EDITOR'S NOTE: As part of NBC10's award-winning special report, Generation Addicted, our journalists gathered experts in the field of addiction treatment to explain the complexities of the issue. Fighting this disease is hard, but recovery is possible. With the Trump Administration declaring a public health emergency on Thursday, we're sharing their insight with the goal of providing you with better context on the opioid epidemic.
To read and watch more stories from Generation Addicted, tap here to visit our special website.
DOCTORS
Brian Work, MD, MPH
Hospitalist, Penn Presbyterian Medical Center
Assistant Clinical Professor of Medicine, Hospital of the University of Pennsylvania
Volunteer Doctor, Prevention Point Philadelphia
Neil Capretto, DO
Addiction Psychiatrist
Medical Director, Gateway Rehab in Aliquippa, Pennsylvania
Bankole Johnson, DSc, MD
Addiction Psychiatrist
Chairman, University of Maryland Department of Psychiatry
Professor of Pharmacology, Anatomy and Neurobiology
Head, Brain Sciences Research Consortium, University of Maryland
Henry R. Kranzler, MD
Director, University of Pennsylvania Perelman School of Medicine Center for Studies of Addiction
Professor of Psychiatry
Q: Why do people who get hooked on prescription painkillers so often eventually wind up using heroin?
Work: It's a simple question of economics. You get hooked on some oxycodone that your doctor gave you or a child up in the community has gotten from their parents' cabinet. They need, let's say, Oxy 80 mg to keep out of withdrawal for the day. That goes for about a dollar a milligram. That's 80 and if you take it twice a day, that's 160 bucks. It gets to be very expensive very quickly. Unfortunately, here in Philadelphia, we got some of the cheapest and best heroin in the country. What that means is when people can't afford using their prescription opiates anymore, they come and they buy heroin because it's much cheaper.
Capretto: The process is they use a pill which is safe though, it's from a doctor, it's from a pharmacy. We know what dose it is. The big drug that really changed the landscape was oxycodone. It was like a nuclear bomb that just ignited the addiction problem. Thousands of people ... You had people everywhere now using prescription medicines. Some for good reasons. I mean, we need to treat pain. I don't want to minimize the importance of that, but there are intelligent ways that doctors should prescribe, but the pendulum swung way too far in the other direction. Skyrocketing amount of prescriptions, and a lot of areas like the state of Pennsylvania were hit very hard because we have an older class of population, a lot of working-class population that needed pain medicine. Some got into the right hands, but thousands got into the wrong hands. People became addicted. Couldn't afford it .... Instead of spending $200 to $300 a day on oxycodone, you could spend $40 to $50 a day on this heroin and, oh this new heroin is so strong you don't have to use a needle because people would say, "I don't want to put a needle in my arm." No you can just start by snorting it or sniffing it.
Q: Why is harm reduction, as is done with the needle exchange at Prevention Point, an important component in fighting addiction?
Work: Since the '90s, let's say, Prevention Point has been providing clean syringes out there in the community and that has stopped the spread of HIV. That was why this was a very important issue for Mayor Ed Rendell back when he was mayor of the city. By providing clean syringes, we have been able to bring the HIV incidence rate in this city from around 50 percent back in the '90s, now down to 5 percent for the last five years. Just think of that. That's a tenfold percentage reduction in HIV incident cases in the City of Philadelphia in under 20 years … What we are trying to do is keep people alive so eventually they can get better and they can recover. Because, as I'm fond of saying, you can't recover, you can't get into recovery, you can't get better if you're dead. If you die from HIV, if you die from Hep C, if you die from an overdose, you can't go through recovery. So what we have to do, and what I think we do a pretty doggone good job at doing is keeping people alive so that eventually they can recover.
Q: What do you see as the outlook on the current heroin epidemic over the next several years?
Work: I am worried that it's going to get a lot worse before it gets better. That whole population of folks who really overutilize, this is, I think, the fault of the medical system. Myself, I take some responsibility, and I think my fellow physician colleagues have to take some responsibility for having been so free with opiates in the past, that so many people were able to develop an unhealthy relationship with opiates. And now that wave is crashing over into heroin.
Capretto: Unfortunately from what I'm seeing, I'm afraid this problem is going to get worse before it gets better. What's encouraging is we have more people involved trying to make a difference in many different areas from treatment, law enforcement, overdose prevention, better availability of naloxone, we are saving more people than ever, but unfortunately we're losing more people than ever.
