In our previous episode, No. 402, we looked at the rise of the opioid epidemic:
Barack OBAMA: We are seeing more people killed because of opioid overdose than traffic accidents.
The tragedy seemed to come out of nowhere, but in fact it had distinctive roots — in the pharmaceutical industry:
Jeanmarie PERRONE: They really somehow fooled us into thinking that pain was a vital sign, and that we needed to treat it more liberally.
In government policy:
Tomas PHILIPSON: What happened during that growth was that prices for opioids came way down due to government subsidies.
And in the highly addictive nature of a medicine that had been promoted as not being addictive:
Stephen LOYD: I was taking 500 milligrams of OxyContin a day. And so it progressed very, very quickly. And I couldn’t stop.
The opioid crisis, we learned, is really a story of supply and demand. In retrospect, there’s plenty of blame to go around — there was inattention and wishful thinking and almost certainly some deception, or at least greed. As a result, hundreds of thousands of people have died, countless families have been broken. And one unintended consequence of the crisis is that many people who have legitimate need for pain management and who have never abused those drugs now find it much harder to get the medicine they need.
One such person wrote to us recently. “I was born with severe scoliosis,” he said, “and needed multiple surgeries starting as an 11-year-old. I was on fentanyl patches for over 10 years. They allowed me to not hurt every minute of the day. I did not get high. I went to a pain clinic every month and was drug tested. A year and half ago, they stopped prescribing me because of government regulations. Now every day is a struggle to get out of bed and be productive.” So, as this man suggests, the prescribing protocols for opioids have changed — in his case, not for the better. How have the new protocols affected potential opioid abuse?
The fact is that more than one in five Americans still gets at least one opioid prescription filled or refilled per year. And a dependence on prescription opioids often leads to a dependence on heroin or synthetic fentanyl, both of which are even deadlier. Just how many people are we talking about here? The Department of Health and Human Services estimates there are roughly 2 million people in the U.S. with what it calls opioid-use disorder. As the healthcare economist Alicia Sasser Modestino told us last week: an entire generation has been addicted at this point. So what’s to be done about that?
Nicole O’DONNELL: It’s treatable. We don’t have to overcomplicate it.
Today on Freakonomics Radio: our second of two episodes about the opioid crisis. The focus today: an addiction treatment option that some people think should be universal.
PERRONE: They can get it as part of routine medical care just like they might get their insulin for their diabetes or their blood pressure medicine.
So is it being universally embraced?
PERRONE: That’s— that’s probably a no.
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Last week, in Part 1, we met Jeanmarie Perrone at the University of Pennsylvania.
PERRONE: I’m an emergency-medicine physician and a medical toxicologist. Which means I was trained in poisonings and overdoses. And more recently I’ve started to do addiction-medicine work.
Perrone has seen the opioid crisis up close as a researcher and a practitioner.
PERRONE: So, we have about 1,000 or 1,200 patients who visited our three hospitals last year, and about 400 of them were overdoses.
Stephen DUBNER: Have you ever used opioids of any sort?
PERRONE: No. Had a couple kids. And broke my leg and broke my wrist. I didn’t have opioids for any of those three things.
DUBNER: Were you offered, in any case?
PERRONE: I broke my leg in Canada — interestingly, I would say, right in the middle of the opioid crisis, and they’d said, “do you need anything?” And I said, “You know, I’m fine with ibuprofen.”
PERRONE: Mountain biking. But anyway, I would—
DUBNER: So you brought it on yourself.
PERRONE: I did bring it on myself. But I would definitely say that I would have a super high threshold for anyone in my family, anyone I know. I mean, I advise against it sort of across the board.
DUBNER: Because it’s just too easy to —
PERRONE: Just that you just don’t need to go there.
DUBNER: So opioid deaths in the U.S. have leveled off, maybe started to decline a little bit. What are you seeing here in Philadelphia?
PERRONE: So they did decline a little bit. I think what is important about the national data is that the deaths that have declined the most are the oral pills. And that’s probably the result of deprescribing, and a little bit of a result of prescription drug monitoring programs preventing the co-prescribing of benzodiazepines with opioids. Maybe a little bit more public awareness, like I shouldn’t drink when I’m taking back-pain medication.
Another potential driver of this slight decline in deaths is the widespread availability of Narcan, an emergency nasal spray of the drug naloxone, which can stop an overdose as it’s happening, wherever it’s happening. Perrone has administered Narcan herself a few times. The most recent was riding the subway home, in Philadelphia, after a night out.
PERRONE: And somebody called and said “Does anyone have Narcan? There’s a man down.” And I do carry Narcan and so I ran five or six subway cars up and there was a man on the ground getting CPR, was blue — cyanotic — was pulseless, really on the brink of death or defined as dead already, maybe. And so we continued CPR, I got my Narcan out, I gave him one dose and he didn’t really respond. And then I gave him another dose and then I thought, you know, we need to do mouth-to-mouth. And then I thought, maybe some of the Narcan was still stuck in his nose and so I sort of scribbled his nose a little bit and kind of irritated it a little bit more and then he took like one teeny, tiny breath and over the course of the next 90 seconds he started to wake up. And then about 10 minutes later E.M.S. came. I was like, “You guys just saved this guy’s life.”
