ISIH S2 E8 / The Opioid Overdose Crisis: Medication-assisted treatment (heroin & hydromorphone too?)
Mark Tyndall: My interest would be to see if we can draw people out and say, "Look, we know you're injecting by yourself, but what you're using right now is highly unpredictable and potentially deadly. Here's an option for you to come just to get the drugs and use them." Then we could start a process of connecting with people that we didn't even know existed.
Celine Gounder: This is Mark Tyndall… he’s the Director of the British Columbia Center for Disease Control in Canada.
Mark Tyndall: Many of these people who died, really, outside of a few emergency department visits, are really off the radar as far as our medical system goes and avoid medical care at all costs. So this would be, I hope, a way to try to offer people a way out.
Celine Gounder: Welcome back to “In Sickness and in Health,” a podcast about health and social justice. I’m Dr. Celine Gounder. In this season we’re tackling the opioid overdose crisis… placing a spotlight on issues that aren’t often covered in the news… like the link between childhood trauma and addiction… the role of law enforcement in drug treatment… and… how fentanyl has compounded the opioid crisis. In today’s episode, we are going to take a look at how medications can play an important role in helping people recover from addiction… and how sometimes… those medications may be the very drug they’re trying to quit.
Paul Cherashore: My name is Paul Cherashore, I'm with the Philadelphia Overdose Prevention Initiative. I was a user and needed clean needles and eventually got recruited to work at the harm reduction coalition and I worked there from 1997 to 2004.
Celine Gounder: Heroin was a daily part of Paul’s life for 30 years. Although, he doesn’t use anymore Paul was the poster boy for what we would call a chronic drug user. Growing up, Paul experienced a lot of of trauma in the home.
Paul Cherashore: A lot of criticism..a lot of judging. My parents were older, a lot older and were traumatized by the Depression and their life experience… And they didn’t have very good coping skills, I mean they had very poor parenting skills...particularly around communication …And so there was really no intimacy in my life.
Celine Gounder: For most of his childhood, Paul’s parents were either distracted or bickering, and as the years went by, his parent’s relationship worsened.
Paul Cherashore: I don’t know, something just happened in their relationshpi...it started going downhill and there was a lot of fighting. And later on they had financial problems right when I entered adolescence, and I kind of was abandoned basically to live to live on my own. I was an only child…
Celine Gounder: When Paul was around 18 or 19 he went to college in the Berkley area, but soon dropped out. He started taking psychedelics and moved into a communal home in San Francisco with people who identified as gay or bi.
Paul Cherashore: I found my way to San Francisco and got involved in the punk scene. I met this guy. I kind of latched on to him because he was, like, everything that I wanted. I mean he was outrageous. I was very controlled and repressed. He was just this outrageous queen and his friends were like these outrageous drag queens.
Celine Gounder: It was 1980. San Francisco was in the throes of sexual liberation in the gay community... and Paul was enveloped in a scene at the intersection of LGBT counterculture and punk rock counter culture. A big part of that world… at that time... was drugs.
Paul Cherashore: ...there was this whole ...just this crazy scene that I wound up in. And there was lots of drugs. First speed and then heroin.
Celine Gounder: Paul tried heroin and became addicted. For years, Paul injected heroin every day… and at points, also sold heroin to support his habit. In the early 80’s, Paul tried to quit a few times, but had trouble staying clean. Eventually, he moved to New York City. It was there that Paul started working at a harm reduction center and going to therapy.
Paul Cherashore: I finally started, like, learning to be a person I guess..I mean I was in my, probably 40 by then… And I started, I just started changing… I was breaking some of my negative behavior patterns because in the past...I really didn't know how to make friends with people, and I would sabotage the relationships, and then I would give up. ...but then… I started like I don’t know.. I was in a stable situation at this office, and it was a good crew people there and we started becoming friends...If you want to stop your use than you need to deal with your problems…
Celine Gounder: Paul’s life was starting to stabilize and he finally had a support system to help him with his addiction. But… he still needed a fix. The thing with opioid addiction is… stopping cold turkey is really hard. In fact… the expression “cold turkey” refers to the goosebumps drug users get when they go into withdrawal… but that’s the least of it. Going into withdrawal is like being deathly ill from the flu… nausea, vomiting, diarrhea, cramps, sweats, chills… and horrible muscle and bone pains. People get really anxious and depressed.