Johnson: There is a frightening scenario, and then there's a hopeful scenario. The frightening scenario is it gets worse. Currently, in some inner-city areas, we have about 10 percent of the population addicted to opiates. We already know that amongst most socioeconomic groups in the United States, we are entering into a stage in which we're going to live fewer years than our own parents. That's hard to imagine; we've all expected health care to keep driving our age expectancy up. But our rates of chronic disease and our rates of severe chronic disease are increasing. That would be the nightmare scenario, that the system will simply not be able to pay for the treatment. It would be too expensive. There'll be too many people who are ill. Therefore, the number of people who are addicted will actually rise. The hopeful scenario, which I'm an optimist and I hope all the time that the best things will happen, is that we get to a stage in which we begin to understand these treatments … My hope is that there's going to be greater awareness, people become better educated, and people have greater access to treatment.
Kranzler: I think what's going to happen and is happening with addiction is ... that it's become fodder for some of the political campaigns. Gov. Christie recently, in the state address, talked about increasing drug treatment. I think President Obama has done that. I think that that's a good thing. I think … it's finding its way into people's consciousness, which I think is crucial.
Q: I or someone in my household has been prescribed an opioid pain medicine. How do I protect my other family members from potentially abusing the drug?
Capretto: Store it properly. If you no longer need them, please bring them back, bring it to a take back. They get rid of them. If you do need them, put them in a locked box. Treat them like it's a loaded gun. You may think that's an overreaction but here is the reality: These pills are killing far more people in our country right now than loaded guns are. We need to really treat them that way.
Q: Is there enough treatment available?
Work: No. There's never been enough treatment … It needs to be a multipronged effort where we try to do everything we can to support people while they are still using and then when we get people to that point where they are ready, that magic point where they are ready to say, "I don't want to use anymore." We have to be able to provide the services and the recovery beds to allow them in, to take advantage of that magic moment and improve their life and get them clean and sober.
Q: What's the average length of treatment people need to be successful in recovery?
Work: It varies with everyone. We do know that for a maintenance/detox program, longer is better, number one. We are talking about six months, 18 months, two years. That with psychosocial services, in addition to whatever, whether it be Suboxone or methadone as a substitute for the heroin, with intensive psychosocial services is better than without. If you get somebody on Suboxone and you give them some intensive psychosocial services and counseling, I would think you might be looking at year to a year and a half, but everybody is different as you pointed out and that's so important.
Q: What's the most effective type of treatment, in your opinion?
Capretto: I think good programs combine all. I mean we're not treating computers with viruses. We're treating complex human beings with minds, bodies and spirits and in an environment that's complex and changing. We have to be mindful of that and plan it and adjust our treatment accordingly.
Johnson: The best treatment of opiate addiction, in my view, is outpatient-based. It's outpatient-based, and sometimes it's intensive outpatient-based. It is medication is the primary driver, either to maintain the person's opiate use for a while and then taper it off, or at a certain point to be able to withdraw it completely and have a period of abstinence and also to prevent overdoses. That should be the hallmark of treatment, is outpatient and community-based treatment … I think that it's difficult to empirically recommend 90-day rehab. I would like to be persuaded by any literature that shows that this is an effective treatment paradigm. Even 30 days is pretty questionable.
Q: There's some debate over whether "detox" works in treating heroin and opiate addiction. Is it effective?
Work: I think detox can work, but I'm talking a year and a half to two-year detox. What is commonly in place in California, it used to be that it was a 30-day detox and, in fact, many states had a 30-day detox. You cannot detox someone off a large dose of opiates in 30 days. They will withdrawal. They will be agitated, depressed, anxious and then withdrawal, physical withdrawal most of the time. You cannot expect somebody to deal with the idea of recovery and getting themselves well when they are physically sick from not having the opiate. It is not a reality to do that in a short period of time. Another example: Many hospitals utilize very short detox, a week detox. That's even more unreasonable.
Q: Why are people at such a high risk of overdosing after coming out of a detox period?
Work: If you are tapering somebody off too quickly and they are withdrawing when they leave your facility, they will go out and they will use not a reasonable amount, but the dose they used to use whereas their tolerance has been brought down. Their tolerance is down. They use their old dose and what happens is they end up overdosing and dying often from the overdose.
Q: Why is addiction so difficult to treat?