DUBNER: You’re saying, “You guys,” but you were the one that gave him the Narcan —
PERRONE: Well no, but they had started CPR. They had called someone for help, they had called 911. I mean, they’d done so much. You know, we simulate resuscitations like that in the hospital and this group of people just got it all together. Did all the right things. So it was really impressive. I mean, it was probably 25 or 30 people at the end of it all, and it was like this amazing — I call it my Philly moment because it was like winning the Super Bowl, when everyone was in the streets and everyone just had this amazing bond. And it was just incredible. It brought tears to my eyes then, it brings tears to my eyes when I talk about it.
So that story had a happy ending. Many overdose stories do not. And Narcan can only do so much. It doesn’t treat the underlying addiction.
PERRONE: The patients who come to the emergency department after receiving Narcan from an overdose, about 6 percent of them are dead at the end of one year. And 10 percent of them are dead at the end of two years. So there is no other medical condition that we currently treat in the emergency department that has that kind of mortality.
DUBNER: So from your perspective, I’m curious: you’re an E.R. doc and people come in for help when they’re in a desperate state already. Right? They’re not typically coming to you to say, “I’ve been thinking long and hard about my life and I want to make a graduated change,” right? So what can you do for them? What was the treatment, let’s say, five years ago when the problem was starting to really turn into a horror, and how does the treatment differ now?
PERRONE: So that’s a great question. Five years ago, an overdose patient hopefully got some compassion in the emergency department, and a little bit of a conversation about why they may have overdosed that day, or what we can do to help them. Maybe as of four or three years ago, they would’ve been discharged with a box of Narcan or naloxone so that if they were exposed to another overdose, somebody could use that on them, or they could use it on a friend or a colleague. I think fast-forwarding from there, what we’ve realized is that giving them kind of a crumpled piece of paper that said, “You should stop using drugs,” doesn’t really work. They’re in a cycle of using and fighting withdrawal every three or four hours. And so that doesn’t lend itself to getting your phone out and making an appointment for Monday morning to see an addiction specialist.
This “appointment model” was failing in other hospitals too.
Gale D’ONOFRIO: We were on the frontlines, just seeing patients being brought in — sometimes being just dropped off at the door and thrown at the emergency personnel.
That’s Gail D’Onofrio.
D’ONOFRIO: I am professor and chair of emergency medicine at the Yale School of Medicine.
She is also chief of emergency services at Yale-New Haven Health. So, like Perrone, D’Onofrio is a practitioner and a researcher.
D’ONOFRIO: So our study in JAMA in 2015 was looking at different models of care for opiate use disorder.
JAMA is the Journal of the American Medical Association. And in 2015, E.R. practitioners like D’Onofrio weren’t having much success treating the many opioid addicts they’d started to see. So she and her team set up a study. It included 300 patients, divided into three treatment groups. In the first group:
D’ONOFRIO: We’ll try to motivate them to get care and then we’ll refer them to the centers of care that we had here at Yale, or in the community.
This was the standard treatment at the time — the “crumpled piece of paper” model that Jeanmarie Perrone mentioned. The second group of D’Onofrio’s patients got a bit extra.
D’ONOFRIO: They got motivational enhancement, which we call the brief negotiation interview.
That was a 15-minute conversation, talking about their addiction and the circumstances that led to it.
D’ONOFRIO: And then those people got a facilitator referral.
Not just a crumpled piece of paper.
D’ONOFRIO: So we actually called the place ourselves, and if it was at night we’d call them in the morning and said we referred this person to you.
And then the third group:
D’ONOFRIO: They got also a motivational enhancement, brief intervention. But then they were started on buprenorphine.
PERRONE: So buprenorphine is an opioid agonist, which means it activates the opioid receptor just like heroin and oxycodone.
Jeanmarie Perrone again.
PERRONE: I think everyone knows methadone, and methadone is our historically opioid-agonist treatment that we use for patients with opioid use disorder. And the only treatment we really had for a long time.
But methadone has issues.
PERRONE: Methadone is dispensed from federal treatment programs and the patient has to go there every single day to get their dose. And the opioid-agonist methadone works by being a very long-acting opioid and acting at the opioid receptor. And in high enough doses, it thwarts the use of other opioid agonists. Buprenorphine is different. First of all, it can be prescribed from a doctor’s office. So the patient doesn’t have to go to a methadone clinic every day. They can get it as part of routine medical care, just like they might get their insulin for their diabetes or their blood pressure medicine. And it’s intended to be less stigmatizing to get it as part of routine medical care. The other thing is that it’s a partial agonist at the opioid receptors, so it doesn’t continue to activate it the way methadone does. So that is what we call a ceiling effect, which makes it much safer, so that there isn’t as much respiratory depression and there isn’t as much risk of opioid overdose and death.