Paul Cherashore: It makes it hard to function… and it's one of the reasons that heroin users function so poorly because they're constantly living with that fear.. of going into withdrawal.
Celine Gounder: And that’s why many long-term drug users need some kind of fix… not to quote unquote “get high”... but rather... to stave off withdrawal symptoms… so they don’t feel sick. To ease the effects of withdrawal symptoms, many addiction treatment programs prescribe medications like methadone or buprenorphine. Both are prescription opioids that are taken by mouth. And because they’re opioids… like heroin… they bind the same receptors in the body… and block the symptoms of withdrawal. But in contrast to heroin, they’re FDA-approved drugs… their production is regulated… the product is clean....and dosing is standardized. Methadone and buprenorphine… unlike heroin… stick around in the body for a lot longer… which means drug users only need to take it once a day to ward off withdrawals… which makes it a lot more convenient to use. And because of how methadone and buprenorphine work… they don’t get people high the way heroin does.
Paul Cherashore: ...I don't think that people take methadone because it's such a great high and Suboxone too ...…I don’t find it really pleasant. I always get really nauseous from it. I mean, it’s a dependency, you’re dependent.. But the whole point of it is that you're dependent on something that you get in a regulated manner. And that's not going to bring you other problems taking it like exposure to infectious disease. And law enforcement. So it's much less harmful for people's lives, and it helps let them stabilize their lives.
Celine Gounder: In other words, addiction treatment programs provide drugs like methadone and buprenorphine... the active ingredient in Suboxone... to stave off withdrawal symptoms… so users don’t turn to heroin. And if they’re replacing their heroin with methadone or buprenorphine... drug users are also a lot less likely to use dirty needles... or buy drugs on the street… which these days… are often laced with fentanyl and other adulterants. Instead of hustling to get their next fix to stave off withdrawal… users can focus on stabilizing their lives... getting a place to live… rebuilding relationships… regaining a sense of purpose… working on the problems that led them to use in the first place. And then… the risk of relapse goes down… by a lot. For Paul, the strategy of slowly tapering off methadone and Suboxone… and then… pairing that with therapy… that’s what helped him eventually stop using heroin.
Paul Cherashore: At a certain point and just cut back on my use. It took me like two or three years to do it, just gradually cutting back from, like, skipping the weekends, then doing it just on the weekends, to then doing it once a month or twice a month, and gradually until I stopped using altogether, and I just went on methadone and stabilized on methadone for, I don't know, for six months, and then I started to taper and did that for about 18 months. And then.. I switched to Suboxone, and then I did that for, maybe a year and a half, and then I went off of that. I just stopped it one day.
Celine Gounder: Paul now lives in Philadelphia… where he’s done a lot of organizing to bring harm reduction strategies to the city. And... his hard work is starting to pay off… In early 2018... Philadelphia announced plans to open a supervised consumption site. It would be among the first in the country.
Celine Gounder: Although methadone and buprenorphine… are first-line treatments for opioid withdrawal... a fraction of users don’t respond to these treatments. So, some folks relapse… which can lead to overdose… and death. For years… many in the addiction field have felt powerless to bridge that gap… to help those who fall through the cracks. But are there alternatives? To understand more, let’s turn to Switzerland… to learn about one solution… that many might think counterintuitive… even... fringe.
Celine Gounder: In the early 1990s, Switzerland was facing an explosion in heroin use... Zurich was notorious for having Europe’s largest open drug scene. There were too many overdoses… too many HIV and hepatitis transmissions… too many bacterial complications. Drug-related crimes like theft surged. Drug camps mushroomed. Things seemed pretty grim. Fast forward more than 25 years... and drug users new to heroin use are few and far between in Switzerland… So, in those intervening years… what did Switzerland do? …and what can we learn from them?
Barbara Broers: My name is Barbara Broers. ...I'm now the head of a substance abuse unit or Unit for Dependency, as we call it here, at the Primary Care Health Department. ...I'm also more active at the national level ..the Vice President of the Swiss Federal Commission for Drug-Related Affairs and of the Swiss Society for for Addiction Medicine.
