody.
Jesse: Just because I own a bicycle helmet doesn't mean I like hitting myself in the head.
Eike: Yeah, so the distribution of naloxone to drug uses has not resulted in increased drug use, and there are multiple studies that document this. It doesn’t increase the frequency or the amount use. So that was pretty successful. The problem is by definition you're unable to administer the medication to yourself. You need to have a second person there.
Jesse: What is the route of administration? Is it a shot? Is it a pill? What is it?
Eike: That's an excellent question. You can give it in various ways. The original version that it was an intravenous injection which of course a lay person can't do. They can however, put a needle directly into the thigh which is something called an intramuscular injection. But the problem with that is you are administering a needle to a person who is at increased risk of having Hepatitis-C or HIV and now you as the bystander are holding a sharp that was just in that patient so that wasn't a great way of delivering the antidote to the lay public.
Along came the nasal atomizer which you can think of a filter that when you push fluid through it foams tiny, tiny droplets and you stick in the nose and you just push the antidote through that atomizer and the tiny droplets get absorbed by the mucusa in the nose and from there it goes directly into your brain and enter the rest of your body. The advantage of it is it's needle-free. The disadvantage of it is it takes a lot longer. It takes maybe a minute to work rather than 30 seconds when I give it to you IV.
So because we live in a society where pharmaceutical companies want to make a lot of money, there was a pharmaceutical company called Kaleo, that develop something called the Evzio. The Evzio, you can think of as an epipen for Naloxone. It is an auto-injector and it is a device that will talk to you. So you activate it and it will tell you where to place it. It is a needle injection but it's designed in a way that the needle will retract back into the apparatus so you can't stick yourself up afterwards.
It needs to go on the outside of your thigh and you push it and it clicks and the needle goes in. It does a countdown timer of five seconds and then you remove it and the needle has already retracted. You can imagine that this is foolproof and very easy to use. If you compare this to using an atomizer which you need to assemble, you need to put the atomizer on top of a syringe and then put it in the nostril and then push half and one half in the other nostril. That's more complicated. If you're a parent of a drug-using child and you have this antidote at home, and you find your kid not breathing, assembling something like this is actually a very difficult task because you are scared shitless.
That's what the Evzio essentially, I don't want to say exploited but that's what they try to address. There's a single study that looked at the efficacy of the atomizer versus the Evzio. That study is industry-sponsored and three out of the five authors on that study work for Kaleo, the company that makes the device. So take everything with the grain of salt here but it's been shown that even without training 80% of people use the Evzio correctly and with training 100% use it correctly so that sounds promising, right?
Here's the problem, remember how we talk about very poor funding for all things drug and rehab related? If you want to bring this out into the community, you need to flood the community with these devices. Naloxone with an atomizer cost you about $20. The Evzio started around $350 and is now several thousand dollars. Just like the epipen they have hiked up the price as much as they could because it's still on the pen and with enough lobbying power you can require for example schools to have the Evzio rather than an atomizer. That's the same that was done with the epipen where schools in United States are not allowed to stock a generic epipen. They need the brand name epipen which has become very expensive lately.
Jesse: That is really unfortunate when big industry and public health do not have their incentives aligned at all.
Eike: Well, I mean they're in the business of making money and they're very good at it. But I'm in the business of helping people and saving lives and sometimes I need to make a utilitarian decision of how I do the most good for the most amount of people. If I have the choice of bringing say 100 units of naloxone into a community for $20 each or five Evzio. The chance of an Evzio being around when you need it even though 100% of people can administer it is going to be hard versus if only half of the people can administer an atomizer correctly but one is available at least I got a 50% shot.
Jesse: Is there somewhere within the population of people that are using opiates, sort of a hidden cache of responsible users in there who are not increasing their use? Maybe not winning themselves off, but also not getting sucked into a downward spiral with it.
Eike: The answer to that is most likely not. And the reason for that being is that the reason people use drugs is to feel good and the way drugs make you feel good is to increase the secretion of dopamine. Among other things also serotonin, but mostly dopamine. Once you have this artificial release of dopamine at this high degrees, the pleasurable effect that heroin must give you must be so intense. I don't know. I've never tried so I can't compare. But from what people tell me, it feels better than eating a great meal. It feels better than hanging out with your friends, and it feels better than having great sex. It's an overwhelming amount of dopamine. Now everything else in life that secretes dopamine in your head will be not as rewarding. After a while, even the response to the same amount of drug will diminish. Now, in order to feel high again, in order to feel good again, you need to use more drugs. So to reach that same level that's a concept called tolerance, you need to use more and more. That is why most people will spiral down once they initiate drug use like that.
