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21: Opioids, Treatment and Hope

Oct 15, 2019

Opioid overdose kills 70,000 Americans every year. Most of those deaths are accidental. Dr. Jeremy Thueson explains the problem of opioid misuse disorder, why most people don’t get treatment, and how you can get treatment for yourself and the people in your life.

Episode Transcript

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Jeremy's Turning Point: Being Defined as Overweight

Dr. Jeremy Thueson is the director of outpatient recovery services at University Neuropsychiatric Institute (UNI) and he cares about his health. Jeremy had his wake-up call during his medical residency. With the long hours, poor eating habits, and stress of residency, he started putting on weight. He hit a lifetime high and his BMI qualified as overweight.

Jeremy fit the medical definition of overweight, and he was over it.

"It's easy to try and be drastic and overhaul everything," says Jeremy, explaining that a lot of guys will immediately go get a gym membership and throw all the food in their cupboard away after they decide to get back in shape. But those changes aren't sustainable for most people.

To lose the weight, Jeremy tried "staying more aware" and started making small manageable changes in his lifestyle. He got a pedometer started walking more in his daily routine. He downloaded a calorie tracking app and actively reached for a piece of fruit rather than his typical bag of chips. Rather than trying to hit the gym hard for an hour a day, he fit in more manageable 15 minute exercise breaks when there was free time in his busy schedule.

Over the next six months to a year, those changes added up, and Jeremy's weight is back under control. He admits that his diligence waxes and wanes through the year. Specifically, he has difficulty exercising during the winter - he hates the cold and doesn't like to go to the gym - but it's something he's mindful of and "course corrects" where he can.

The Big Picture Problem of Opioids

Opioid addiction, or opioid use-disorder, affects the lives of many Americans. And the overdose deaths related to those drugs are an epidemic. In 2017, a little over 70,000 people died in the U.S. of drug overdose. In the state of Utah, 450 people die every year from opioid overdose. That's one to two Utahns dying every single day.

While those numbers may seem staggering already, Dr. Jeremy Thueson believes that the numbers are actually underreported.

Opioid overdose impacts more than just the people struggling with addiction. Troy's emergency department has recently completed a pilot study investigating the community impact of overdose deaths. The initial study asked 200 patients in the ER if they had a family member die of opioid overdose. One-third of patients responded that they had lost someone to opioid overdose death.

These deaths are often accidental or unintentional. Many people with opioid use disorder are completely unaware how close to an overdose they are. Some use high amounts of the drug to feel normal and other will accidentally mix their meds with other substances like alcohol unintentionally.

These deaths are mostly preventable, through education on the disorder, proper treatment, and overcoming the social stigma related to addiction.

How Do People Become Addicted to Opioids?

It's important to remember that there is no specific "type" of person that becomes addicted to opioids. Opioid addiction crosses all demographics and sectors of society. Many people struggling with opioids are high functioning. They work in the business sector. They're physicians. They're parents.

Opioid addiction, or opioid use disorder, usually begins with a patient being prescribed the drug through legitimate means. Whether it be surgery, wisdom teeth removal, etc. the patient is first exposed to opioids for acute pain management. Then slowly increased use creeps up over time. It can be years of slightly increased use before people realize they're addicted.

Many People Use to Prevent Withdrawal, Not to Get High

In the ER, Troy has first hand experience with opioid use disorder. One individual shared his experience with Tror and a group of physicians. This man explained that he was no longer using opioids to get high, but to avoid getting sick from withdrawal symptoms. For this man, the opioid withdrawal is so horrible, he would do anything to go through it. So he continued using the drug.

Whatever upside people experience using opioids ultimately has diminishing returns over time. Very early in the timeline of opioid misuse, addiction and physical dependence will take hold of the user. For these individuals, they can suffer severe withdrawal symptoms if they don't get their opioids.

"It's a horrifically stressful way to live," says Dr. Thueson, "it's very taxing on your body and mind. It's hell. People are not enjoying that for very long."