D’ONOFRIO: It’s really hard to overdose on it. It’s hard, even if a child takes a pill of their adult family’s or friend, off a table, that they will die from it. Because it does eventually just reach that ceiling effect.
So buprenorphine, which is itself an opioid, would seem to offer a safer and more flexible treatment for opioid addiction. But how effective is it? That’s what D’Onofrio was really looking for her in her study at Yale.
D’ONOFRIO: And so what we found was that those patients that were in the buprenorphine group were two times more likely to be in formal treatment at 30 days, one month.
That was a huge improvement over the two other groups in the study.
D’ONOFRIO: So about 37 percent of patients in the referral group were in treatment and about 45 percent in the brief-intervention group and then almost 80 percent in the buprenorphine group.
PERRONE: So they were able to double the rate of engagement of patients who showed up for a follow-up meeting.
When Jeanmarie Perrone of Penn saw the Yale study, she was impressed and excited.
PERRONE: And that is so critical to getting people into treatment. And that medication stabilizes the cycle of withdrawal that patients are experiencing. So it’s really important to not say, “You can come in tomorrow for your first appointment,” but, “Here’s a medication, the next twelve hours won’t be the hell you think it’s going to be if you start on this medication now.”
DUBNER: So that sounds like a wildly useful drug that I’m sure every hospital and medical board and state legislature must be in favor of dispensing more of this antidote, yes?
PERRONE: That’s — that’s probably a no. I think there’s a lot of good people in theory who do want to do this and expand our treatment. I think the logistics of learning how to administer buprenorphine sounds more complicated than it might be, and that is a barrier.
DUBNER: What do you mean by the logistics of administering it?
PERRONE: So first of all, in order to write a prescription for buprenorphine, you have to get something called an X-waiver, which means that you have to take an eight-hour training program and you have to apply to the D.E.A. to get a special waiver.
DUBNER: Does the same sort of waiver-licensing process apply to prescribing medical opioids in the first place?
PERRONE: It does not. So I can in fact treat your opioid use disorder with oxycodone or hydromorphone if I wanted to. And that would be not regulated at all.
DUBNER: So why the extra level of regulation for buprenorphine?
PERRONE: It’s complicated, but when we went from the late ’60s, when we started methadone and we had people who needed treatment, but we weren’t going to let just any doctor prescribe it. And so that’s why methadone was restricted to these federal treatment programs. But then when we said, well, in 2000 buprenorphine became available and was approved in the United States, but we weren’t just going to let every doctor put out a shingle and start administering buprenorphine.
Buprenorphine is most commonly administered in a name-brand drug called Suboxone, which also contains naloxone. Buprenorphine was invented by the pharma firm Reckitt Benckiser in 1966, one of many synthetic opioids designed in the 20th century. They were meant to treat pain but be less addictive than opium itself; but as it turned out, most of them were addictive. That is the foundational problem of the prescription-opioid crisis.
In the 1990s, Reckitt Benckiser recognized buprenorphine’s potential for treating opioid use disorder, and it spun off its buprenorphine division into what is now a subsidiary company, called Indivior. Several years ago, another drug company thought about getting into the buprenorphine market: Purdue Pharma, which makes OxyContin, one of the most widely abused prescription opioids. A Purdue memo at the time called buprenorphine “an attractive market” — but they never did jump in.
Today, Purdue is the target of thousands of lawsuits, charged with having downplayed the addictive nature of OxyContin. Just how influential was Purdue in the opioid universe? Consider this startling development: The World Health Organization recently “retracted its two main guidelines” for using opioids to treat pain. Why? Because the guidelines, it has now been discovered, were “unduly influenced by opioid manufacturers,” including Purdue’s international subsidiary. And yet, at this moment, OxyContin is still legally and widely dispensed, as a useful painkiller that is also easily subject to abuse. Suboxone, meanwhile, is much harder to abuse but is also harder to get.
What do medical professionals who treat opioid addiction think of this? Here’s what one doctor wrote on the HealthAffairs blog: “Buprenorphine has the potential to be a transformative tool in healthcare practitioners’ fight to reduce deaths from opioid overdose” but that the X-waivering process is “onerous, outdated, and hampers our ability to help patients manage and recover from opioid addiction.” An editorial in JAMA Psychiatry made the same complaint, and noted that easing the restrictions on buprenorphine in France helped drive down deaths from opioid overdose there by nearly 80 percent. “If extrapolated to the United States,” the authors wrote, “this translates to more than 30,000 fewer annual deaths from opioid overdoses.”
PERRONE: So globally, the statistics are tremendous. No doubt in the evidence there.
