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Pc. He

1:04

their it's even dubner. We just

1:06

finished a two part series that

1:08

looked at the very long lasting

1:10

opioid crisis. It's. Horrible. It's

1:12

absolutely horrifying. We. Learned

1:15

why the opioid epidemic has endured,

1:17

and we learned about the billions

1:19

of dollars in settlement money and

1:21

how that should be used. Don't.

1:23

Spend any money on anything some other

1:26

funding stream covers today we wanted to

1:28

play for you. A bonus episode. This

1:30

is an update of a piece we

1:33

published in early Twenty Twenty. Abuse.

1:35

It was also about the opioid

1:38

crisis. As you will hear the

1:40

crisis seemed to be leveling off

1:42

back then, but as it turned

1:44

out it wasn't. It continued to

1:46

worsen, especially during the pandemic. although

1:49

there are signs that now it

1:51

really is leveling off. In this

1:53

episode, we spoke with some University

1:55

of Pennsylvania positions about an addiction

1:58

treatment that they thought. The

2:00

Be Universal. They can get it as

2:02

part of routine medical care. Just like

2:04

they might get their insulin for their

2:07

diabetes or their blood pressure medicine. So

2:09

is this treatment now universal? That's that's

2:11

probably a know. You also hear a

2:13

bit more from Stephen Lloyd, that Tennessee

2:16

physician who was featured in our new

2:18

series. And stick around to the end

2:20

of this episode for an update on

2:23

the team at Penn Medicine. As always,

2:25

thank you for listening. His

2:40

radio. with

2:45

your even. Jean

2:56

Marie Per own is a professor

2:58

in the department of Emergency Medicine

3:00

at the University of Pennsylvania. I'm

3:02

an emergency Medicine says listen and

3:05

Medical Toxicology. Ss

3:08

and more recently I've started to

3:10

do addiction medicine work for own

3:13

has seen the opioid crisis up

3:15

close. As a researcher and practitioner,

3:17

So. We have about a thousand or twelve

3:20

hundred patients who visited our three hospitals last

3:22

year, and about four hundred of them are

3:24

overdoses. Have you ever used

3:26

opioids of any sort of. Now had

3:28

a couple kids and broke my leg

3:31

and broke my wrist. am I didn't

3:33

have appeared for any of those three

3:35

things where you offered. In any case,

3:37

I broke my leg and Canada. Interestingly

3:39

I would say right in the. Middle.

3:41

Of the opioid crisis and Spade said,

3:43

you know you need. Anything and Eight

3:45

I seven. yeah I'm fine with I'm

3:47

for have been skiing mountain biking but

3:49

anyway I were allowing yourself to bring

3:51

it on myself. But I would definitely

3:53

say that I would have a super

3:56

high threshold for anyone in my family.

3:58

Anyone I know, I mean eight. I

4:00

advise against it sort of across the

4:02

board because it's just too easy to

4:05

see, just don't need to go there.

4:07

So opioid deaths in the Us has

4:09

leveled off, maybe started to decline a

4:11

little bit. what are you seeing here

4:14

in Philadelphia? So they did decline a

4:16

little bit. I think. what. Is.

4:18

Important about the national. Data is that the

4:21

death that have declined. The most are

4:23

the oral. Pills And that's probably the

4:25

result of d prescribing a little bit

4:27

of. A result of prescription

4:29

drug monitoring programs preventing the

4:32

to prescribing. Of benzodiazepines with

4:34

opioids. Maybe a little bit more

4:36

public awareness like as and drink when I'm

4:38

taking back pain medication. Another

4:42

potential driver of the slight decline

4:44

in death is the widespread availability

4:46

of narc him an emergency nasal

4:48

spray of the drug the locks

4:50

on which can stop an overdose

4:52

as it's happening wherever it's happening.

4:55

Per. Own has administered nor can herself

4:57

a few times. The most recent was

4:59

riding the subway home in Philadelphia after

5:01

a night out. And.

5:03

I'm somebody called. answer.

5:09

Room for six the breakers up

5:12

with a man on the grounds

5:14

and getting Cpr was blue sign

5:16

was post was really. On

5:18

the brink of death or defined as dead

5:20

already? Maybe. And so we continue Cpr. I

5:23

got mine are can out, I gave him

5:25

one and isn't really respond and lemme give

5:27

him another dose. And then I thought you

5:29

know we needed to mouth to mouth and

5:32

then I thought maybe some of our chemists

5:34

still stuck in his nose and so service

5:36

Scribblers knows a little bit and kind of

5:39

irritating a little bit more. And then he

5:41

took like one teeny tiny breasts and over

5:43

the course of the next ninety seconds he

5:45

started to wake up. And then about ten.

5:48

Minutes. Later M S came as like you guys

5:50

to save this guy's life you say you guys

5:52

but you're the one that came with Well no

5:54

but they have started Cpr. They. Had called someone

5:56

for help. they called nine One. I mean they've

5:58

done so much you know we said the resuscitation

6:00

like that monster on this group of you know

6:03

people just got it all together. did it all

6:05

the right thing so it was really impressive. Me

6:07

was probably twenty five or thirty people at the

6:09

end of it all and it was like this

6:11

amazing. I caught my silly moment because was like

6:13

winning the Super Bowl when everyone is in the

6:15

streets and everyone just had this amazing Barnes and

6:17

it is. It was incredible. brought tears to my

6:19

as a free Sears has I talked about it.

6:25

So. That story had a

6:27

happy ending. Many overdose stories do

6:29

not and nor can can only

6:31

do so much. It doesn't treat

6:33

the underlying addiction. The. Patients

6:36

who come to the emergency department after receiving

6:38

are can from an overdose. About six percent

6:40

of them are dead at the end of

6:42

one year and ten percent of them are

6:44

dead at the end of two years to.

