403. The Opioid Tragedy, Part 2: “It’s Not a Death Sentence”

in our previous episode number 402 we looked at the rise of the opioid epidemic we are saying more people killed because of opioid overdose than traffic access the tragedy seemed come out of nowhere but in fact it had distinctive roots in the pharmaceutical industry they really somehow fooled us into thinking that pain was a vital sign that we needed to treat it more liberally in government policy what happened during that growth was that prices for opioids came way down due to government subsidies and in the highly addictive nature of the medicine that had been promoted as not being addictive 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 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 a 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 are roughly two million people in the u.s with what it calls opioid use disorder as the health care 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 it's treatable we don't have to overcomplicate it today on freeconomics radio our second of two episodes about the opioid crisis the focus today an addiction treatment option that some people think should be universal 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 that's that's probably a no from stitcher and dubner productions this is freeconomics radio the podcast that explores the hidden side of everything here's your host steven dubner last week in part one we met gene marie perone at the university pennsylvania i'm an emergency medicine physician and a medical toxicologist which means i strained in poisonings and overdoses and more recently i've started to do addiction medicine work perone has seen the opioid crisis up close as a researcher and practitioner so we have about a thousand or twelve hundred patients who visited our three hospitals last year and about 400 of them are overdoses have you ever used opioids of any sort no had a couple kids and broke my leg and broke my wrist um i didn't have opioids for any of those three things were you offered in any case i broke my leg in canada interestingly i was right in the middle of the opioid crisis and they said you know do you need anything and i said you don't find the ibuprofen team mountain biking but anyway 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 advise against it sort of across the board because it's just too easy to you just don't need to go there so opioid deaths in the u.s have leveled off maybe started to decline a little bit what are you seeing here in philadelphia 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 the 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 perone has administered narcan herself a few times the most recent was riding the subway home in philadelphia after night out and um 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 there's a man on the ground um getting cpr it was blue cyanotic was pulseless um 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 i thought maybe some narcan is still stuck in his nose and so i sort of scribbled his nose a little bit and kind of irritated him a little bit more and then he took like one teeny tiny breath and over the course of the next you know 90 seconds he started to wake up and then about 10 minutes later ems game i was like you guys just saved this guy's life you're saying you guys but you're the one that came well no but they had started cpr they had called someone for help they called 911 i mean they've done so much you know we simulate resuscitations like that in the hospital and this group of you know 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 bomb and it was just it was incredible brought tears to my eyes and it brings tears to my eyes and i talked 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 the patients who come to the emergency department after receiving narcan from an overdose about six percent of them are dead at the end of one year and ten percent of them are dead at the end of two years so there is no other medical condition that we currently treat the emergency department that has that kind of mortality so from your perspective i'm curious you're an er 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 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 have overdosed that day or what we can do to help them maybe as of four or three years ago they would have 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 colleague i think fast forwarding from there what we realized is that giving them kind of a crumpled piece of paper that 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 we were on the front lines just seeing patients being brought in sometimes being just dropped off at the door and thrown at the emergency personnel that's gail donofrio 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 perone donofrio is a practitioner and a researcher 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 er practitioners like donofrio weren't having much success treating 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 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 gene marie perone mentioned the second group of donofrio's patients got a bit extra 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 and then those people got a facilitated referral not just a crumpled piece of paper so we actually called the place ourselves and if it was at night we called them in the morning and said we refer this person to you and then the third group they got also a motivational enhancement brief intervention but then they were started on buprenorphine so buprenorphine is a opioid agonist which means it activates the opioid receptor just like heroin and oxycodone gene marie perone again 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 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 receptor so it doesn't continue to activate it the way methadone does so that's 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 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 and off the 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 in her study at yale and so what we found was that those patients that were in the buprenorphine group were two times more likely to be in informal treatment at 30 days in one month that was a huge improvement over the two other groups in the study 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 so they were able to double the rate of engagement of patients who showed up for a follow-up meeting when Jean-Marie Perrone of Penn saw the yale study she was impressed and excited and that is so critical to you know 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 medication the next 12 hours won't be the hell you think it's going to be if you start on this medication now so that sounds like a wildly useful drug i'm sure every hospital and medical board and state legislature must be in favor of dispensing more of this antidote yes that's 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 what do you mean by the logistics of administering it 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 dea to get a special waiver does the same sort of waiver licensing process apply to prescribing medical opioids in the first place it does not so i can in fact treat your opioid use disorder with you know oxycodone or hydromorphone