DUBNER: Do you see the the waiver requirement for buprenorphine as a sort of overcorrection, over-response, to the medical community’s own embrace of opioids in the first place? Like, “We messed up big time and at the very least, what we’re not going to do now is mess up in the same direction,” even though this might be a different direction?
PERRONE: I think it lingers because of some of those concerns. But if we go back to 2000, we didn’t really have any kind of opioid crisis in 2000. So it was really approved in the absence of a big surge in opioid use at the time. I think not repealing it at this point is probably multifactorial. People are worried about Suboxone diversion. So the same substance that we want to prescribe is also available on the street and we acknowledge that. But it’s not used on the street to get high. It’s used for patients to treat their own withdrawal symptoms when they’re unable to get other medications. So I think that’s part of why there’s been some resistance to taking away the X-waiver. I think it also is going to take an Act of Congress, which is fairly hard to accomplish. And I think that repealing the X-waiver isn’t entirely going to open the floodgates for prescribers who want to prescribe buprenorphine. There’s still some education and some stigma that needs to be addressed before more people are going to be willing to prescribe.
DUBNER: How would you describe the weirdness, or the paradox, or whatever, of the fact that buprenorphine is so difficult to prescribe versus — I mean, if I’m a medical resident, let’s say, can I prescribe OxyContin?
PERRONE: Yes. Prescribe is different. So prescribe is writing a prescription. So in order for them to order OxyContin in the hospital, there are no requirements. In order for them to write a prescription for OxyContin, they would of course need their D.E.A. number. But in order for them to prescribe Suboxone or buprenorphine, they would need to take that eight-hour training.
DUBNER: On the other hand, if a drug is as valuable as buprenorphine sounds it may be, is an eight-hour training program such a big barrier or even shouldn’t it be something that we should applaud as proving the worth of being able to prescribe it?
PERRONE: I think that there’s some value to training. I think our original activism around opioids, we thought all doctors should learn a little bit more about any opioid that they prescribe, because there was clearly a lack of education about the addictive nature. The problem is in primary care, if you’re going to prescribe buprenorphine and you need to take an eight-hour training, that’s okay if you plan to treat a lot of patients. But if you’re only going to treat five or six patients, just sort of as part of their other medical problems, it becomes a much bigger barrier. In the cases of the emergency department, we had to get all of our doctors X-waivered just to be able to write the occasional prescription for somebody who has opioid use disorder. I can understand the historical evolution of this, but I cannot understand the modern response.
DUBNER: Modern response meaning?
PERRONE: Modern lack of response. Modern ways of addressing some repeal of the waiver or modifying the waiver.
DUBNER: I see that some hospital chains and some state and local governments are moving in the direction that you advocate. But I see that others are moving in the opposite direction — including the state of Pennsylvania, which has kind of pinballed. Can you describe that?
PERRONE: So the state of Pennsylvania, despite everything we thought, was moving in the right direction, the state legislature introduced a bill that would add an additional layer to the X-waiver. So even if you were already X-waivered like myself, you would have to pay $500 a year to get an additional X-waiver license in order to prescribe in Pennsylvania. I think that it came out of perhaps some well-intended sense that they needed to decrease the amount of buprenorphine prescribing that wasn’t being as tightly administered as they might wish.
That bill passed the Pennsylvania state Senate, by a vote of 41-9, and is now in the House. But the X-waiver and training requirement and extra fees aren’t the only things holding buprenorphine back from widespread use.
Stephen LOYD: If you look at residential treatment programs across the country, most of them, over 70 percent of them, are still abstinence, 12-step-based programs.
That’s Stephen Loyd, a physician in Tennessee who specializes in addiction. In last week’s episode, we heard how Loyd himself was for years addicted to prescription painkillers.
LOYD: Basically, I took pills all day long. When I got out of bed in the morning, I had withdrawn during the night, so I was sweating. I felt like an 80-year-old man, and I was in my early 30s.
Loyd went into a detox program and then a 30-day residential rehab facility, which got him turned around. Today, he’s the medical director for a network of addiction-treatment centers.
LOYD: I’m a big believer in medication-assisted treatment. And we know that the most effective thing that we can do for opioid addiction is actually medication-assisted treatment with the use of drugs like buprenorphine, methadone, and naltrexone. And I’ve taken heat from this in the local treatment community as well as the treatment community statewide, and even nationally.
DUBNER: Can you just describe where that pushback and that reluctance is coming from?
LOYD: Well, unfortunately Stephen, the pushback comes from people in the recovery community. And one of the problems with addiction medicine is that most of the people that work in the field, or a lot of the people that work in the field, had the issue themselves. That’s how they got in the field. Like myself. But they believe that the only way to get healthy is how they got healthy. So it’s totally anecdotal.