6:46

There is no other medical condition that we

6:48

currently treat an emergency department that has that

6:50

kind of mortality. So from your perspective I'm

6:52

curious. your In Er Doc. And

6:55

people come in. For

6:57

help when they're in a desperate

6:59

state already. right? They're not typically

7:01

coming due to say. I've

7:03

been thinking long and hard about my life

7:05

and I want a maker. a graduated change,

7:08

right? So what can you do for them?

7:10

What? Was the treatment? Let's say five years

7:13

ago when the problem was starting to

7:15

really turn into a horror. And

7:17

how to see treatment different now. So.

7:19

That's a great question. Five years ago and

7:21

overdose patients hopefully got some compassion and emergency

7:24

department and a little bit of a conversation

7:26

about why they may have overdosed that day

7:28

or what we can do to help them

7:30

may be. As of for three years ago

7:32

they would have been discharged with a box

7:34

of nor can earn a lockdown so that

7:37

if they were exposed to another overdose somebody

7:39

could use that on them. or they could

7:41

use it on a friend or or colleague

7:43

and think fast forwarding from there on What

7:45

we realized is that giving them kind of

7:47

a crumpled piece of paper said you. Should

7:50

stop using drugs. doesn't really.

7:52

Work They are in a cycle

7:54

of using and fighting. withdraw. Every

7:56

three or four hours and so that

7:58

doesn't lend itself to. The your phone

8:00

out making appointments from Monday morning to

8:03

see an addiction specialist. Disappointment

8:08

model was failing and other hospitals

8:10

to. We. Were on the

8:12

front lines. Just seeing patients being

8:14

broad and sometimes been just

8:16

dropped off at the door

8:18

and thrown at the emergency

8:20

personnel. But. Skilled enough. Real.

8:23

I. Am professor and chair of

8:25

Emergency. Medicine at the Yale School

8:27

of Medicine. She. Is also

8:29

Chief of Emergency Services at Yale

8:31

Newhaven Health so like prone to

8:33

not. Ryo is a practitioner and

8:36

a researcher. So. Our study

8:38

and Gm and two thousand and fifteen was

8:40

looking at different models of care for opiate

8:42

is to sort of. The Ama

8:44

is the journal of the American

8:46

Medical Association and in two thousand

8:49

and sixteen your practitioners liked in

8:51

Austria weren't having much success treating

8:53

the many opioid addicts they'd started.

8:55

See So sooner team set up

8:57

a study. It. Included three

9:00

hundred patients divided into three

9:02

treatment groups. In the first

9:04

group. Will try to motivate

9:06

them to get care and then we'll

9:08

refer them to the Centers of Care

9:10

that we had here at Yell Eric's

9:13

in the community. This. Was

9:15

the standard treatment at the time the crumpled

9:17

piece of paper model but Jean Marie prone

9:19

mentioned. The. Second group of opry

9:22

of patients got a bit extra. Take.

9:24

Off motivational enhancement what we

9:27

call the brief negotiation Interview.

9:29

That. Was a fifteen minute conversation talking

9:32

about their addiction and the circumstances

9:34

that led to it. And

9:36

then those people got a facilitator of

9:38

from. Not. Just a couple

9:40

piece of paper. So we actually called

9:42

the place ourselves and if it was at night

9:44

with called them in the morning and said we

9:46

were first person to yell. And. Then

9:49

the third group. They. Got also a

9:51

motivational enhancement freeze intervention but then

9:53

they were started! On deepen Arsene. Lupin.

10:00

Arsene is a opioid agonist,

10:02

which means it activates the

10:04

opioid receptor just like heroin

10:06

and Oxy code on. Jean.

10:08

Marie per own again. I. Think everyone

10:11

knows Methadone and message on his

10:13

are historically opioid agonist treatment that

10:15

we use for patients with opioid use

10:17

disorder and the only treatment really

10:19

had for a long time. But.

10:21

Methadone as issues. Message.

10:24

On his defense from several treatment programs

10:26

and the patient has to go there

10:28

every single day to get their dose

10:30

and the operate agonists, Methadone works by

10:32

being a very long acting opioids and

10:34

acting as the opioid receptor and in

10:36

high enough doses as sorts. The use

10:38

of other opioid agonist buprenorphine is different.

10:40

First of all, I can be prescribed

10:42

from a doctor's office so the patient

10:44

doesn't have to go to a methadone

10:46

clinic everyday. They can get it as

10:48

part of routine medical care just like

10:50

they might get their insulin for their

10:52

diabetes or their blood pressure medicine. And

10:54

it's intended to be less stigmatizing. To

10:56

get it as part of routine medical care.

10:58

The other thing is that it's a partial. Agonist

11:01

that the opioid receptor so it doesn't

11:03

continue to activate it the way methadone.

11:05

Does so that's what we call a

11:07

ceiling effects which makes it much safer

11:09

so that there isn't as much respiratory

11:11

depression and there isn't as much risk

11:13

of opioid overdose and death. It's

11:15

really hard to overdose on. It

11:18

is hard even if the child

11:20

take the pill of they're adults,

11:22

sam, laser, friend and off the

11:24

table that they will die from

11:26

it because it does eventually just

11:28

reach that ceiling of fact. So.

11:31

Buprenorphine, which is itself an opioid,

11:33

would seem to offer a safer

11:36

and more flexible treatment for opioid

11:38

addiction, but. How. Effective is.