Celine Gounder: Barbara has been on the frontlines of Swiss drug policy for years. In the early 90s... at the height of Switzerland’s heroin problem... officials didn’t have clear solutions… traditional law enforcement tactics weren’t working. The government decided to try a harm reduction approach… as part of a broader policy. They introduced measures like... access to clean syringes… and large clinics with oral opioid substitution treatment… where users could get methadone and other services.
Barbara Broers: But quite quickly people realized that there was a small group that did not really want to go into these oral substitution treatments or ...who failed in treatment. Who said, “it's not the same for me.”
Celine Gounder: As is the case for so many medical conditions… what works for one patient… doesn’t always work for another. Therapy needs to be individualized.
Barbara Broers: ...some people said, you know, "Methadone I don't feel well with, I don't function with, I sleep all day and I cannot function well." … That’s one..Other people, they were really also, let's say, addicted to the addiction part. They like the ritual, and they feel better with heroin. They really feel better …
Celine Gounder: Many of these users repeatedly failed in conventional substitution treatments… So, the Swiss government decided to take a chance... on a radical idea.
Barbara Broers: It was decided in 1992, 3 that we should do something else for them and try to see what happens when you provide the substance they prefer in the way they like it. That means real heroin by injection.
Celine Gounder: So, starting in 1994, Switzerland started providing prescription heroin… as a last resort for that fraction of drug users… that 25% or so for whom methadone and buprenorphine don’t work... And, in 2008, Swiss voters agreed to make it an official piece of national drug policy. Here’s how it works: Heroin never leaves the treatment center… so patients have to visit the clinic a couple times a day… to receive their prescription heroin under medical supervision. While there... they can also get treatment for other medical or mental health issues. The program is highly regulated… and every patient needs to have federal authorization to be in the program.
Celine Gounder: Okay… to many who haven’t heard of heroin-assisted treatment… this might sound crazy. The idea here is to go one step beyond supervised consumption sites. You might remember supervised consumption sites from our last episode. These facilities give drug users a safe, clean place to use… off the streets and out of public spaces… with sterile equipment. If someone overdoses, medical staff is on-hand and at the ready to intervene.
Celine Gounder: Prescription heroin programs take it one step further. These clinics give drug users the heroin they want… but this heroin is different. It’s pure, unadulterated… and outside of the black market.
Barbara Broers: … street heroin is extremely dangerous because we don't know what's in it. It exposes people to a lot of risks related to the quality of the product, the context of buying, the consequences of getting caught. The problem of using it in an unsafe place.
Celine Gounder: The results of the prescription heroin program have been very positive for drug users who don’t do well on methadone. The NAOMI Trial… a randomized controlled trial… the kind of study that’s considered the gold standard of proof in medicine… demonstrated the effectiveness of heroin. The trial compared heroin versus methadone… to treat drug users who’d already tried methadone to quit, but were not successful… The NAOMI Trial showed that when these drug users were given heroin instead of methadone… they were far more likely to stay in treatment… and far less likely to use street drugs or engage in other illegal activity.
Celine Gounder: You might say… well obviously… they’re being given the drugs they want… so obviously they’ll stay in treatment. But what’s the point of giving them heroin if we want them to stop using heroin? And even worse… aren’t we rewarding them for their behavior… helping them get high? Well… for one thing… they’re not getting very high doses of heroin… but rather, just enough to make them comfortable… to ward off withdrawal… but not to get high. And… what they’re getting is a safer product… not laced with fentanyl or other adulterants. So they’re less likely to overdose… to have complications of drug use… and to die. A
Barbara Broers: If you really want to be abstinent, help them to get there but it's not by leaving people in the street. And getting all kinds of diseases and getting, doing criminal things to get the products and put them at risk to get into contact with the police, with people who you misuse them, etc., etc. ... So you As a parent, what do you prefer? You know your child is taking drugs, do you prefer that it is done under supervision with people who know the drug, and can help your child to get rid of the side effects, to get rid of everything and to get forward into life? Or do you prefer that your child was in the street and gets no help. Is truly alone. And takes a drug which is potentially dangerous because he doesn't know what's in it.
