With 78 opioid overdoses per day in the United States, experts say opioid addiction constitutes a public health emergency. Developing the best plan of action requires an understanding of the science behind opioid addiction, which was the topic of a panel discussion at HUBweek on Tuesday in Cambridge, Mass.
Speaking were Monica Bharel, Massachusetts Department of Public Health commissioner; Sarah Wakeman, medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital; Scott Lukas, director of the Behavioral Psychopharmacology Research Laboratory at McLean Hospital in Belmont; and Seth Mnookin, codirector of MIT’s graduate program in science writing and a former opioid user. STAT senior enterprise reporter David Armstrong led the panel.
Here’s an edited version of the discussion.
What is it about opioids, compared to other drugs, that make them so desirable?
Lukas: Opioids mimic endorphins in the brain, and heroin crosses the blood brain barrier almost instantly. It not only can makes people feel “high,” but it also acts on the spinal cord, the brain, and receptors that affect physical pain and the perception of it. But it also affects receptors in the brain that sense carbon dioxide; that’s the basis of stopping breathing with an opioid overdose.
Wakeman: Dopamine tells your brain to pay attention to something, and to want to continue to do something. It’s released by activities like food and sex — things we need to survive. But heroin releases much more dopamine in the brain than these natural triggers. For someone who has developed opioid addiction, who is craving the feelings that opioids cause, everyday things don’t release as much dopamine in comparison, and so you don’t pay attention to other things as much — you ignore things that someone without heroin addiction would find hard to understand not caring about.
With continued use of opioids, you need to use just to avoid being sick. You shift from needing to use the substance to feel good to needing it just to feel normal. People who are addicted to opioids are literally trying to survive and trying to function. Not having opioids won’t kill you, but it’ll make you feel like you’re going to die.
Mnookin: The first time I used heroin was at 10 a.m. on a Sunday morning. I had already been in and out of rehab for other drugs, and with heroin, I went pretty quickly from using in the morning to feel good to trying to figure out what amount would keep me from throwing up on my way to work.
The physical need when you are suffering an active addiction is not like anything else I can describe. Another thing that I just want to mention is that your body transitions from an opioid being a substance that causes these desirable effects to it being a substance your body feels like it needs. What eventually happens is you’re using heroin just trying to feel like you’re not drowning.
How do medications work to treat addiction?
Lukas: People sometimes say, ‘Oh, you’re just trading one addiction for another.” Hogwash! Data have shown that when people are on these meds, emergency room visits and rates of HIV transmission go down. Buprenorphine takes the place of the heroin and eliminates drug-seeking behavior, and you do not have to go to a methadone clinic every day to get your medication. For years, I walked through that line of patients waiting to get methadone on the way to my office. That’s not the way we should be treating our patients.
Naloxone is the plastic covering that goes over the electrical outlet. It binds to the opioid receptor, keeping the heroin or morphine from getting to that receptor. You would not give an antagonist like this to someone who’s actively using; it would throw them into withdrawal. Suboxone is buprenorphine with naloxone, so they don’t crush the buprenorphine and inject to get high. Clinicians can now treat up to 275 patients with suboxone in the privacy of their own office.
Let’s talk about how the introduction to these substances, in many cases, is a legal one.
Bharel: To understand how we got to where we are, we need to take a step back 10, 15, 20 years. We need to talk about how we as a society think about calming our inner responses, starting with children. Today, we want quick responses to everything. Within the last couple of decades these very powerful opiates have been introduced, and they are incredible pain relievers.
But opioids have become something that could be used not only for acute pain or cancer pain, but for other types of pain as well. They started to be used more for a societal expectation for quick pain relief. We need to balance the need for pain relief with the potential for substance misuse.
I’d like to turn now to treatment. One of the things we’ve learned is that treatment can be very difficult. The rates of success with various treatment approaches range widely.
Wakeman: We have decades of evidence about substance use treatment. Yet current treatment strategies are more driven by dogma than by evidence. Just like diabetes, [substance use disorder] is a chronic illness, and cure is not the goal. However, you can be in long-term remission, and you can prevent long-term relapse. And we need to work to keep patients addicted to opioids safe while we get their disease under control.
A study last year looking at MassHealth patients that compared those on medication treatments with those on abstinence-based treatments found a 50 percent reduction in relapse in those receiving treatment with medication. Just like in HIV, along with efforts along the lines of social justice and lifestyle changes, medications are important in tackling the opioid epidemic.
A previous version of this story incorrectly edited one of Wakeman’s comments. The story has been updated.