11:41

That's. What dinner for your was really looking

11:43

for in her study at Yale. And.

11:45

So what we found was

11:47

that those p sense that

11:50

we're in the buprenorphine group

11:52

or two times more likely

11:54

to be informal. Treatments at

11:56

thirty days and one months.

11:59

Of the. Huge improvement over the two other

12:01

groups in the study. So. Up

12:04

thirty seven percent of patients in

12:06

a referral group were in treatment,

12:08

and about forty five percent in

12:10

the brief intervention group, and then

12:12

almost eighty percent in the buprenorphine

12:14

group. So. They were able

12:16

to double the rate of engagement of patients

12:19

who showed up for a follow up meeting.

12:21

With. Jean Marie Per own of Penn

12:24

saw the Yale study see was

12:26

impressed and excited. And

12:28

that is so critical to

12:30

you know, getting people. Into.

12:32

Treatments And that meditation stabilizes

12:35

the cycle. Of. Withdraw that that patients

12:37

are experiencing. So it's really important to

12:39

not say you can come in tomorrow

12:41

for your first appointment. But here's the

12:43

medications. The next twelve hours won't be

12:46

the how you think it's gonna be

12:48

if you start on this medication now.

12:50

so that sounds like a wildly useful

12:52

drugs. I'm sure every hospital and medical

12:54

board and state legislature must be in

12:56

favor of dispensing more of this antidote.

12:59

Yes, That's. That's that's

13:01

probably a now am I think there's a

13:03

lot of. Good people in theory

13:05

who do wanna do this and expand

13:07

our treatments. I think the logistics. Of

13:09

learning how to administer group intervene sounds more

13:11

complicated than it might be in that is

13:14

a barrier. Would he mean by

13:16

the logistics of administering? It's So first

13:18

of all, in order to write a

13:20

prescription for buprenorphine, you have to get

13:22

something called an ex waiver, which. Means that

13:24

you have to take an eight hour training program

13:26

and you have to apply to the Da to

13:29

get a. Special Waiver says the same

13:31

sort of waiver licensing process applied

13:33

to prescribing medical opioids in the

13:35

first place. It is not. So

13:37

I can in fact treat your

13:39

opioid use disorder with. You

13:41

know, oxycodone or hydromorphone? If

13:43

I wanted to and that

13:45

would be not regulated, that

13:47

our why be extra level

13:49

of regulation for Buprenorphine. It's

13:52

complicated, but. When we went from the

13:54

late sixties when we started Methadone and you

13:56

know we had people who needed treatment but

13:59

we weren't going to let just and doctor

14:01

prescribe it's and so that's why methadone was

14:03

restricted to the federal treatment programs. But then

14:05

when we said well you know in two

14:07

thousand people working became available and with approved

14:10

in the eyes states but we weren't Just

14:12

can let every doctor put out a single

14:14

and start in Missouri Buprenorphine, Buprenorphine

14:18

is most commonly administered in a

14:21

name brand drug called Suboxone which

14:23

also contains the locks on. Buprenorphine

14:26

was invented by the farmer from

14:28

Reckitt Benckiser in Nineteen Sixty six,

14:31

one of many synthetic opioids designed

14:33

in the twentieth century. they were

14:35

meant to treat pain but be

14:37

less addictive than opium itself. But.

14:40

As it turned out, most of

14:42

them were addictive. That is the

14:44

foundational problem of the prescription opioid

14:47

crisis. In the nineteen

14:49

nineties, Reckitt Benckiser recognized Buprenorphine

14:51

potential for treating opioid use

14:53

disorder and spun off it's

14:55

Buprenorphine division into what is

14:57

now a subsidiary company called

14:59

In Db or. Several

15:02

years ago, another drug company thought

15:04

about getting into the Buprenorphine market.

15:06

Purdue. Pharma which makes Oxycontin

15:08

when the most widely abused

15:11

prescription opioids. A produce

15:13

memo at the time called Buprenorphine

15:15

an attractive market. But. They never

15:17

did jump in. Today, Purdue

15:19

is the target of thousands of

15:22

lawsuits charged with having downplayed the

15:24

addictive nature of oxycontin. Just

15:26

how influential was Purdue in

15:28

the opioid universe? Considered.

15:31

The Sterling Developments: The World

15:33

Health Organization recently retracted It's

15:35

to mean guidelines for using

15:37

opioids to treat pain. Why?

15:41

Because the guidelines it is

15:43

now been discovered were unduly

15:46

influenced by opioid manufacturers including

15:48

Produce International subsidiary. And

15:50

yet at this moment, Oxycontin

15:52

is still legally and widely

15:55

dispensed as a useful painkiller.

15:57

That. Is also easily subject to abuse.

16:00

Suboxone, meanwhile, is much harder to

16:03

abuse, but it's also hard to

16:05

get. What do medical professionals who

16:07

treat opioid addiction think of this?

16:10

Here's what one doctor wrote on the Health

16:12

Affairs blog. Buprenorphine has the

16:15

potential to be a transformative tool

16:17

in healthcare practitioners fight to reduce

16:20

deaths from opioid overdose, but

16:22

that the x we bring process

16:24

is onerous, outdated, and hampers our

16:26

ability to help patients manage and

16:29

recover from opioid addiction. An editorial

16:31

in Jama Psychiatry made the same

16:34

complaint and noted that easing

16:36

the restrictions on Buprenorphine and France

16:38

help drive down deaths from opioid

16:40

overdose. There are nearly eighty percent.

16:44

He extrapolated to the United States.

16:46

The authors wrote this translates to

16:48

more than thirty thousand your annual

16:51

deaths from opioid overdoses. So.