if i wanted to and that would be not regulated at all so why the extra level of regulation for buprenorphine it's complicated but when we went from the late 60s when we started methadone and you know 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 you know 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 wreckett benkizer 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 wreckett benkizer 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 sterling development the world health organization recently retracted its two main guidelines for using opioids to treat pain why because the guidelines has now been discovered were unduly influenced by opioid manufacturers including produce 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 addictions think of this here's what one doctor wrote on the health affairs blog buprenorphine has the potential to be a transformative tool in healthcare practitioners fight to reduce deaths from opioid overdose but that the ex-wavering 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 restrictions on buprenorphine in france help drive down deaths from opioid overdose there by nearly 80 percent if extrapolated to the united states the office wrote this translates to more than 30 000 fewer annual deaths from opioid overdoses so globally the statistics are tremendous no doubt in the evidence there do you see the waiver requirement for buprenorphine as a sort of over correction 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 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 you know 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 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 yes i 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 dea number but in order for them to prescribe suboxone or buprenorphine they would need to take that eight-hour training 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 should it be something that we should applaud is proving the worth of being able to prescribe it 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 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 you know five or six patients just sort of as part of their other medical problems it becomes a much bigger barrier in case 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 a good use disorder i can understand the historical evolution of this but i cannot understand the modern response modern response modern lack of response modern ways of addressing some repeal of the waiver or modifying the waiver 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 the opposite direction including the state of pennsylvania which is kind of pinballed can you describe that so the state of pennsylvania despite everything we thought you know was 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're already x-waivered like myself uh you have to pay five hundred dollars 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 vote of 41 to 9 and is now in the house but the x-waiver and training requirement and extra fees are the only things holding buprenorphine back from widespread use 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 lloyd a physician in tennessee who specializes in addiction in last week's episode we heard how lloyd himself was for years addicted to prescription pain killers 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 you know i felt like an 80 year old man and i was in my early 30s lloyd 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 i'm a big believer in medication-assisted treatment and we know that the most effective thing 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 even nationally can you just describe where that pushback and that reluctance is coming from well unfortunately steven that 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 people work in the field have 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 lloyd 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 even less that said one stanford study compared addicts who quit with the help of aa versus those who quit on their own and found that aa nearly doubled the success rate steven lloyd's argument is that abstinence is the chosen half for the recovery community but that medical professionals embrace mat medication assisted treatment you've got the world health organization you've got nida that is the national institute on drug abuse 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 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 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 you know 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 i 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 mt does i can't stand it i read somewhere recently that several years back purdue pharma tried to acquire the marketing rights of 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 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 well i don't know how much more i need to break it down you just did you know that's the classic biopsychosocial 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 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 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 are you raised in do you have a high aces score adverse childhood experiences where you're 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 except it's 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 you and many others call addiction generally a disease and it sounds like the 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 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 they don't exercise correctly and so we treat that widely with medication to try to decrease the bad outcomes with diabetes so you know i look at addiction as being much the same if you know about addiction addiction is a brain disease the old enough real again from yell 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 use parts of my brain my mental 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 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 can you talk for a minute about federal policy toward medication assisted treatment and perhaps buprenorphine specifically uh from what i've read the policy recommendations during the trump administration have been evolving very rapidly if you look at you know president trump's first appointment to the head of department 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 hhs right now they're 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 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 of the united states to me those are much more reflective of effective treatment than whether or not somebody's totally abstinent from all drugs because some 12-step group says they have to be stephen lloyd's philosophy as well as that of gail donofrio and gene marie perone 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 extensionists people 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 harm reductionists seems to be even wider why is that what's different about opioids it's always been stigmatized i don't know why 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 after the break how that help happens when it happens and we talked to two addicts in recovery one of whom now works at the university pennsylvania hospital helping other addicts break the grip you're listening