Jesse: Do you see any perfectly well-adjusted happy people that also just happen to be opiate addicts?
Maria: All the time. I think one of the saddest stories for me was a man who -- hard-working man, built his own business, suffered a back injury, and was prescribed pain medication. Went through multiple different types of therapies, physical therapy, other such to try to resolve this issue. The only thing that could relieve his pain was opiate pain medication. He did successfully so for a long period of time. Then exactly what you were talking about happened, an acute stressor occurred.
I can't remember what exactly it was but I think his business had a rough quarter of something and next thing you know, he developed a full blown addiction and crisis. I think the tragedy of this is that prior to this, he had a happy marriage, three kids, his own business, and over the subsequent 10 years he lost all of that, and had to go through rehab multiple times. When I met him, he was clean but he related the story to me where he'd been at the breakfast with his teenage son that morning and had found out that his son had to use percocets at a party and treated it very casually.
For this man, it was sort of the most tragic thing because he had seen his whole life fall apart due to a substance and his son, who was a teenager, and quite ignorant, and quite naive, was really expressing a common thought amongst youth that these things are not very dangerous so they are not going to have long term consequences. I'm sure you've seen in the media, everyone always loves to write about it. It affects every layer of society. That's because injuries and pain affect everyone.
Jesse: Yeah, arthritis and car accidents are no -- respect your social class.
Maria: I think the statistic that recently came out was that 20% of Americans are going to see their benefits change if the new republican plan gets pass through, and 2 million of those 20 million are substance abusers who will be affected by that. So you're right that there's a disproportionate number of addicts who have less economic resources or who might've had other problems but it really is a problem that affects all layers of society.
Eike: So it used to be true that you could use really non-validated clinically indicators that doctors use colloquially, like something we call tooth to tail ratio. If you have more tattoos than you have teeth. This used to be the first we would easily identify as an addict, that's no longer the case especially with opioids in pill form. The disease of addiction has really moved into suburbia, into middle class and upper class families. This is no longer the homeless guys, no longer the junkie that you imagine. It is the housewife, it's the 15-year old kid in school that got hooked, those are people we see now.
Jesse: There is still a lot of social stigma, I think around any sort of addiction but it's interesting that some addictions are more stigmatized than others.
Maria: I think you're right. I think what you're speaking to is sort of a growing trend in public policy and in the public viewpoint that addiction can't really be viewed as that. It needs to be viewed as a disease and you're entirely right in that a prescription painkiller addiction versus intravenous drug addiction to heroin may be viewed differently in society. Medically, it's a different method and there's different health risk associated with using intravenous drugs but the opioid addiction is identical if you're addicted to opioids. There are very few addicts who stay with just the prescription pills.
I think as the medical side becomes more aware of the problem and changes their practices, people are moving towards heroin use and changing that dynamic. After a while, you run out of money and heroin is much cheaper than prescription pills.
Jesse: How much does it cost to become a heroin addict these days?
Maria: 20 to 100 dollars a day is the typical heroin habit.
Jesse: So, that's not nothing. That's a car payment or it could be an apartment.
Maria: And you're not able to work or contribute and maintain a job while doing that so.
Eike: The stigma is still there because you associate drug use as a moral failing and that's really not the case. We have really good evidence and we have functional MRI's to back this up that shows that people that start using a substance have a change in brain anatomy that sets up this reward circuit that is hard to come out of.
So when you do an activity, that feels really good. That biochemistry in your brain stabilizes those neuronal connections and you're more likely to engage in that same behavior again. Whereas if something feels bad, the opposite happens. So now, you hijack this pathway and that's what all drugs of abuse have in common, they hijack the reward pathway. And by so doing, they will stabilize the neuronal circuitry that caused the behavior to begin with. And so once that has taken place, it is now an anatomical problem.
They have it changed in their brain anatomy that results in their behavior just like you can’t yell at a diabetic to make more insulin in their pancreas, you can’t yell at a drug addict to just stop. There's more to it. There's a behavioral component to it of course but there's also a medical component to it. There's a definite anatomical change in the brain that occurs.