16:55

Globally. The. Statistics are

16:57

tremendous and no doubt in

16:59

the evidence there to use.

17:01

See the waiver requirement for

17:03

buprenorphine as a sort of

17:05

over correction over response to

17:07

the medical community east own

17:09

embrace of opioids in the

17:11

first place like. We. Messed

17:14

up. Big. Time And at the

17:16

very least, what we're not going to do

17:18

now is messed up in the same direction.

17:20

even though this might be a different direction,

17:23

I think it lingers because.

17:25

Of some of those concerns, but we if we

17:27

go back to two thousand and we didn't really

17:29

have any kind of opioid crisis in two thousand,

17:31

so it was really approved in the absence of

17:33

a big surge in opioid use at the time.

17:35

I think not repealing it at this point.

17:38

Is probably multi factorial. People are worried

17:40

about suboxone diversion, so the same substance

17:42

that we want to prescribe is also

17:45

available on the street, and we acknowledge

17:47

that, but it's not used on the

17:49

street to. Get High is used for

17:51

patients. To treat their own withdrawal symptoms

17:54

when they're unable to get other medication.

17:56

So I think that's part of why

17:58

there's been some. Resistance to.

18:01

Taking. away the x waiver I. Think

18:03

it also is gonna take an act

18:05

of Congress which is fairly hard to

18:07

accomplish and I think that repealing the

18:09

actually were isn't entirely and of you

18:12

know, open the floodgates for prescribers who

18:14

want to prescribe in for nursing. There's

18:16

still some education and some Sigma that

18:18

needs to be addressed before more people

18:20

are gonna be willing to prescribe. Situation.

18:24

Has changed somewhat since we first

18:27

published this episode in Twenty Twenty

18:29

Three. President Biden did sign a

18:31

bill eliminating the federal requirement for

18:33

doctors to obtain an ex waiver

18:36

to prescribe Buprenorphine, but some states

18:38

still have their own restrictions on

18:40

prescribing the medication. And that isn't

18:42

the only thing that's keeping buprenorphine

18:45

for being used more widely. If.

18:47

You look at residential treatment programs across

18:50

the country, most of them over seventy

18:52

percent of them still abstinence to us

18:54

that based programs. That. Is

18:56

Stephen Lloyd, a physician in

18:59

Tennessee who specializes in addiction.

19:01

Lloyd himself was addicted to

19:03

prescription painkillers for years. Basically.

19:06

I took feals all day long and when I

19:08

got out of bed in the morning, I had

19:10

withdrawn during the night so I was sweating, felt

19:12

felt like an eight year old man and I

19:14

was in my early thirties. Void went

19:17

into a detox programs and then

19:19

thirty day residential rehab facility which

19:21

got him turned around. Today.

19:23

He's a medical director for a

19:25

network of addiction treatment centers. I'm

19:28

a big believer in medication assisted treatments

19:30

and we know that the most effective

19:32

thing that we can do for opioid

19:34

addiction is actually medication assisted treatment with

19:36

the use of drugs like buprenorphine, methadone

19:39

and are now track zone or and

19:41

I've taken a from this in the

19:43

local treatment community as well as the

19:45

the treatment community statewide any be nationally.

19:47

Can. You just described were that pushed

19:49

back and that reluctance is coming from

19:52

Will unfortunately stephen that the pushback comes

19:54

from people into recovery community and the

19:56

one of the problems with addiction medicine

19:58

is that most of the. People at

20:00

Work in a field, or lot of the people

20:02

at work in a field had a issue themselves.

20:04

That's how they got in the field like like

20:06

myself, but they believed that the only way to

20:09

get healthy is how they got healthy. So it's

20:11

totally anecdotal. As

20:16

Lloyd noted, most addiction treatment

20:18

programs do stress total abstinence,

20:20

including twelve step programs like

20:22

alcoholics Anonymous and Narcotics Anonymous.

20:25

How successful are such programs?

20:28

That. Is a famously difficult question.

20:31

Solid. Data are hard to come

20:33

by after all. Anonymity is a feature

20:35

of such programs, and they're all kinds

20:38

of possible: selection bias, Ease. Alcoholics.

20:41

Anonymous claims that seventy five

20:43

percent of it's participants stay

20:45

sober. But. Academic studies put

20:47

the success rate closer to ten percent

20:49

breathing loss, That. Said one

20:51

Stanford study compared addicts who quit with

20:53

the help of A versus those who

20:56

quit on their own and found that

20:58

a nearly doubled the success rate. Steven.

21:01

Lloyds argument is that abstinence

21:03

is the chosen path for

21:05

the recovery community, but that

21:07

medical professionals embrace M a

21:09

T medication assisted treatment, You.

21:11

Get the World Health Organization you got night

21:13

us. That. Is the National Institute

21:15

on Drug Abuse. Everybody who

21:17

looks at this is the role of medication

21:20

is paramount. it should be the cornerstone yet

21:22

is is so hard to get people into

21:24

those programs because of the stigma. So she

21:26

was it. Lot of times will be from

21:28

parents have had numerous parents taught their kids

21:31

out of medications because they said to retrain

21:33

one drug for another and and a few

21:35

months down the road I get the call

21:37

that they've overdosed and dad and I can't

21:39

tell you how heartbreaking your goals or. If

21:42

I say to you, I don't like

21:44

the idea of the pharmaceutical industry being

21:47

able to be the chief beneficiary of

21:49

medication assisted treatment because they helped drive

21:51

this problem in the first place. It's

21:54

a little bit like, you know, I.