As Loyd noted, most addiction-treatment programs do stress total abstinence — including 12-step programs like Alcoholics Anonymous and Narcotics Anonymous. How successful are such programs? That is a famously difficult question. Solid data are hard to come by; after all, anonymity is a feature of such programs, and there are all kinds of possible selection biases. Alcoholics Anonymous claims that 75 percent of its participants stay sober. But academic studies put the success rate closer to 10 percent or even less. That said, one Stanford study compared addicts who quit with the help of A.A. versus those who quit on their own, and found that A.A. nearly doubled the success rate. Stephen Loyd’s argument is that abstinence is the chosen path for the recovery community — but that medical professionals embrace M.A.T., medication-assisted treatment.
That is the National Institute on Drug Abuse.
LOYD: Everybody who looks at this says the role of medication is paramount, it should be the cornerstone. Yet it’s so hard to get people into those programs because of the stigma associated with it. A lot of times, it’ll be from parents. I’ve had numerous parents talk their kids out of medication because they said they were trading one drug for another, and then a few months down the road, I get the call that they’ve overdosed and died. And I can’t tell you how heartbreaking those calls are.
DUBNER: If I say to you, I don’t like the idea of the pharmaceutical industry being able to be the chief beneficiary of medication-assisted treatment because they helped drive this problem in the first place. It’s a little bit like I set a house on fire, then I’m the hero who calls in the fire to the fire department. I don’t like the optics of that. I don’t like the economics of that. What do you say to that argument?
LOYD: I have to say I agree with you a million percent. It makes me choke every time I think about it. But I don’t have a better option. I don’t have anything else that’s going to stop my patients dying at the rate that M.A.T. does. I can’t stand it. I read somewhere recently that, several years back, Purdue Pharma tried to acquire the marketing rights to buprenorphine, which just absolutely is unconscionable to me, and so I would agree with you one thousand percent. I wish there was a better option. But right now, there’s not. And so I can’t let my feelings get in the way of trying to help my patients and help them stay alive.
DUBNER: Could you describe for me the underlying causes of opioid addiction? I guess what I’m looking for is, if you could break it down between a physiological addiction or craving, as well as the psychological and environmental drivers.
LOYD: Well, I don’t know how much more I need to break it down, you just did. You know, that’s the classic model, psychosocial model that you just described. So that’s really the three big components of developing any addiction, in this case opioids. So you’ve got the — I teach it in terms of a slot machine, you know, when the three sevens come down on the pay line, that’s when the money comes out. So the first seven is the bio component, and that’s simply genetics. Do you have a family history of any addiction? If you do, then that first seven comes down on the pay line. And addiction is about 60 percent genetic, for the most part.
The second part is the psychological component. What kind of household were you raised in? Do you have a high ACE score — adverse childhood experiences. Were you physically, sexually, or emotionally abused? Do you have that chronic trauma, maybe even later in your life? If you do, then that second seven is down on the pay line. And then the third seven is the social component, and that’s just the availability. You know, what is widely available? And the thing that’s most widely available and accepted is alcohol, and that’s still mostly what we see people abusing and addicted to. But in the late 1980s, early ’90s, and into the 2000s, opioids became much more widespread.
DUBNER: You and many others call addiction, generally, a disease, and it sounds like the factors that may determine your likelihood for the disease are pretty much everywhere. So do you see this as a different sort of disease than we typically think about with epidemiology?
LOYD: Let’s take a disease that everybody agrees on. Type 2 Diabetes mellitus. You know, nobody has a problem with Type 2 Diabetes being a disease. Right? I never hear any discussion about that. Yet, for the most part it’s behavioral, right? Why do people get Type 2 Diabetes? Well, they don’t eat right, and they don’t exercise correctly. And so we treat that widely with medication to try to decrease the bad outcomes with diabetes. So I look at addiction as being much the same.
D’ONOFRIO: If you know about addiction — addiction is a brain disease.
Gail D’Onofrio again, from Yale.
D’ONOFRIO: And we know by looking at scans of the brain that even though I maybe have had treatment and I’m no longer physically dependent, the minute you show me something — whether it’s a syringe or it could be just a place that I used — parts of my brain, my amygdala will light up, showing that I still have this craving. I still have this possibility to use if I get back in that situation. I can’t pray myself out of it. I can’t will myself out of it.
LOYD: So it doesn’t matter if I call it a disease or a learning disorder. It is a rewiring of the brain, the reward system in the frontal lobe interaction, and to where the primary focus becomes acquisition of this substance for me to be okay. And so when I look at it in those terms, it looks a lot like diabetes to me.
DUBNER: Can you talk for a minute about federal policy toward medication-assisted treatment and perhaps buprenorphine specifically? From what I’ve read, the policy recommendations during the Trump administration have been evolving very rapidly.
LOYD: If you look at President Trump’s first appointment to the Head of Department of Health and Human Services, was Dr. Tom Price. He came out early on and said, “Well, you know, this is simply switching one drug for another.” And those of us in the addiction field had serious angst about that. But you have folks in H.H.S. right now that are giving really good direction with regards to medication-assisted treatment and making it more widely available.
