"The first thing you have to understand [is that] our opioid crisis is not a drug abuse problem — it's not a problem of people taking dangerous drugs because it feels good and they're accidentally harming themselves... The opioid crisis is an epidemic of opioid addiction," says Andrew Kolodny, MD, co-director of opioid policy research collaboration at Brandeis University and a medical advisor for the recently released HBO documentary Warning: This Drug May Kill You.
However, when we talk about the opioid crisis as if it's a drug abuse or misuse problem, Dr. Kolodny says, "that suggests that there are a lot of people behaving badly and [our issue is figuring out] how we stop them from behaving badly — and that isn't the case."
Ahead, we talked to Dr. Kolodny about what these drugs really are, why we're facing this crisis now, and how we can help those most severely affected get the treatment they need.
Let's start with the basics: What are opioid drugs?
"Opioids are drugs that come from opium. Some of the more commonly prescribed opioids are drugs like hydrocodone and oxycodone, which literally come from opium — you need opium to make them. Hydrocodone is in Vicodin and oxycodone is in Percocet and Oxycontin.
"They are both what we would term 'semi-synthetic' opioids because you start with something natural and you treat it chemically to create a more potent version of opium. Heroin is also a semi-synthetic opioid.
"Many people don’t realize — including many of the doctors who prescribe opioids — that the effects of drugs like oxycodone and hydrocodone are indistinguishable from the effects produced by drugs like heroin. So if you’ve ever been curious about what heroin feels like, if you've had a Vicodin, that's basically the same thing."
When taken on a daily basis long-term, opioids are really lousy drugs.
We hear so much about misuse of opioids — so what are opioid drugs supposed to be used for?
"These are very important medicines for easing suffering at the end of life. They're also very useful when used on a short-term basis for severe acute pain, after major surgery or a serious accident, for example.
"Unfortunately, the bulk of the prescribing of opioids in the U.S. is not for end-of-life care or a couple of days after surgery — it's for common conditions where opioids may be more likely to harm the patient than help them. In fact, we have about 10-12 million Americans who are on opioids for chronic pain. They're taking them every day. They take a drug like Oxycontin...every day, morning and night, for months or years. We have so many people on daily opioids that drug companies that can now make money off of drugs to treat the side effects of opioids, such as constipation.
"When taken on a daily basis long-term, opioids are really lousy drugs. One reason is that they’re addictive … But also, opioids have some unique characteristics: You very quickly develop a tolerance to the pain-relieving effects, meaning you’ll need higher and higher doses in order to continue getting to get pain relief. And the other effect is what we call 'physiological dependence,' which means that if you try to stop taking the drug after taking it on a regular basis, you feel very sick — not just a flu-like illness, but you can also feel very severe anxiety and agonizing pain as a symptom of opioid withdrawal.
"So the other problem with taking them long-term [besides addiction] is that evidence tells us they don’t work — they can become ineffective and make pain worse."
These drugs have been around for decades — why are we seeing the epidemic now?
"Beginning around 20 years ago, the medical community decided to prescribe [opioids] much more aggressively. The prescribing of opioids quadrupled from around 1999 to 2012. As prescribing starts to go up rapidly, it leads to this parallel increase in addiction and overdose deaths. In other words, the epidemic has been caused by doctors overprescribing opioids, and they really overexposed the U.S. population to prescription opioids.
"What led to the change in culture of prescribing? Starting in the late '90s with the release of oxycontin by Purdue Pharma, that launched a multifaceted campaign designed to increase opioid prescribing. When they were putting Oxycontin on the market, which is extended-release oxycodone, [drugs like that were mostly] used in palliative care settings.
"Purdue wouldn't have been able to have much financial success had it only been used in palliative care — patients at the end of their lives with cancer pain is not a common condition, and the patients won't be under medicine for very long. They needed to see it prescribed for common, especially chronic problems.
"So the campaign they launched was focused on getting the medical community more comfortable with opioids as a class of drug. Purdue would ultimately get into trouble in 2007 for some of the specific ways they marketed Oxycontin as less addictive [than other opioids]. But what they never really got in trouble for (which was much more damaging) was to mislead the medical community about the safety and effectiveness of using opioids on a long-term basis.
"As part of the campaign, doctors started to hear that they were allowing patients to suffer needlessly because we were under-prescribing opioids. We would start hearing that the risk of addiction had been overblown, that legitimate pain patients very rarely get addicted. A statistic that was used was that 'much less than 1%' of our patients will get addicted. We started hearing that, for just about any complaint of pain, opioids are 'the safest and most effective option.'
"We didn’t just hear it from the drug companies — doctors would have been smart enough to be skeptical of marketing from a drug company — but the marketing was really, in many ways, disguised as education. The medical community began hearing from pain specialists eminent in the field all of these messages, we start hearing it from professional societies, state medical boards... From just about every direction we began hearing that, 'If you’re an enlightened, caring doctor, you’ll be different form those stingy, puritanical doctors of the past that let people suffer.'
"As we responded to this brilliant campaign and as opioid prescribing took off, it led to a public health catastrophe."
As we responded to this brilliant campaign and as opioid prescribing took off, it led to a public health catastrophe.
What is the ideal treatment plan for opioid addiction?
"Most people with opioid addiction don’t do well with abstinence-based approaches, meaning going for detox or going to a rehab for 30 days and then coming home. That doesn't work for many people and, in fact, when you come back from detox, rehab, or jail and your tolerance has gone back to normal, people are at a very high risk for an overdose death.
"There's also a drug called Vivitrol, which is a monthly injection of naltrexone (an opioid blocker). Even though that's a medicine, that's really more of an abstinence-based approach.
"Unfortunately there’s not adequate access to buprenorphine. There are many restrictions and rules that limit the ability of doctors to treat people with this medicine, which is pretty crazy because buprenorphine is much safer than drugs like Oxycontin. For the more dangerous opioids that are causing addiction and people are overdosing on, there are very few restrictions. Yet for the medicine used to treat opioid addiction, we have too many restrictions."
Why is the use of buprenorphine sometimes considered "controversial" ?
"Among experts, there is no controversy about using buprenorphine. But there is a strong stigma and bias against these treatments, including very concerning statements by HHS Secretary Tom Price a few days ago. But there are many people who are making the mistake of thinking [treatment with buprenorphine] is substituting one opioid drug for another.
"I’ve treated patients with opioid addiction by prescribing them buprenorphine for many years. I didn’t have too much success getting them off buprenorphine — it’s very hard to come off without relapsing — but while my patients are on it, I’ve watched them lead very productive lives. They get married, have babies, graduate college, hold good jobs — you would never know looking at them that they were on a drug. They would tell you they felt perfectly normal.
"It’s certainly not a cure, and it would be nice if we had other options. It's certainly always better if someone can manage a chronic illness without taking a medicine... but it's similar to diabetes. For type 2 diabetes, if someone can really control their diet and lose weight and exercise regularly, they can get off their insulin and just be on oral hypoglycemics. And if they do a really good job, they can even get off the oral medicine. That's definitely better than being on insulin or pills, which have side effects.
"But a lot of people can’t do it. And if you insist on it — if we told people, 'You can only have your insulin for six months and then you have to be better,' we'd be in a really bad place. We'd see a lot of people going blind or losing limbs from untreated diabetes. That's kind of where we are with opioid addiction, because not enough people are accessing the treatments that are effective."