21:56

Said a house on fire and then I'm the

21:58

hero who calls in the fall it to the

22:00

fire department I don't like the optics about. I

22:02

don't like the the economics of that would you

22:04

say that argument. I. Say I agree

22:07

with your miriam percent. It makes me choke

22:09

every time I think about it. But I

22:11

don't have a better option. I

22:13

don't have anything else this event had

22:15

stop my patience dying at the rate

22:17

at him a T does, I can't

22:19

stand it. I read somewhere recently that

22:21

several years back Purdue Pharma tried to

22:24

acquire thus the marketing right to be

22:26

been orphaned which just absolutely is unconscionable

22:28

to me. and so I would agree

22:30

with you one thousand percent. I wish

22:32

there was a better option, but right

22:34

now there's not. and so I I

22:36

can't let my feelings as get in

22:38

the way of trying to help my

22:40

patience and help them stay alive. Could

22:42

you. Describe for me the

22:44

underlying causes of opioid addicts I

22:47

guess and I'm looking for is

22:49

if you could break it down

22:51

between us physiological addiction or craving

22:53

as well as the psychological and

22:56

environmental drivers. Well.

22:58

I don't know how much more need to

23:00

break today. And you just did. You know

23:02

that's the classic Miles Psycho social model that

23:04

you just described. So that's really the three

23:07

big component said. Any addiction in this case

23:09

opioid. So you've got the A teach it

23:11

in terms of a slot machine. You know

23:14

when a three seven come down on the

23:16

pylon, that's when the money comes out. So

23:18

the first seven is the bio component net.

23:20

Simply genetics. Do you have a family history

23:23

of any addiction? I? if you do, the

23:25

net for seven comes down to pay. Lance

23:27

An addiction is about sixty percent genetic for

23:30

the most part of the second part is

23:32

a psychological component. What kind of household you

23:34

raised in do have a high A score?

23:36

Adverse childhood experiences for you, physically, sexually or

23:39

emotionally abused. Do you have that chronic trauma

23:41

maybe even lighter in your life if you

23:43

do than that? Second seven is down on

23:46

the pylon and in the third seven is

23:48

a social component and that's just the availability

23:50

of what is widely available and that think

23:52

is most widely available except it's alcohol and

23:55

at still mostly what we see a people

23:57

abusing. And addicted to but in

23:59

and. Late Nineteen eighties, early nineties,

24:01

and into the two thousands, opioids

24:04

became much more widespread. You.

24:06

And many others call addiction

24:08

generally a disease and is

24:11

sounds like the the factors

24:13

that may determine your likelihood

24:15

for the disease are pretty

24:17

much everywhere. So. Do

24:19

you see this as a different sort

24:21

of disease and we typically think about

24:23

with epidemiology. Lists

24:25

like a disease that everybody agrees own Type

24:28

Two Diabetes Mellitus. You know nobody has a

24:30

problem with Type Two diabetes. be in a

24:32

disease or and I never hear any discussion

24:34

about this yet for the most part his

24:37

behavior or why do people get Type two

24:39

diabetes will they don't eat right? They don't

24:41

exercise correctly and so we treat that widely

24:43

with medication to try to decrease the bad

24:46

outcomes with diabetes. So you know I look

24:48

at addiction is being much the same. If

24:50

you know about addiction, addiction as a

24:53

brain disease. Guild. Offria again

24:55

from yell. And we

24:57

know I looking at stands of

24:59

the brains that even though I

25:01

may be have had treatment and

25:03

I'm no longer physically dependence and

25:06

minute you show me some things

25:08

whether it's a syringe or it

25:10

could be just a place that

25:12

I used parts of my brain

25:14

I need her will light up

25:16

showing that I still have this.

25:19

Craving. I still had this

25:21

possibility to use. I get back

25:23

in that situation a chance. Pray

25:25

myself out of that. I can't

25:27

will myself out of it. So

25:29

it. Doesn't matter if I call it a disease

25:32

or a learning disorder, it is a rewiring

25:34

of the brain. The reward system in the

25:36

frontal lobe interactions and to were the primary

25:38

focus becomes acquisition of this substance for me

25:40

to be okay. And so when I look

25:42

at it in those terms, it looks a

25:44

lot like diabetes to me. Can.

25:46

You talk for minute a bow. Federal

25:48

policy toward medication assisted treatment and

25:50

perhaps Buprenorphine specifically. From what I've

25:53

read, that the policy recommendations during

25:55

the Trump Administration have been evolving

25:57

very rapidly. If you look. It

26:00

in a President Trump's first appointment said to

26:02

the head of Department Health and Human Services

26:04

was Doctor Tom Price. Stitch came out early

26:07

on and said well you know this is

26:09

simply switching one drug for another and in

26:11

those of us in the addiction field had

26:13

serious angsty about that. But you have folks

26:16

in Hhs right now that are giving really

26:18

good direction with regards to medication assisted treatment

26:20

and making it more widely available. It is

26:22

evolving quickly and I think we're to the

26:25

point now that's some of the stigma is

26:27

being decrease simply because so many people have

26:29

died. Instead of defining recovery is

26:31

total abstinence from any medication. I wanted

26:33

to find recoveries in those parameters of

26:35

your life getting better. Are you still

26:37

going to jail? Do have your kids

26:39

by, You have a job. Are you

26:41

a member of the tax paying citizenship

26:44

and United States? To me those are

26:46

much more reflective of effective treatments and

26:48

whether or not some buddies totally absent

26:50

from all dogs because some twelve step

26:52

group says they have to be. Stephen

26:56

Lloyds philosophy as well as that of

26:58

Gail didn't offer yell and Jean Per

27:01

Own falls under the umbrella of what

27:03

is called harm reduction. It's the idea

27:05

that you treat risk, not is something

27:08

that must be driven to zero. In

27:10

a recent episode called the Truth about

27:12

the Beeping Crisis, we talked about the

27:14

battle between smoking and sinister. People argue

27:17

that nobody should be consuming any nicotine

27:19

in any form and harm reduction. Us

27:21

to argue this V thing may carry

27:24

risks, but they're almost certainly smaller than.