It is evolving quickly, and I think we’re to the point now that some of the stigma is being decreased simply because so many people have died. Instead of defining recovery as total abstinence from any medication, I want to define recovery in those parameters of, is your life getting better? Are you still going to jail? Do you have your kids back? Do you have a job? Are you a member of the tax-paying citizenship in the United States? To me, those are much more reflective of effective treatment than whether or not somebody is totally abstinent from all drugs because some 12-step group says they have to be.
Stephen Loyd’s philosophy, as well as that of Gail D’Onofrio and Jeanmarie Perrone, falls under the umbrella of what is called “harm reduction.” It’s the idea that you treat risk not as something that must be driven to zero. In a recent episode called “The Truth About the Vaping Crisis,” we talked about the battle between smoking abstentionists — people who argue that nobody should be consuming any nicotine, in any form — and harm reductionists, who argue that vaping may carry risks but they’re almost certainly smaller than the risks from smoking cigarettes. When it comes to opioid abuse, the gap between the abstentionists and the harm reductionists seems to be even wider. Why is that? What’s different about opioids?
PERRONE: It’s always been stigmatized. I don’t know why.
LOYD: So I think any time you lessen the stigma associated with addiction, you increase people’s opportunity to step out of the shadows and ask for help.
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As we’ve been hearing, treating opioid addiction with another opioid, like buprenorphine, is not a concept that is universally embraced. But a lot of smart and dedicated people are in favor — including Jeanmarie Perrone, a medical researcher and E.R. doctor at the University of Pennsylvania. She and her team have been creating a new treatment protocol for opioid addiction that includes buprenorphine or Suboxone — but more than just that. They are changing the way addicts are treated from the moment they wind up in the E.R. This treatment includes what they call a “warm handoff.”
PERRONE: So a warm handoff is a new-ish term. It’s the idea that a patient at a hospital, or a clinic is going to be discharged having already met a peer or someone who’s going to either accompany them to an appointment or they’ve met the doctor or clinician who will take care of them. So there’s a close connection between the patient and the patient’s next step in recovery.
And there’s another member of the warm-handoff team: a peer counselor.
PERRONE: Our peer counselors are people who are in recovery themselves and who can start the dialogue right there about what it would look like if they tried medication, or tried to get into a treatment program, or tried to engage in care right then. It’s all about engagement.
These peer counselors are on staff at the hospital; they’ve gone through certification training, and they’ve got firsthand experience as opioid addicts.
PERRONE: I think they’re the some of the most, not just dedicated, but you know, people who have been through more than I’ve ever been in my super easy life, and who have come to the other side and who want to help other people, and who are successful at helping other people. They’re special.
DUBNER: People like Nicole.
PERRONE: People like Nicole. Absolutely.
Nicole O’DONNELL: I am Nicole O’Donnell and I’m a certified recovery specialist in emergency rooms at Penn.
DUBNER: So Nicole, what’s your story? How do you get to be in this position?
O’DONNELL: So from using to here? It was a lot of work. So my first love was benzos — which was Xanax. That’s what I became addicted to. I went to rehab, I was 21. My first time I went to treatment, in-patient treatment, and it worked. It worked for about two years. And then there was opioid painkillers around. So that’s, you know, why not, right? And then — OxyContins weren’t really as readily available then. So it was like Perc 30s and opiates that were someone’s prescription that we got. And then — they are very expensive. So it was easier to get heroin.
DUBNER: And then what happened? How’d you finally get clean?
O’DONNELL: I was tired of stalling withdrawal. Because that’s all I was doing in the end, was using so I wasn’t in withdrawal, right? So I came to this realization that I’m going to continue to be in withdrawal every single time until I do something idiotic, because the withdrawal is awful. And nobody wants to be in it, and I realized my life was trying to figure out how I was getting drugs just to stop withdrawal. It’s not fun in the end, it’s not a party, nobody’s happy. You’re just really trying not to be sick and barely functioning.
DUBNER: You had a sister, yes?
O’DONNELL: Yes. Three years younger than me. Jessica.
DUBNER: Yeah. And I understand she died of an overdose?
O’DONNELL: She did. In — it was December 14th of ’14.
DUBNER: Okay. And what was — what were her drugs? Or drug?
DUBNER: And what was your relationship like with her then?
O’DONNELL: We used together. She gave me heroin for the first time. So I was doing restaurant management for the first seven years of my recovery, and then I lost my sister. And that’s when I started doing outreach. I needed to give her death purpose. And I needed to maybe be the person for people that she probably didn’t encounter in her active addiction.
O’Donnell introduced me to one of the people that she’s been helping.
Eileen RICHARDSON: My name’s Eileen Richardson. I am a restaurant manager. I’m also an alcoholic and an addict. I’m from the Jersey Shore originally. New to Philadelphia. I’ve been here a little over a year now. I’m married. I have a wife. I have a son. He just turned three.