Celine Gounder: Although prescription heroin works for a small group of the population, Barbara emphasized that this is the last line of defense… and just one option from a menu of harm reduction interventions that have helped turn the tide in Switzerland.
Barbara Broers: We should not think ... that we should propose this to everybody. It's for a particular group of people...methadone is a very good treatment and buprenorphine also. Oral treatment is and should be always the first line treatment for people. Because, it's the most convenient form of using a substance, orally..If you provide it in a correct way, supervised way.. it is really a very safe treatment for a large majority and for a cost that is not comparable to heroin prescription.
Celine Gounder: Because prescription heroin is tightly regulated… far more so than just about any other drug in Switzerland… it’s a highly bureaucratic process. And, because it’s given intravenously or IV, it requires a different level of medical supervision that is very personnel-intensive… requiring staff 24 hours a day, 365 days a year. This drives up the costs… by a lot. Plus, some people think that having to go to a clinic multiple times a day to get heroin... is really restrictive. It’s hard to do much else. And that can get in the way of the other work that needs to be done on the road to recovery.
Mark Tyndall: They are highly medicalized and not acceptable to, I think, the majority of people using drugs, who don't want to go to a place three times a day and have their drugs observed.
Celine Gounder: That’s Mark Tyndall… you heard from him at the top of the show... he’s the Director of the British Columbia Center for Disease Control in Canada… Mark has been leading the charge to develop new… out-of-the-box solutions for the opioid overdose epidemic in Canada… It’s urgent. Just in British Columbia last year… almost fifteen hundred people died from opioid overdoses… 80% of those deaths… involved fentanyl.
Mark Tyndall: In BC we had over 20,000 overdose calls--in the province British Columbia, over 20,000 overdose calls last year and 1,500 deaths. Clearly, we can't get all those people in a highly medicalized, expensive program. So that's what led to the idea that, "Well, we just need to get back to giving people some hydromorphone pills…”
Celine Gounder: The Crosstown Clinic in Vancouver has been providing pharmaceutical grade heroin to drug users for years… but it’s a small program… and too expensive to expand and take to scale. And that’s why Mark and others have been looking for alternatives… other options for drug users who don’t do well on methadone or buprenorphine… but cheaper than prescription heroin… and legal. Hydromorphone… a potent prescription opioid also known as Dilaudid… seems to fit the bill. In 2016, a landmark study showed that chronic drug users who failed therapy with methadone or buprenorphine -- that 25% or so that seems to do better on heroin-assisted treatment -- they did as well on hydromorphone as they did on heroin. In other words, hydromorphone was found to be as effective as prescription heroin.
Celine Gounder: OK… so now we’ve got another oral prescription opioid in our toolbox… hydromorphone… in addition to methadone and buprenorphine. But how do we ramp up access… safely… so these treatments get to people with addiction… but don’t create new users? To solve that… Mark had another idea… an ATM that dispenses hydromorphone.
Mark Tyndall: The idea of getting them through a machine, I think is a good one, where we could make it more available, but still regulate the amount that people get out of it. ...
Celine Gounder: The British Columbia Center for Disease Control has gotten approval from the Canadian government to pilot and study three hydromorphone dispensing machines. Drug users deemed to be at high risk for drug overdose… would be registered in the program… and could get two to three hydromorphone pills… three times a day from the machines. The cost per patient would be under $2.50 a day. To put this in perspective, heroin-assisted treatment at the Crosstown Clinic in Vancouver… costs almost $20,000 per year for one person. Hydromorphone ATM machines are a whole lot cheaper. And, as far as safety… these machines are highly controlled.
Mark Tyndall: ...it's a 715 pound steel box, more like an ATM, that regulates in real time every pill coming out. It's biometric, so people put their finger on a pad to identify them and they get the pills out and, as I said, we could account for them in real time.00:30:04 For me, this is a technology that would allow us to regulate the drugs very closely, send messages to people, and make it a form of connection. And also give the message of some autonomy to people. For days when they really don't want to face somebody face-to-face, which is a lot of days for people, that they can just go and get it.