27:26

The risks from smoking cigarettes when

27:28

it comes to opioid abuse, The

27:31

gap between the of census and

27:33

the harm reduction. this seems to

27:35

even wider. Why Is that? What's

27:38

different about opioids? It's

27:40

always and stigmatizes. I don't know why.

27:42

So. I think any time use less than

27:44

the stigma associated with addiction, you increase people's

27:47

opportunity to step out of the shadows and

27:49

ask for help. After

27:51

the break how that help happens

27:53

when it happens and we talked

27:55

to two addicts in recovery one

27:57

of who now works at. The

28:00

Virtue Pennsylvania Hospital helping other addicts

28:02

grapes grip you listen to for

28:04

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P. C. As

30:59

we've been hearing, treating opioid

31:02

addiction with another opioid, late

31:04

Buprenorphine is not the concept

31:06

that is universally embraced, but.

31:09

A lot of smart and

31:11

dedicated people are in favor,

31:13

including Jean Marie Peron medical

31:15

researcher and your doctor at

31:17

the University of Pennsylvania. See

31:19

and her team have been

31:21

creating a new treatment protocol

31:23

for opioid addiction that includes

31:25

buprenorphine or suboxone. But

31:27

more than just that, they are changing

31:29

the way addicts are treated from the

31:31

moment they wind up in the are

31:33

the street and includes what they call

31:35

a warm handoff. So. Warm

31:37

Hand Off isn't newish term is the

31:39

idea that a patient at a hospital

31:41

or clinic is gonna be discharged having

31:44

already met appear or someone who's gonna

31:46

either accompany them to and appointments or

31:48

they've met the doctor that were. Innocent

31:51

who will take care of them said there's a

31:53

close. Connection between the patient and

31:55

the patience. Next step in

31:57

recovery. And there's another member

31:59

of the warm and off team: a

32:01

peer counselor. Or pure counselors are

32:03

people who are in recovery themselves and who

32:06

can start the dialogue right there and about

32:08

in a what it would look like if.

32:10

They tried meditation.

32:12

Or tried to get into a treatment program

32:14

or tried to engage in care rate Than

32:17

it's all about engagement. Be pure.

32:19

Counselors are on staff at the hospital.

32:21

They've gone through certification training. And

32:24

leave that first hand experience

32:26

as opioid addicts. I

32:28

think there's some of the most ah, I'm

32:31

not just dedicated, but you know people

32:33

who have been through more than I've ever

32:35

been in my super easy life and

32:37

who have come to the other side and

32:39

who want to help other people and who

32:41

are successful at helping other people. They're special

32:44

people at Nicole. People like Nicole. Absolutely. I.

32:48

Am the call it on on on A

32:50

certified recovery specialist, an Emergency Rooms. At Penn

32:52

said nicole, what's your story had you get

32:55

to be in this position. Cel from

32:57

using the here have a lot

32:59

of work sell. My first love

33:01

was Banjo is what's a Xanax?

33:03

That's what I became addicted to.

33:05

I went to rehab I was

33:07

twenty one. My first time I

33:10

went to treatment inpatient treatment. And

33:12

it worked. It worked for about two years. And

33:15

then they are wise. Opioid

33:17

painkillers around, so that's

33:19

you know? why not?

33:21

Rates: And then oxy

33:24

cotton's weren't really eyes readily

33:26

available then. So it was

33:29

like. Perks. Thirty years

33:31

and opiates that were You

33:33

know, someone's prescription that resides

33:35

and then. They are

33:38

very senses so it was

33:40

easier to get heroin. As

33:43

in what happened had you finally get

33:45

queen? I was

33:47

tired of stalling withdraw because that's all

33:49

I was doing in the and was

33:51

using so I was in West are

33:53

all right So I came to this

33:55

realization that. I'm going to

33:57

continue to be in withdraw every single time.

34:00

And how I do something idiotic. Was the

34:02

withdrawals awful and nobody wants to be?

34:04

And it and I realized my life

34:06

was trying to figure out how I

34:08

was getting drugs just to stop withdraw.

34:10

It's not fun in the and it's

34:12

not a party, nobody's happy. You know

34:14

you're just really try not to be

34:16

sex and barely functioning. You had

34:18

a sister. Yes, Yes, one

34:20

guess three years younger than me? Jessica

34:23

Jones and I just since he died

34:25

of an overdose. see. Did and it

34:27

was December fourteenth of fourteen. Okay

34:30

and what was what were her drugs or

34:32

drug heroin and what was your relationship like

34:35

with her Then we used to gather your

34:37

arms she gave me her when for the

34:39

first time. So I was doing. Restaurant

34:42

Management for the first seven years

34:44

of my recovery and then I

34:46

lost my sister and that's when

34:48

I started doing outreach. I needed

34:50

to give her death purpose and

34:52

I needed to maybe be the

34:54

person for people that she probably

34:57

didn't encounter in her active addiction.

35:00

Odonil introduced me to one of the people

35:03

that she's been helping. My. Name's I

35:05

mean Richardson. I am a restaurant

35:07

manager. I'm also an alcoholic and

35:09

an addict. I'm

35:11

from the Jersey Shore originally.