DUBNER: Congratulations. What’s his name?
RICHARDSON: His name is Henrik. Or Henrik Matthew Richardson, as he likes to say.
On the day we spoke, Richardson had been in recovery for 93 days. She had come into the Penn E.R. after overdosing.
RICHARDSON: And Nicole came to meet me in the hospital. I believe it was the physician that I saw, asked me if I was interested in getting help. And he said he had somebody he knew that I could talk to. And Nicole showed up to talk to me.
DUBNER: Yeah. You overdosed on what?
RICHARDSON: On heroin and fentanyl.
Nicole helped Eileen get on Suboxone.
RICHARDSON: I’m still doing the Suboxone. You know, I take it every day. The Suboxone helps. I don’t have cravings. And right away that started. When I went back in the second time to the Suboxone clinic, the recent time, they upped my dose. And from that day on, I haven’t had a single craving for any opiate since.
DUBNER: What’s that feel like?
RICHARDSON: Pretty awesome. Pretty amazing.
DUBNER: So how much of your success would you attribute to working with Nicole, and having a peer who understands it; the drug itself; and then any other third or fourth reason.
RICHARDSON: I mean, they all play a big part. I wouldn’t want to break it into percentages or graphs or anything like that, because for me it’s all intertwined.
DUBNER: But do you think that Nicole without the Suboxone would do it?
RICHARDSON: No, the Suboxone is definitely something I needed. But if I was just doing the Suboxone and nothing else, I would stop taking the Suboxone. It wouldn’t — I wouldn’t keep taking it. You know, the drug helps the physical part, and then everything else I do helps me become a new person — a new human being, which is my goal.
DUBNER: So the Suboxone helps you get back to the level that Nicole can work with.
RICHARDSON: Exactly. Yeah. In my belief. Yeah.
DUBNER: So Nicole, Suboxone sounds like a really good solution — at least for some of the people, some of the time, right? Can you talk about — I guess the problem, or the barrier of being able to use it as widely as it might ought to be used.
O’DONNELL: So from my perspective, aside from the X-waivering and the medical barriers that the doctors experience, from our experience too, is there is a big stigma with it in the recovery community. The recovery community traditionally has been abstinence-based. And that means nothing — no medications, no illicit drug use, nothing.
DUBNER: How come?
RICHARDSON: It’s just this, it’s this deep-seated thing. The 12-step programs — there’s a lot of tradition and stuff like that. And there’s not a lot of change. And I’m not going to lie — I love the twelve steps and I love the program and it’s done so much for me. But I don’t talk about the fact that I use Suboxone. My sponsor knows. You know, my close friends know, but I don’t bring it up in meetings. And there’s different twelve-step programs obviously, and one of them specifically states that M.A.T. is not considered clean.
DUBNER: Eileen, right before we started recording, you told us that a friend of yours just died. Just now. I don’t know how much you want to say about those circumstances — it’s a friend you knew for how long? And how’d they die?
RICHARDSON: I have known him since I started going to the 12-step group that I go to — what we call our home group — back in February. He was coming up on a year sober in 18 days. He would have had a year. And he — this is how it happens, is that people stop and then they go back out and they think they can use the same amount that they were using once before, and you just can’t anymore. You’re pretty much killing yourself if you go back out. Not people always close to me, but I know someone that’s dying every week. But I mean, this one, I was with him yesterday. And we were talking and joking about the fishing trip that we’re going on next week. And his mom was just talking to him on Facebook about how proud she was of him and — it’s just, it’s a horrible disease. You know.
DUBNER: It was heroin?
RICHARDSON: Probably heroin and fentanyl — everything’s fentanyl now.
The opioid crisis really began with prescription pills, then moved into heroin, and now synthetic fentanyl, which presents a particularly high risk of overdose. To that end, there’s another idea currently under consideration in Philadelphia:
O’DONNELL: We’re all harm reductionists here.
Nicole O’Donnell again, the certified recovery specialist.
O’DONNELL: So we advocate for safe injection practices, the needle exchange. But there’s this Safehouse that we’re all advocating for, and it’s a place to go for people to safely not overdose. They go use drugs, get tested, they have medical staff, they have peers, hopefully, there to navigate them into treatment the same way we do in the emergency room.
The legal, official kind of safe-drug-use site that O’Donnell is describing doesn’t exist yet, at least not in Philadelphia — or elsewhere in the U.S., though it’s been proposed in several cities. It does exist in several Canadian cities. In the U.S., Philadelphia is at the leading edge. The Safehouse nonprofit is backed by many local and state officials, but the U.S. Justice Department sued, saying it would be illegal to provide a facility to consume illegal drugs, even in the interest of preventing overdoses. A federal judge recently ruled in favor of Safehouse, but there will be more legal action before any such facility can open.