Celine Gounder: For Mark, the technology is well-suited to break down some of the barriers to entry to the medical system... giving drug users access to a safe supply of drugs… while cutting out the blackmarket with its dangerous drug dealers and traffickers… even where drug treatment programs are scarce.
Mark Tyndall: We have a lot of hotspots around the province, where there's no real access for people to get on methadone even if they wanted to. So we could strategically set them up at these places.
Celine Gounder: It’s also a way… Mark hopes... to draw out drug users… who too often stay in the shadows… and out of the reach of medical and social service providers.
Mark Tyndall: I think the other thing that has real promise, and that we really need to test out in our research, is if this can draw people out of their isolation. So we could put a supervised injection site on every street corner in the whole province and we'd still miss about 60% or 70% of the people who aren't coming to these kind of initiatives.
Celine Gounder: Mark is hoping that hydromorphone-dispensing machines could eventually connect people who were previously using alone… to services… and medical care. 70% of people who die of an overdose… die alone… are found… alone. And so many of those deaths today... are due to fentanyl. To Mark… the situation is critical… one that mandates an emergency response… especially since over-prescribing of opioids by doctors... fueled much of the addiction.
Mark Tyndall: If you told a patient, "Look, I can't prescribe you this anymore. You have to go out on the street and use," they would, and they'd find white powder heroin or pharmaceutically diverted pills, and they would use them, and they wouldn't die. They may come back in six months and try methadone again or something like that. Now, fentanyl has, sort of, changed everything. ... All of a sudden, if you send people out without without a prescription for opioids, then they're going to get something that could very well kill them.
Celine Gounder: To Mark… the situation is critical… one that mandates an emergency response… especially since over-prescribing of opioids by doctors... fueled much of the addiction.
Mark Tyndall: Clearly trying to limit or prevent people from accessing these drugs unnecessarily is just reasonable prescribing practices. … I think we do need to do our part in not prescribing drugs needlessly, but that is much different from the person who comes in begging for a prescription because they're dependent on these drugs and withdrawing and saying, "I'm sorry we can't do that," and basically telling them to go find their own.
Celine Gounder: Over the last three episodes… we’ve heard a lot about harm reduction programs. … From the Allegheny County Jail Cooperative... we learned about parenting and relationship coaching… and how these strategies can be used to prevent intergenerational transmission of trauma and addiction. We heard about decriminalization… not legalization... of drugs in Portugal… the forerunner to Seattle-King County’s pre-booking diversion LEAD program... both of which direct drug users to social services … to get them housed and into treatment. We’ve also talked about supervised consumption sites… how they take drug use off the streets… and into safe spaces… where drug users can access medical and social services. And in this episode... we learned about medication-assisted treatment… which helps drug users control withdrawal symptoms… and allows them to stabilize… get housing… and work on the problems that drove them to use drugs in the first place.
Celine Gounder: Success is about how you define it. None of these solutions is about sending drug users to jail or prison. But all are backed by data showing they work… if you define success in terms of saving lives… today… and tomorrow.
Celine Gounder: Next time… we’ll talk about what can happen when harm reduction isn’t a part of the response to opioid abuse and addiction. In the past… we thought of opioid abuse and addiction as a problem of urban blight. But in the past couple years… it’s become very much a problem of rural America and suburbia. In late 2014, opioid and injection drug use… hit rural Indiana… starting an outbreak of HIV and hepatitis. We’ll hear about what happened… how public officials responded… and where conditions are ripe for this to happen again.
Celine Gounder: Today’s episode of “In Sickness and in Health” was produced by Nora Ritchie and me. Our theme music is by Allan Vest. You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com, that’s insicknessandinhealthpodcast.com.
Celine Gounder: If you or a loved one needs help, you can reach out anonymously and confidentially to SAMHSA’s National Helpline at 1-800-662-HELP, that’s 800-662-4357. SAMHSA stands for Substance Abuse and Mental Health Services Administration. You can also find information online at www.findtreatment.samhsa.gov, that’s www.findtreatment.samhsa.gov.
Celine Gounder: I’m Dr. Celine Gounder. This is “In Sickness and in Health."