to freaking out radio i'm steven dupner we'll be right back 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 jean marie perone a medical researcher and er doctor at the university 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 er this treatment includes what they call a warm handoff so a warm handoff is a newish term is 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 our peer counselors are people who are in recovery themselves and who can start the dialogue right there about you know 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 first-hand experience as opioid addicts i think they're some of the most um 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 in helping other people they're special people like nicole people like nicole absolutely i'm nicole donald i'm a certified recovery specialist in emergency rooms at penn so nicole um what's your story how'd you get to be in this position so from using to here i 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 inpatient 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 per 30s and opiates that were you know someone's prescription that we got and then they are very expensive so it was easier to get heroin and then what happened how'd you finally get clean 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 about it 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 know you're just really trying not to be sick and barely functioning you had a sister yes yes one yes three years younger than me jessica yeah and i understand she died of an overdose she did in it was december 14th of 14 okay and what were her drugs or drugs heroin and what was your relationship like with her then we used together um 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 that 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 my name is 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 congratulations what's his name 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 pen er after overdosing 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 yeah you overdosed on what on uh heroin and fentanyl nicole helped i mean get on suboxone i'm still doing the suboxone you know i take it every day the suboxone helped 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 what's that feel like pretty awesome pretty amazing 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 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 but do you think that nicole without the suboxone would do it no 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 you know i wouldn't keep taking it but 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 so the suboxone helps you get back to the level that nicole can work exactly yeah yeah in my belief yeah 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 all be used so from my perspective aside from you know the x-weavering and the medical barriers that the doctor's experience from our experience too is there's 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 how come it's just this thing you know it's this deep-seated thing you know the 12-step programs there's a lot of tradition and stuff like that and there's not a lot of change but i'm not gonna like i love the 12 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 up in meetings and there's different 12-step programs obviously and one of them specifically states that mat is not considered clean i mean right before we started recording you told us that a friend of yours just died just now yeah i don't know how much you want to say about those circumstances um the friend you knew for how long and how they die um 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 a year and he you know this is 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 you know i was with him yesterday and we were talking and joking about the fishing trip that we're going on next week and you know uh his mom was just talking to him on facebook about how proud she was of him it's just it's a horrible disease you know it was heroin yeah 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 is another idea currently under consideration in philadelphia we're all harm reductionists here nicole o'donnell again the certified recovery specialist so we advocate for you know safe injection practices the needle exchange but there's this safe house 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 safe house non-profit 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 safe house but there will be more legal action before any such facility can open my point of advocacy for safe house is for people like your friends that just passed because he's in recovery right if i use i want to die fortunately through my years of you know this advocacy i have a person i have a safe health 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 the opposite of addiction is not recovery the opposite addiction is community and relationship you can't have community if you're dead dr steven lloyd again 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 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 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 worn 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 in an average day we could see up to six people i mean whether they're inpatient for a medical reason inpatient in our our inpatient drug and alcohol treatment or they're through the emergency room and of those six how many are willing to at least have a conversation with you about medication assisted therapy honestly there's not many that say they don't want to talk whether they want things or not it's 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 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 that opiate disorder is treatable it's not a death sentence it's not you know it's a medical condition and it's treatable 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 because we like to over complicate things and it really doesn't need to be over complicated 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 over complicate it coming up next time on free can i'm radio san francisco going to the super bowl with a big win tonight over green bay the san francisco 49ers were one of the best teams in nfl history five super bowl championships but lately they've been terrible and also surrounded by controversy and chaos so the team ownership opted for total reset new coach new general manager new players new mindset we chronicled this reset just before the 2018 nfl season in an episode called how to stop being a loser well the 49ers have stopped and now they've got a shot at winning their sixth super ball brings back a lot of great memories for sure this is a great night for the 49ers how did that happen we will find out next week on free economics radio free economics radio is produced by stitcher and dubner productions this episode was produced by zach lipinski with help from miles brine our staff also includes allison craiglow greg riffin matt hickey daphne chen harry huggins and corin wallace our theme song is mr fortune by the hitchhikers all the other music was composed by louis guerra you can get free economics radio on any podcast app if you want the entire back catalog use the stitcher app or go to free economics.com 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