O’DONNELL: My point of advocacy for Safehouse is for people like your friend that just passed, because he’s in recovery, right? If I use, I’m going to die. Fortunately through my years of this advocacy, I have a person. I have a safe house. I have a person that I would call if I didn’t want to die to make sure I didn’t overdose if I used. I have that. That’s a safety net, right? Not everyone has that. So this is a place that we want people to be able to go. Like your friend, if he was at this place, he wouldn’t have died.
LOYD: The opposite of addiction is not recovery. The opposite of addiction is community and relationship. You can’t have community if you’re dead.
Dr. Stephen Loyd again.
LOYD: So the first thing is to keep patients alive. Now, the longer that we keep them alive, the more that we need to be able to engage them in supportive environments around really everything.
DUBNER: And what’s your position on, I guess, legal dispensaries of illegal drugs? And I’m curious if there’s any movement toward that in Tennessee?
LOYD: You’re really putting me in a position to get in trouble. I think we have to look, at this point, at all harm reduction strategies. So I think anytime you lessen the stigma associated with addiction, you increase people’s opportunity to step out of the shadows and ask for help. And I’m for any modality that gets people to that point.
The warm-handoff program at UPenn is still relatively new. I asked Nicole O’Donnell, the recovery specialist, how many patients she will see in a given day.
O’DONNELL: In an average day, we could see up to six people. I mean, whether they’re inpatient for a medical reason, inpatient in our inpatient drug and alcohol treatment, or they’re through the emergency room.
DUBNER: And of those six, how many are willing to at least have a conversation with you about medication-assisted therapy?
O’DONNELL: Honestly, there’s not many that say they don’t want to talk. Whether they want things or not is a different story. You know, then we have a harm reduction conversation. But nobody really throws you out of the room and says, “I don’t want to talk about anything.”
DUBNER: So if there’s one misperception about opioids — about use, abuse, whatever — that many people — like public-radio nerds, who are going to listen to this — if there’s one thing they really don’t know, what would you want to tell people?
O’DONNELL: That opiate use disorder is treatable. It’s not a death sentence. It’s not— it’s a medical condition and it’s treatable.
DUBNER: It sounds so simple when you say it that way. But there’s all this conversation going on around the topic now. In the political community — and it’s never said that simply. Why not?
O’DONNELL: Because we like to overcomplicate things. And it really doesn’t need to be overcomplicated. Eileen takes her medication, she engages, and she goes to meetings. And she’s doing amazing. And she’s a mom to her son, right? It’s treatable. We don’t have to overcomplicate it.
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Freakonomics Radio is produced by Stitcher and Dubner Productions. This episode was produced by Zack Lapinski, with help from Miles Bryan. Our staff also includes Alison Craiglow, Greg Rippin, Harry Huggins, Matt Hickey, Daphne Chen, and Corinne Wallace. Our theme song is “Mr. Fortune,” by the Hitchhikers; all the other music was composed by Luis Guerra. You can subscribe to Freakonomics Radio on Apple Podcasts, Stitcher, or wherever you get your podcasts.
- Dr. Jeanmarie Perrone, Professor of Emergency Medicine at the Hospital of the University of Pennsylvania and director of the Division of Medical Toxicology and Addiction Medicine Initiatives at the University of Pennsylvania.
- Gail D’Onofrio, Professor and the Inaugural Chair of the Department of Emergency Medicine at the Yale School of Medicine.
- Stephen Loyd, Chief Medical Officer at JourneyPure.
- Nicole O’Donnell, certified recovery specialist at Penn Medicine’s Center of Excellence.
- “Toward Healthy Drug Policy in the United States — The Case of Safehouse,” by Evan D. Anderson, Leo Beletsky, Scott Burris, and Corey S. Davis (The New England Journal of Medicine, 2020).
- “Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder,” by Leo Beletsky, Kevin Fiscella, and Sarah E. Wakeman (JAMA Psychiatry, 2018).
- “Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence,” by Gail D’Onofrio, Patrick G. O’Connor, Michael V. Pantalon, Marek C. Chawarski, Susan H. Busch, Patricia H. Owens, Steven L. Bernstein, and David A. Fiellin (JAMA, 2015).
- “Buprenorphine-Naloxone Therapy In Pain Management,” by Lucy Chen, Kelly Yan Chen, and Jianren Mao (National Institutes of Health, 2014).
- “Prevalence and Correlates of Street-Obtained Buprenorphine Use Among Current and Former Injectors In Baltimore, Maryland,” by Jacquie Astemborski, Becky L. Genberg, Mirinda Gillespie, Chris-Ellyn Johanson, Gregory D. Kirk, Shruti H. Mehta, Charles R. Schuster, and David Vlahov (U.S. National Library of Medicine National Institutes of Health, 2014).
- “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” by Art Van Zee (U.S. National Library of Medicine National Institutes of Health, 2009).
- “The Truth About the Vaping Crisis,” Freakonomics Radio, 2019.