35:14

New to Philadelphia. Has. Been here a little over

35:16

a year now. I married I have

35:18

a wise I have a son. he just turned

35:20

three. Situations: What's his name? His

35:22

name is Henrik Herbs. Henrik Matthew

35:25

Richardson as he likes to say. On.

35:27

The day we spoke, Richardson has been in

35:29

recovery for ninety three days. She'd.

35:31

Come into the pen your after

35:33

overdosing. And Nicole came to

35:36

meet me in the hospital. By.

35:38

Believe it was the physician that I saw

35:40

ask me if I was interested in getting

35:42

help and he said he had somebody he

35:44

knew. That I could thought sale and

35:46

Nepal showed up to talk to me

35:49

and yeah, yeah, overdose on what on

35:51

heroin and fentanyl? Nicole.

35:54

Helped I leaned get on suboxone.

35:56

I'm still doing this a box and you

35:58

know I'd take it. Everyday this box

36:01

and helps I don't have cravings. And

36:03

right away that started. When I went

36:05

back in. The. Second time to

36:07

the sub box and clinic. The recent

36:09

time they up my dose and. From

36:12

that day on, I haven't had a single. Craving

36:14

for any opiate sense with that

36:17

feel like pretty awesome, Some pretty

36:19

amazing. So how much of your

36:21

success would you attribute to working

36:24

with Nicole? And having

36:26

a pure and who understands it, the

36:28

drug itself and then any other third

36:30

or fourth reason. I mean, they

36:33

all play a big part it. I wouldn't

36:35

want to break it into percentages, are graphs

36:37

or anything like that, because for me, it's

36:39

all intertwined. But you think that Nicole

36:41

without the suboxone would do it? And

36:44

know I know this a box and is definitely

36:46

something I needed. But. If

36:48

I was just so in this avast and and nothing

36:50

else I would stop taking this box and. A

36:53

wooden. you know I wouldn't keep taking it

36:55

said. you know the drug helps the physical

36:58

part and then everything else. I do. Helps

37:00

me become a adds a new person,

37:02

a new human being which is my

37:04

goal. This a box and helps you

37:06

get back to the level that. Nicole

37:09

can work exactly right? Yeah, yeah,

37:11

I'm in my blazer. Some Nicole

37:13

suboxone sounds like a really good

37:15

solution, least for some the people.

37:17

Some of the time rates can

37:19

you talk about. I guess

37:22

the problem or the barrier of being able to

37:24

use it as widely as it might oughta be

37:26

used. So from my perspective,

37:28

aside from you know, the axe

37:31

lever and and the medical barriers,

37:33

that's the dancers experience. From our

37:35

experience to his, there's a big

37:37

segment with it. In the recovery

37:39

community. The. Recovery

37:41

community is traditionally has been absent

37:44

as beast and that means nothing.

37:46

No. Medications. Know

37:48

illicit drug use? Nothing. How come?

37:51

It's just as thick the you know? it's

37:54

this deep seated thing. You know that twelve

37:56

step programs. There's a lot a tradition and

37:58

stuff like that. and there's not. What a

38:00

change! But I'm no not gonna lie like

38:02

I love that was dabs that I love

38:04

the program and it's done so much for

38:06

me. But. I don't talk about the

38:08

fact that I used to box and my sponsor

38:11

knows. You know my close friends now. But

38:13

I don't bring it up in meetings. and

38:15

there's different sunset programs, obviously, and when one

38:17

of them. Specifically

38:19

states dead. M

38:22

eighty is not considered clean. I

38:24

lean rate before we started recording.

38:26

You told to sit have a

38:28

friend. Years just died yet us.

38:30

Now you know how much you

38:32

wanna. Say. About those circumstances,

38:34

the friend you new for how long

38:37

and how they die. Ah my!

38:39

have known him since I started

38:41

going to the twelve step group

38:43

that I said i go to

38:45

what. At what we call our Home Group

38:47

back in February, she was coming up on

38:50

a year. Sober. And.

38:52

Eighteen days he would a had a

38:55

year and see You know this. Is

38:57

this is how it happens? Is that people

38:59

stop and then they they go back out.

39:01

And they think they can use the same

39:04

amount as if they were using once before

39:06

and it needs his care anymore. You're pretty

39:08

much killing yourself to you go back out.

39:10

Not people always close to me but I

39:13

know someone that's dying every week. But.

39:16

I mean this one, you know. I was with

39:18

him yesterday. And we're talking and

39:20

joking about the fishing trip that we're

39:23

going on next weekend. you know, His

39:26

mom was just talking. Over a month he spoke about

39:29

how proud she was of I'm an. Assist.

39:31

It's a horrible disease, you know? Who's.

39:34

Heroin. Probably heroin and

39:36

fentanyl. Everything spent on out. The.

39:42

Opioid crisis really began with

39:45

prescription pills, then moved into

39:47

heroin and now synthetic spent,

39:49

which presents a particularly high risk

39:51

of overdose. To that

39:53

end, there is another idea currently

39:55

under consideration in Philadelphia. Brawl. Harm

39:58

reductionist here. Nicole

40:00

Donald again the Certified Recovery

40:02

Specialist. So we advocate

40:04

for. You know safe injection

40:06

practice is then needle exchange

40:08

but there's there's safe house

40:10

that were are advocating for

40:13

and it's a place to

40:15

go for people to safely

40:17

not overdose. They go use.

40:20

Drugs. Get tested. They have medical

40:22

staff they peers. Hopefully they're to

40:24

navigate them into treatment to see

40:26

my we do in the emergency

40:28

room. The legal official kind

40:30

of safe drug use site that

40:33

Odonil is describing doesn't exist yet.