Work: The whole process of addiction is not just a simple physical problem where you give a pill and it's all better. People adapt their lifestyles in their way of interacting with other people and the environment slowly over time with their addiction. They have a whole set of behaviors where the end result is the addiction. By merely removing the physical dependence, you have not fixed the problem. You need to bring people along with you and ... as I've said, we get much higher success rates if we treat the dependence and we treat the people with intensive psychosocial interventions.
Johnson: When you start to try and get off opiates, it's very difficult to because you felt withdrawal symptoms. The withdrawal symptoms are rather unpleasant. Individuals get jittery, anxious. They have a great deal of stomach upset. It's really unpleasant … It's really a multifaceted problem. Therefore, the answer to this problem requires a multifaceted approach. The last thing that I'll say is that many places that try and get individuals off opiates are not using medication to do it and not using it appropriately. If you don't use medication to get someone off opiates, it's not only very difficult to do it, their chances of relapse afterward are much higher, and the risk of illicit use, whether it be getting infections or HIV or hepatitis, become actually much more accentuated. To sum up, poor education, lack of access to treatment, poor treatment, incorrect treatment, and incorrect appreciation of the disease are all part of the constellation of factors that make it hard to get off opiate use.
Q: Why are opiates and heroin so difficult to stop using once someone is addicted?
Johnson: What happens with opiates, as with many drugs of abuse, is they hijack a system in the brain that is for the reward of pleasure and learning and, if you like, emotional reinforcement … In fact, opiates are one of the most powerful reinforcing substances now … Once someone has had something like heroin a few times, the likelihood of them becoming addicted is extremely high.
Q: What responsibility do doctors have in prescribing painkillers with respect to the risk of addiction?
Capretto: We have to be very honest. I mean, the prescription pills on the street aren't coming from Afghanistan or Colombia. They're coming from our medical community. They're coming from our pharmacies. They're being written by our prescriptions for the most part … We're not telling the physician never order an opioid pain medicine like an oxycodone, but make sure you've thought: Are there other options? Does this person really need it? How am I going to help this person control this? Screen this person for addiction. I mean a lot of doctors don't even really understand what addiction is. There's still very little training in medical school, so who's at risk? Somebody that has a past history of addiction ... You know they're at high risk. That's something that goes into your equation, and we do this with other conditions we treat. Then if you are going to have a person on it, monitor them very closely. Give them only the smallest amount they need for the time they need it. Again I'm not saying people should be tortured by pain, but pain, remember, pain is a symptom. It is not a diagnosis.
Johnson: Poor prescribing is one of the major reasons why we have the epidemic. The guidelines have been fairly soft. We haven't had an integrated program of understanding what doctors prescribe. For example, it's been difficult to even monitor a patient going to one doctor, getting a whole bunch of pills, and then going to another doctor and getting a whole bunch of pills, and another doctor, and so on. They can go from state to state and do this. There's nothing stopping you in Washington, D.C., from coming to Maryland if you have a prescription in Maryland. What you really require is some kind of a database.
Q: What role do families play in addiction?
Capretto: Addiction is a family disease. More than any condition I know, this impacts the entire family. We do a lot of work. A big part of our treatment is to involve families when they're available to be involved, their significant others, and learning about the disease, but also telling them to get help for themselves. They often are affected or impacted. Family members of people with addiction have higher rates of health problems, reduced work productivity, a variety of other issues. They may need their own counseling … For every person who has addiction, there are at least four or five other people significantly impacted in their life. A parent, a spouse, a kid, a significant other. If you do the next circle of co-workers, close friends, you may be up to 10 or 15 more people. It's a huge ripple effect. When one person, unfortunately, struggles and goes down with addiction, there's a lot of collateral damage to many people. That's the dark side, the bad side.
Q: Why should addiction be considered a disease?
Capretto: People make a choice one day to try a drug for whatever reason, to experiment or to block some physical pain, mental health pain, but in a short period of time, many people – it varies based on genetics and other biopsychosocial medical factors – may develop the disease of addiction. At that point they're trapped. They are compelled to keep using. If they don't use, they get very sick and it compels them to use more. It's really pain that drives addiction. People that we see are not using to experience pleasure or to party. They use because if they don't, they experience such severe pain from their withdrawal or mental health symptoms or some other personal life symptoms or post-traumatic stress disorder that they have to use to avoid that pain. That's what gets them trapped in there. Again, it is a disease that does respond to treatment if they get it and get it at an adequate intensity for an adequate length of time.
