Opioid Myths Busted

Shut down detox centers. Get people bed rest. And methadone.

Those might not sound like the most popular ideas for dealing with the growing opioid crisis.

Two experts who have studied the crisis in depth, as part of seeking solutions, argue that those ideas will work better than what society is doing now.

They also argue that focusing on evil pharmaceutical companies — suing Big Pharma, for instance, as New Haven is doing — misses the point, overlooks the systemic reasons the vast majority of people are turning to heroin and fentanyl and dropping to the ground daily.

Yale public health Professors Lauretta Grau and Robert Heimer made those arguments during an appearance on WNHH FM’s ​“Dateline New Haven” program.

They spoke as well about how important it is to tackle the opioid crisis, how fast it’s growing. In 2012 Connecticut was seeing about 200 to 300 opioid-related deaths a year, according to Grau. That number jumped to 848 in 2016. She predicted Connecticut will see 1,100 or more in 2018.

The New Haven Fire Department dispatched its paramedics to 547 overdoses last year, about three-fifths of which are presumed to be for heroin, according to Rick Fontana, the city’s emergency services chief. (Click here for a recent story following them on calls.)

Grau and Heimer have spent decades immersed in public health research aimed at tackling tough social challenges. For instance, Heimer led a team that studied an experimental needle-exchange program in New Haven 38 years ago. His results — that it saved lives — convinced New York and other cities across the country to adopt what had then been a taboo idea.

In research on opioids, Grau reported, they’ve discovered that hardly anyone who dies from an overdose developed a heroin or oxycontin addiction because a doctor first prescribed him or her the drug for pain relief. The popular version of the crisis makes that the dominant narrative, and therefore it drives policy. The roots of the crisis are systemic and complex, Grau said.

Following is a transcript of excerpts (with some editing of questions for clarity) from the ​“Dateline” interview about how the pair believe the crisis should be viewed and how to tackle it.

Why We Go Wrong

Heimer: We have a systems problem. The best treatment is bed rest. Most people who have chronic pain are in jobs where they can’t afford to take three months. They’ll lose their jobs, they’ll lose their insurance, so that option is out.

The next option is to go to physical therapy three times a week for six months. Well, most insurance plans don’t cover that, and it’s very very expensive.

WNHH: So we prescribe drugs instead because it’s easier? 

Heimer: Yeah, I can write you a refillable 30-day scrip for an opioid now, and the patient goes home happy. and the doctor feels like he’s done something.

Grau: It’s so easy to see things as black and white or to blame this group or that group when actually this was a multi-factorial problem.

The popular story I always hear is that doctors, the sleazy companies pay off the doctor, the doctor makes tons of money by overmedicating people, and [patients are] all getting opioids and then going over to heroin. 

Heimer: There certainly were doctors who set up pill mills specifically for that, but they were less than 1 percent of doctors. And when the DEA went after those people and shut down that supply, that’s when people turned to heroin and eventually fentanyl.

That’s why we see the increases in drug deaths in this state. People have been pushed off of pharmaceutical opiates, where they got a dose of a drug where they knew what it was, every time they took it. Instead, they were going out on the street and buying a bag of dope and experimenting on themselves every time…

We’ve known even before this that the supply-side war on drugs is a failure. You’re never going to get rid of the narco-traffickers so long as you have a black market to feed an economic incentive to have that market. When you take a bunch of people who are addicted to these opioids — the pharmaceutical opioids — and withdraw the pharmaceutical opioids without treatment — effective treatment, proper treatment, evidence-based treatment — then all of a sudden they turn to narco-traffickers, creating new markets for heroin throughout the country.

So should we legalize heroin and fentanyl then and regulate it?

Heimer: No. No. The funny thing is that even though we have controlled the flow of pharmaceutical opioids, and the number in circulation has been decreasing since 2010, the number of drug deaths is going up. So no.

What we need to do is provide better prevention of drug use among adolescents, and provide treatment for people who have developed opioid abuse disorders. We know what effective evidence-based treatment is. This state has done both some good things in this regard, at the level of the methadone providers, who have expanded their services and have gotten rid of waiting lists. So you can walk into one of these clinics in New Haven or Bridgeport and be in proper medical care within 90 minutes.

Grau: This is not to be blamed on one group or another. This was a process with the [recognition of pain as] fifth vital sign, then the pharmaceuticals kind of doing more marketing of the opioids. We’re now starting to get the results of that, and saying ​‘Oh My God, this is a problem,’ and cutting back. I think it’s much more difficult for you today to go and get a [prescription for opioids].

And isn’t that mostly good? I know an addict who really needed pain medication for a physical injury and couldn’t get it from the doctor. We were kind of glad.