40:35

At. Least not in Philadelphia. To

40:37

sites have been approved in the

40:40

U S, one in New York

40:42

City which is up and running,

40:44

and one in Providence, Rhode Island,

40:46

which is still in development. Sites

40:48

like this also exist in several

40:50

Canadian cities. The Safe House nonprofit

40:52

is backed by many local and

40:55

state officials, but it has faced

40:57

pushback from the Us. Justice Department.

40:59

Things today don't look promising. Federal

41:01

court recently ruled against Safe House

41:03

in a multiyear case against the

41:05

Justice Department. My. Point

41:07

of advocacy for Safe House is for

41:10

people like your friends that just ps

41:12

that he's in recovery re if I

41:14

use i'm gonna die. Fortunately,

41:16

through my years as you know this advocacy

41:18

I have a person I have a say

41:20

so hot that I have a person that

41:23

I would call if I didn't want to

41:25

die to make sure I didn't overdose of

41:27

I used I have that that's a safety

41:29

net Gray Not everyone has that said. This

41:31

is a place that we want people to

41:34

be able to go like your friends. If

41:36

he was at this place he wouldn't have

41:38

died. The. Opposite of addiction is

41:40

is not recover. The opposite. Addiction

41:42

is community in relationships. He can't

41:45

have community if you're dead. Doctor.

41:47

Stephen Lloyd again. So. The first

41:49

thing is to keep patients alive. Now the

41:52

longer that we keep him alive, the more

41:54

that we need to be able to engage.

41:56

the I'm in support of environments around really

41:58

everything and what's your. This in on

42:00

I guess legal dispensary is of illegal

42:02

drugs and I'm curious if is any

42:04

movement toward that in Tennessee. You're really

42:07

putting me in a position to get

42:09

in trouble. I think we have to

42:11

look at this point it all harm

42:13

reduction strategies. So I think any time

42:15

you less than the stigma associated with

42:17

addiction, you increase people's opportunity to step

42:19

out of the shadows and ask for

42:21

help. And I'm for any modality to

42:23

get people to that point. The

42:28

warm hand off program at U Penn

42:30

is still relatively new. I ask Niccolo

42:32

Donald, the recovery specialist, the how many

42:34

patients see we'll see in a given

42:36

day. In. An average day we

42:39

could see up to six people. I.

42:41

Mean whether they're in p sense for

42:43

a medical reason, in peace and in

42:45

are in peace and drug and alcohol

42:47

treatment or at their through the emergency

42:49

room. And of those six, how

42:52

many are willing to at least have

42:54

a conversation with you about medication, assisted

42:56

therapy? Honestly there's

42:58

not many that say they don't wanna talk

43:00

whether they want things are not a different

43:02

story he now than we have a harm

43:04

reduction commerce the sense but nobody really throws

43:06

out of the room and says i don't

43:08

want to talk about anything. So

43:18

if there's one misperception

43:20

about opioids about. Use

43:23

Abuse Whatever. That many people like

43:26

public radio nerds who are going

43:28

to listen to this if is

43:30

one thing they really don't know.

43:32

What would you wanna tell people?

43:35

That. Obese is what or is treatable.

43:38

It's not a death sentence, it's

43:40

nights. he now eight a medical

43:42

condition and it's treatable. Is

43:44

sounds so simple when you say about

43:46

why isn't plan as there's all this

43:48

conversation going on around the topic now

43:51

Ghana political community and it's never said

43:53

that simply why not leave his. At.

43:55

We like to over complicate things, and

43:57

it really doesn't need to be over

44:00

complicate. Irene teach her medication, she engages,

44:02

and she goes the meetings and she's

44:04

doing amazing And she's a mom to

44:06

her son. Rights, It's treatable.

44:08

We all have over

44:11

complicated. That

44:18

was our report on the opioid

44:20

crisis from Twenty Twenty. We.

44:22

Recently reached out to the team

44:24

at and for an update. Here's

44:26

what Doctor Prone told us: Our

44:28

program has grown substantially since we

44:30

last spoke. We started a new

44:32

center at Penn called the Center

44:34

for Addiction Medicine and Policy and

44:36

have multiple dance to sustain our

44:38

work. For Economics

44:41

Reduced Produced by Stutter and Ren

44:43

But Radio. you can find our

44:45

entire archive on any podcast app.

44:47

Also, it freakonomics.com or we publish

44:49

transcripts and so notes. This episode

44:52

was produced by Zach Lipinski. Er.

44:54

Staff also includes Alina Coleman, Augusta

44:56

Chapman's Dell Bin Abdulaziz, Eleanor Osborne,

44:58

Elsa Hernandez, Deborah Ross, Reg Griffin,

45:01

Jasmine Klinger, Jeremy Johnson, Julie Camper

45:03

Lyrics: Outage: Morgan Levy Milk, Ruth

45:05

Rebecca We Douglas, Sarah, Lily and

45:07

Tail Jacobs. Our theme song is

45:09

Mister. Fortune by the Hitchhikers and

45:12

our composer is Louise Gareth. As

45:14

always, thank you for listening. Treat.

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with my heart of was late reply

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for self aware Chicago Illinois. This.

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Black Music Month State Farm once to

46:23

take a moment to appreciate all the

46:25

ways Black Music brings everyone together. From

46:30

the Saturday Morning Soundtrack That gets the

46:32

whole family cleaning the house. To

46:37

the beats at block parties that bring a

46:39

whole community together. Celebrate

46:42

the impact of Black music this month and

46:44

beyond with State Farm. Like

46:47

a good neighbor state. Farm is there.