Jesse: One of things that I'm wondering about is the distinction, to the extent that there is one, between an opiate that would come through medical channels versus a street drug like heroin. Biochemically, how close are we talking?
Maria: It's extremely easy to get and they carry different names so you're talking about oxycodone versus heroin versus Morphine but the same sort of active metabolite in your body. The difference is the formulation and how quickly they affect you, how long they affect you. But actually, if you wanted to get heroin, I guarantee you could get it far more easily than you think. I think a few question here and there, it's everywhere. It's one of those things that until you know what to look for, you don't see it but once you know what you're looking for, you'll realize just how common it is.
Jesse: Let's say that I break my leg, I go into the hospital. I need a pain reliever. I'm given an opiate by prescription by my doctor. Is there the mythical you take something once or twice, and you get hooked despite your best interest or does that never happen? Is somebody always like going a little beyond what their prescription requires and at some point, is it a conscious choice or do people get addicted by accident?
Eike: So probably a little bit of both. I don't think that people get addicted from taking a single pill of pain reliever if they have a legitimate injury. If you come in with a broken leg, those things hurt, and you deserve pain control. We're not out as physicians to leave you suffering and in pain out of fear that you may become an opiate addict. We need to treat you appropriately but pain is also an okay response to have. The goal should be to get your pain to a level where it’s tolerable but not to get you pain-free because by the time I get you pain-free, I have overshot. I've given way too much pain medication. If you cannot feel your broken leg, you have way too much morphine on board.
Maria: 1 to 3 percent of patients prescribed pain medications do not stop taking it so when it becomes an addiction is when they stop using it for therapeutic purpose, meaning that they no longer have pain. And once you're using an opioid without the pain, your chance of addiction is vastly increased. However, you can also still be addicted while you have pain.
Eike: So another that's happening in the drug world right now is that we see less and less heroin and more and more panthenol. Panthenol is in the same class as heroin, it is an opioid. It goes to the same receptors but it's a lot more powerful and it is completely synthetic. In order to produce heroin, you have one point in time you need to import poppies or you need to import the paste of the opium from, usually the Middle East, Afghanistan for example, which means you have to cross several borders.
Smuggling drugs is a dangerous business, and it's much cheaper if you can produce it locally. And because Panthenol is completely synthetic, it can be produced right here in the United States. You don't need to cross borders and because the chemical structure looks completely different from, let's say heroin or morphine or hydromorphone, a lot of drug dogs simply aren't trained to sniff it. Panthenol will also not trigger the standard urine dipstick opioid teste because it looks nothing like morphine. So because of that, the market really has changed and more and more people are distributed panthenol when they buy heroin. The problem is that if you have a drug that is a thousand times more potent, measuring the right amount to take without dying, becomes more difficult because now, if you make a 1% error, that's a problem.
That may be why we see more and more overdoses now because people don't know that they're getting panthenol. And in addition to that, panthenol binds to the receptor so tightly that it's hard for the antidote to bump it off. So even if we give naloxone or narcan, and typically we give 0.4 mg or 2 mg, sometimes it doesn't cut it. I've had people I needed to give between 10 and 20 milligrams so 10 times the dose that I normally give to get them breathing again which then makes distribution of naloxone totally public problem because if I give you a 2mg dose to have at home to treat a heroin overdose and the acute overdoses on panthenol, you can give it. It's not going to do anything, it's not powerful enough to reverse it.
Jesse: Is panthenol a purely illicit substance or is there any medical use for that?
Eike: No, actually it is one of the main medical pain control agents that we use especially in anesthesia. Unlike morphine, and hydromorphone, and all those other IV opioid pain control medications that we have, panthenol doesn't affect your blood pressure very much. So in a trauma patient who was bleeding to death, you don't want to give a medication that lowers the patient's blood pressure further so we use a lot of panthenol actually in the medical world but panthenol does not come as a pill. It is a medication for in-hospital use only. It's nothing that gets prescribed.
Jesse: People that are having problems with opioid addiction, I'm wondering about sort of the demographics age-wise, is it biased towards a certain age group? Is it biased towards men versus women?
Maria: I think it is definitely biased to men towards women. Per usual, women are making smarter choices.
