Today’s show is a little bit of a hybrid between the usual monologue and a guest interview—think of it as a BOGO. First, we’ll dive into the history of the opioid epidemic and look at the disconnect between research-recommended opioid treatment versus the most commonly administered treatment. Then, we’ll talk about how to quit opioids with podcast host and TEDx speaker Eric Zimmer who, at the age of 24, was homeless, addicted to heroin, and facing long jail sentences. Today, he’s a seasoned behavior coach and host of the excellent podcast, The One You Feed.His podcast title is based on an old parable about two metaphorical wolves who battle within us.
So first, let’s talk history. To paraphrase the Talking Heads, how did we get here? How did the opioid epidemic become the opioid epidemic?
Let’s start where we are now: every day, 130 Americans die from an opioid overdose. In 2017, that added up to more than 47,000 people. It’s to the point where, for the first time in decades, life expectancy in the U.S. is decreasing, driven in part by opioid overdoses.
The First Wave
The opioid epidemic didn’t just develop from one seed; it grew from many. One sprouted in 1980, when a five-sentence letter to the editor was published in one of the most prestigious medical journals, The New England Journal of Medicine, which stated that opioids were not addictive. Like a game of telephone gone wrong, what followed was hundreds of citations of the letter justifying increased prescription of opioids. But few of the citations noted that the letter referred to inpatients prescribed opioids during brief and closely monitored hospital stays. The letter was never meant to apply to opioids in an outpatient setting, nor for long-term use.
Meanwhile, another seed was planted. Many doctors and pain organizations, including the World Health Organization, began a well-intentioned campaign to treat pain. From breakthrough cancer pain to chronic backache, they said pain was undertreated, and there was no reason patients should have to suffer. The arguments were all very logical and humane and they quickly spread across the healthcare industry.
And a final seed: after Purdue Pharma introduced OxyContin in 1995, the manufacturer began aggressively marketing the drug to doctors. According to a New York Times investigation, the company knew of significant abuse of OxyContin within months of its release but concealed the evidence for years.
So, aggressive marketing, combined with a movement to relieve patients’ pain, plus the carte blanche interpretation of the NEJM letter, ignited the first wave of the opioid crisis.
The Second and Third Waves
The second wave began in 2010 as early efforts to cut back on prescriptions made opioids harder to get. Many people turned to heroin, which in turn led to skyrocketing heroin deaths.
The third wave hit hard in 2013 when illicitly manufactured synthetic fentanyl became widely available. Look at a graph of fentanyl deaths per year throughout the opioid epidemic and you’ll see a near-vertical line shooting upwards starting in 2013.
The Paradox of Opioid Treatment
Where does this leave us? Today, the biggest challenge is how to help those who are currently addicted to opioids, an estimated 2 million people.
But there is surprisingly little connection between the gold standard of treatment and what actually happens in many addiction treatment centers.
Research finds that something called Medication Assisted Treatment, or MAT, is most effective. Medication Assisted Treatment is exactly what it sounds like—addiction counseling combined with an opioid-replacement medication like methadone, Suboxone, or buprenorphine, which prevents withdrawal symptoms and reduces cravings.
However, around 90% of treatment facilities use a counseling-only abstinence-based approach. This is similar to traditional abstinence-based treatment of alcoholism.
And those brain changes don’t automatically snap back after detoxing off opioidsBut there’s a fatal flaw: opioids change the brain in very different ways than alcohol, cocaine, or other drugs. How? Prolonged opioid use alters brain regions that regulate reward, learning, memory, decision-making, and stress response, among others. And those brain changes don’t automatically snap back after detoxing off opioids. Furthermore, mix those brain changes with possible mental illness or trauma and barriers to getting treatment (like the price of treatment and finding a doctor who can prescribe MAT) and it’s tough to make changes stick.
Medication Assisted Treatment isn’t miraculous. Tapering can be difficult and can take years.
But the numbers speak for themselves: a landmark study followed 375 people on MAT. After 42 months, 32% were off both opioids and MAT. Twenty-nine percent were still on MAT but not using opioids, and 39% had relapsed and were using opioids again.
There are two big objections to Medication Assisted Treatment from abstinence-based treatment facilities. One common refrain is that MAT replaces one addiction for another. Another is that Suboxone or methadone, if abused, can cause a high.
But the numbers speak for themselves. In the MAT study, 39% had relapsed after 42 months. However, according to prospective studies, in abstinence-only based treatment, more than 90% of people relapse within 12 months.
Now, not all is lost with abstinence-only treatment. A study in the journal Addiction found that more frequent attendance at 12-step group meetings, like AA or NA, went along with higher abstinence rates, but it’s unclear if the group contributed to staying clean and sober or if people committed to abstinence were more likely to stick with a 12-step program.
No matter what path you’re on, how does one navigate the long, challenging road of addiction recovery? Well, as I mentioned at the beginning of the episode, at the age of 24, Eric Zimmer was homeless, addicted to heroin and facing jail time. In the years since, he has found a way to recover from addiction and build a life worth living for himself. He currently hosts the award-winning podcast, The One You Feed, based on an old parable about two wolves at battle within us. Eric has also been a behavior coach for the past 20 years and has coached hundreds of people from around the world to make real, lasting change in their lives. His story and his work have been featured through TedX, Mind Body Green, Elephant Journal, the BBC, and Brain Pickings.