Johnson: The best thing I can think of is an analogy. The way it would be like would be if you're in the desert, for example, and you'd been in the desert for a day. You're extremely thirsty. You'll have a biological drive to drink. There will be parts of your brain that will want you to drink. Even if you found an oasis and the oasis had poisoned water, well, the first day I told you that this water is poison at this oasis and you can't drink it, you probably won't. But by the second or the third day, you are going to be compelled to drink it because that's just the way it is, even though your rational brain knows that it's going to be bad for you. A rational brain knows that it's obviously going to kill you, drinking this poisoned water, but your brain is so compelled. This is because the systems in the brain that are associated with the expression of addiction are all embedded in parts of the brain that are resulting in our drive state. They actually determine what we are like, an individual. Those circuits are not placed there just to be addiction circuits. They were placed there for us to be able to survive, to be able to respond to external threats, to be able to go and learn from the outside world, to be able to reinforce things that are good for us. They're very powerfully embedded in our brain processes.
Q: How does opiate addiction change your brain, and does your brain ever go back to normal?
Johnson: We think that your brain can get back to normal, but your brain becomes what's termed neoplastic. It becomes, actually, much more difficult for it to respond. The best guess that I can say is that it probably takes a number of years for the brain to recover adequately, and that's with appropriate treatment. But we don't have an answer to say whether the brain will recover fully, because it depends on the severity of the brain insult that the person has incurred, and a lot of factors like their preconditioned mental state and the state of their brain and the other parts of their body before they became addicted.
Kranzler: The brain clearly adapts to the level of exposure and the chronicity. The longer the exposure, the greater the adaptation, the more one uses a substance in a defined period of time, the more the adaptation … When you withdraw [opioids] from someone who's dependent, you get a certain amount of agitation, anxiety. The effects differ from substance to substance, but what's common across substances is that the withdrawal effect is the opposite of the acute drug effect. The adaptation is what makes that opposite effect occur during withdrawal.
Q: What happens in a person's body after they inject heroin?
Johnson: For an experienced user, when the person basically starts to think about injecting, they start to get the emotional fix, if you like … Sometimes, if you like, the thrill or the excitement has to do with even injecting, and that starts because it activates opiate receptors, the injection process. Usually, an individual can get a rush when they actually inject the drug into their system. Often after that, there's a period of rest in which the person feels content. That's in an early-beginning experienced user. But typically, with a well-established user, which the person's addicted, that's not actually quite exactly what happens, because the injection is now associated with the desire to reduce the pain of withdrawal. They get very little excitement, very little buzz from it. In fact, there's very little, or an attenuated, rush. That's why sometimes people tend to use more and more drug, to try and chase that rush, if you like. With chronic use, the effects seem to be blunted. Therefore, it's a vicious cycle of diminishing returns.
Q: Why can some people use painkillers for a short period of time, such as after a surgery, and not become addicted, but others become addicted and potentially wind up on heroin? What's the difference between people who go one way and people who go another?
Johnson: The risk of addiction is actually quite low if you have true pain. Once the pain has begun to subside but you continue to use opiates, then the risk of addiction begins to rise.
Q: Who is most at-risk for developing an addiction?
Kranzler: Novelty-seeking people who are kind of thrill-seeking. People who get into trouble as kids, what we call conduct disorder, are at increased risk for substance abuse. Other psychiatric disorders you mentioned, eating disorders, depression. Bipolar disorder is a high risk diagnosis for co-occurring substance use. There are a number of vulnerabilities that can lead people to use substances chronically. That's really the issue. People who are using them occasionally are not at the same kind of risk the people who end up using substances chronically are.
The person who gets addicted may have any of a number of kinds of vulnerabilities. It's hard to pick just one, and I'm not sure they operate in isolation. They may not be happy with their lives. There may be aspects of their daily lives that they find stressful, they find it difficult to cope with them, in addition to the pain.
Q: What role do genetics play in addiction?
Kranzler: What heritability represents is the inheritable portion of the risk. Probably for opioids and cocaine, it's as high as 80 percent, so 80 percent of the risk. It doesn't mean 80 percent of people, but 80 percent of the risk in the aggregate can be attributable to genetics. Alcohol is more in the neighborhood of 50 percent, tobacco probably 40 or 30 percent.
NBC10’s Digital Team spent nearly six months investigating the issue of opioid addiction in the Philadelphia region and beyond. We discovered a generation of addicted people and a public health and law enforcement system ill-equipped to save them. Watch and read the stories of our award-winning report Generation Addicted, by tapping here.
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