Heimer: The funny thing is that we know for acute, post-surgery trauma pain gets in the way of healing. As someone who has had two knee replacements and really appreciates what the opiates did so that I could rehabilitate my knees, I understand the importance of treating acute pain with opioids. You’re not treating the underlying problem; you’re masking the pain so that you can recover. But once you’ve reached the point of opioid use disorder, you don’t recover from that, and you need a different approach.

So it sounds like what you’re saying is that instead of holding back on prescribing opioid pain medication, you have to intelligently manage pain and have some regulation of it instead of black market.

Heimer: Bingo.

Just Say No To Just Say No

I wanted to ask you about the role of rehab. You’ve said what has the biggest impact on opioid addiction is treatment as opposed to residential rehab. Is that correct? Because there’s a big push on residential rehab and in-patient programs right now.

Heimer: Let’s start with the intake process. if the primary intake process is detox. Detox is an unethical mess, plain and simple. To put someone into a detox program that lowers their tolerance without treating their long-term chronic disease — opioid use disorder — and releasing them, whether to the street or some other abstinence-based program, without dealing with their craving and their desire to start using again … [that] results in overdose deaths. More than if they were still using.

Because their tolerance goes down. But they go back out on the street and they use drugs like they used before, or they’re using alcohol, and the combination of alcohol and opiates is doubly dangerous,

You don’t need to do the detox. You need to start people on medication based treatment on suboxone, buprenorphine is the effective ingredient, or methadone. It turns out that in head-to-head comparisons, methadone is the more effective treatment.

So you’re against detox?

Heimer: I think detox is unethical. I would shut down detox programs, because — for opioids — they put people at greater risk. If your Hippocratic Oath says do no harm, you’re doing harm by putting people at risk.

This is so interesting, because the gut reaction says, ​‘Give them a chance to get off drugs and feel what it’s like so they can feel that and say, ​“I want to be like this and drug-free.”

Heimer: You don’t feel that relief. What you feel first of all is, it’s called cold turkey. You sweat, you get goosebumps, you’re miserable for a long time.

Aren’t people going to say they don’t want to experience that again?

Heimer: Supposedly.

But you’re saying the data doesn’t show that at all?

Heimer: The failure rate for detox programs, even when you add 21 days subsequent abstinence-based in-patient treatment, the failure rate is about 90 percent. So a 10 percent success rate.

You put people in methadone, and the success rate can run anywhere from 50 percent in badly run programs to 80 percent in well-run programs. So let’s take the average, 65 percent or so.

I have two choices for you: Do you want a 10 percent successful treatment? Or do you want 65 percent successful treatment?

But because of the stigma around drug use, people are choosing the 10 percent success rate, which is just dead wrong. And I literally mean dead, because they’re dying of overdose.

Controlling The Message

Have you ever not revealed something you found out because you thought it would lead to a bad policy you didn’t agree with?

Heimer:I’m wrestling with that right now, not that I’m not going to reveal it.

I’ve discovered something that was very disconcerting in a study we finished just a couple years ago comparing HIV and drug users in two former Soviet countries, Russia and Estonia. Estonia has done all these things to try and control their epidemic among drug users. Russia has done everything wrong. And Estonia has done everything right. Yet there’s no difference in incidents in HIV among drug users in these countries.

So do you fear people will say: ​“No matter how you try to help, addicts are going to do what they’re going to do?”

Heimer: Someone will misuse the data.

The conclusion I would reach is that the scale of the program in Estonia is inadequate because we know from so many other places that these approaches work — only if they’re scaled up to a sufficient size.

Would another side say, ​“So let’s defund [treatment] efforts? It makes no difference — in Russia they didn’t care, addicts are going to be addicts”?

Heimer: Yes they would.

In Russia, they’ll say, ​“See, you do it in our culture, and it doesn’t work, so we don’t have to feel guilty that we haven’t implemented it. We don’t have to do it here. We can shut down the programs that actually have worked.

So what’re you going to do with this data given now that you’re wrestling with it? How are you wrestling with it, and what’s going to be the outcome of your wrestling? 

Heimer: I’m still going to have to present it, but I’m going to have to present it with the appropriate caveats. No policymaker is going to read my six-page long single-spaced double-column scientific article. They’re probably not going to even read the 250-word abstract.

Hillary might’ve read it … 

Heimer: But they’re going to read the title.

We’ve seen this happen before with needle exchanges. There was an outbreak among drug users in Vancouver, British Columbia, in the late 1990s. They had a needle exchange program. But it wasn’t big enough. And the title of their article was ​“Needle exchange is not enough.” People jumped on this to say needle exchanges didn’t work. I was so upset with the people who crafted that title when the title should’ve been: Needles exchange is necessary but not sufficient.”

Click on the above audio file or the Facebook Live video below for the full episode of WNHH FM’s ​“Dateline New Haven” with Robert Heimer and Lauretta Grau.

Click on the Facebook Live video for the full episode of WNHH FM’s ​“Dateline New Haven” with Robert Heimer and Lauretta Grau.