Jesse: I'm not touching that.
Maria: I have so many statistics for that one, but in terms of age-wise, I think it’s not as biased as you think. I don't have the numbers out of the top of my head but it really does affect many different age groups.
Jesse: Are there any popular misconceptions about opiate use that you think your average man on the street would be just shocked to hear?
Eike: Yeah, a couple. So there's a reluctance to inject the drug because you need to get a needle, it has higher stigma, you start getting track marks and people can actually see that you're doing these so people try not to inject drugs. There is a technique with heroin called chasing the dragon. In brief, what you do is you take a piece of aluminum foil and you put a little bit of heroin on it, you hold a lighter underneath and that causes paralysis of the heroin, and you then take a straw, and the term chasing the dragon comes from you chasing the smoke with the straw. You inhale the smoke, you inhale the particle of heroin, and this is perceived to be a safer way of administration because you don't stick yourself with a needle.
The problem with this technique is it is associated with something we call heroin associated spongiform leukoencephalopathy or HASL, which is essentially the same as mad cow disease. It's a different mechanism but it is also a spongiform leukoencephalopathy. We don't know why it happens this way. We don't know if it's a problem with the aluminum foil or if there's a combustion product of the heroin that's doing this. We simply don't know at this time. There have been a lot of cases reported in the Netherlands where chasing the dragon is one the most common routes of administration of heroin.
Just a couple of weeks ago, I saw somebody in the emergency department myself that had that, so this is something that's perceived as safe but truly isn't. The other thing that is common now especially among teenagers that try to get high is the use of loperamide which we talked about earlier. That's may be something we should address here because loperamide is available over-the-counter so you can just go to your local grocery store and just buy that stuff, and it is an opioid.
Now you have in your intestine and in your brain something called a P-Glycoprotein Pump. Think of the P-Glycoprotein Pump as a bouncer. If it identifies a substance that shouldn't enter, it will pump it back out. So the reason why imodium or loperamide is over-the-counter even though it's an opioid is because it is very well recognized by the P-Glycoprotein Pump. So it can’t even cross the intestinal wall, it doesn't even get absorbed. But a bouncer can only keep out so many people from the club so if you take enough of it, you will overcome the ability of P-Glycoprotein to pump loperamide back out into the intestinal lumen and you start absorbing it. But then, you still need to cross them to the brain so you need to take a whole lot to also overcome the P-Glycoproteins that are in the brain.
So if loperamide only had the opioid effect and it does, it does get you high, and it also causes respiratory depression just like heroin. But because you need to take so much of it, another toxicity ensues with loperamide, and that is cardio toxicity. The loperamide will bind to several electrolyte channels in the heart muscle and that will make people very prone to arrhythmias. So these people come in intoxicated with opioids, not breathing but also in cardiac dysrhythmias. The problem with these dysrhythmias is that they're very difficult to treat.
We treat these things with magnesium and sodium bicarbonate, and intralipid, an amiodarone and sometimes even peze. We simply can’t get people out of dysrhythmias. They're very, very resistant dysrhythmias. There are multiple cases of people that are brought in unresponsive on cardiac arrest and when they wake up, they have a pacemaker implanted with a defibrillator. The reason that happens is because nobody knew why they were down, nobody knew they were abusing loperamide. And so, we attributed them being unconscious than having an arrhythmia.
Jesse: At this point, given the state of where we're at, what is the game plan for trying to solve this problem of dealing with these addictions that people are not opting into in the normal way?
Maria: That's a great question and that's the question that city councils, and state councils, and national all have been trying to answer. From the medical perspective, medical education and policy has changed significantly in that physicians undergo training now in terms of what is safe prescribing practices. There's been lots of research in how to manage chronic pain and it's realized that Opioids are not a good solution for that. So the prescribing practices have really changed in an effort to conduct creating potential new addictions. The reality is that the supply has vastly increased.
So as much as we can do on the medical side, you can’t really change the fact that it's out there on the streets and people can get access to it. The work that we particularly have done is looking at naloxone and again that's just a Band-Aid to the problem. It doesn't help people relive their addiction or reduce the prevalence in the community so no one really knows, honestly, what to do right now. The only programs we have which have been in place forever have been the suboxone programs and methadone programs but in terms of stopping the growing trend, if you have a solution, please share.