To compound the problem, there is a tendency in medicine to minimize the experience of opioid withdrawal within the medical community. Most physicians are taught that opioid withdrawal is not considered "medically dangerous." While the mortality risk of opioid withdrawal is lower than other substances like alcohol, the experience is every bit as awful for opioid users. According to Dr. Thueson, it's not uncommon for people to become suicidal while experiencing the pain of withdrawal.

There is a lot of shame, guilt, frustration navigating the system to get help with recovery. And for most of these people dealing with opioid addiction the fear of withdrawal is what keeps them in the cycle of substance abuse.

There Are Many Barriers for Treatment

Many people who find themselves reliant on opioids have an element of denial about their situation. There is a very real fear of speaking up about their problem and how it may impact their personal and professional life. There isn't a lot of socially acceptable ways to speak about having opioid addiction without facing judgement.

There is still a social stigma today about opioid misuse. It can often be framed as a moral weakness or character flaw in the person suffering.

"There's more debate about [opioid addiction] than I'd like to see," says Dr. Thueson, "The best evidence we have now is to conceptualize this as a medical problem that needs treatment, like anything else. And not something else we need to be shaming people for ending up in that situation. I have not yet seen a patient who set out to get addicted to opioids."

The Best Opioid Addiction Treatments Available

The standard of care for opioid use disorder in 2019 is medication. There are three FDA approved medications available that have proven effective:

Methadone - A medication that has been used for 40 years in the U.S. to treat substance abuse. It's proven effective at helping treat withdrawal and minimizing cravings for opioids.

There are a few drawbacks to methadone. First, the treatment itself can prove cumbersome. Each dose of the medication is given in a clinic or office every day of treatment, which can be difficult. Those clinics must be officially licensed by the federal government to provide methadone. Additionally, there are many challenges and risks with the use of methadone.

Buprenorphine - Often known by the brand name Subutex, this medication treats opioid withdrawal and cravings through a prescription drug that can be taken at home. For a majority of patients, it has been proven the best balance of risk and ease of use. While the drug doesn't need to be dosed in an office and clinic, it can only be prescribed by a licensed physician.

Naltrexone - Unlike the other two medications, naltrexone is an opioid receptor blocker. The medication helps minimize cravings by preventing the body's reaction to opioids. Without the positive effects of taking the drug, patients are less likely to use it.

The drug can be administered through an oral medication or a once a month injection.

In addition to medication, behavioral therapy can help patients get off opioids. These mental health treatments can include individual and group psychotherapy, mutual support groups, and formal recovery programs.

Medications in concert with behavioral therapy is the frontline treatment against opioid addiction.

How a Person Can Get Help

Once a person has decided to seek treatment for their dependence on opioids, there can be many barriers between them and the proper treatment and resources. Treatment can be a non-starter for a majority of people without insurance or financial means.

In Utah, the University of Utah has created a program to help people struggling with opioid addiction. The BRIDGE program is run through the emergency department. If a patient is experiencing opioid dependency or suffering from withdrawal symptoms, they can go to the ER and receive immediate treatment. Patients are given an initial buprenorphine dose as well as a prescription for the initial month of medication. After receiving the medication they need, they're referred to an outpatient clinic that can continue treatment by developing a custom tailored long term care program

There is no cost to the patient. The program is state funded by a grant that aims to fight the opioid epidemic in Utah. The goal is to get the patient's addiction stabilized and their head clear so they can focus on the other struggles in their life.

For people not in Utah, there are similar programs available in other states. Patients should speak with their primary care physician or go to a clinic to get professional help and find out what resources are available for treatment.

Remember, doctors are required to have a federal waiver to prescribe substance abuse medications. It's important to find out what doctors, centers, and facilities are permitted to help treat opioid addiction

Use the SAMHSA online database to find a provider near you that can prescribe these drugs.

For a lot of people in withdrawal or actively using, navigating the already complicated system can be impossible. Programs like BRIDGE and certified physicians can help individuals get the help they need.

"Until we make this as easy as staying on heroin, we're making this tough on people," says Dr. Thueson. He urges fellow physicians to step up and get certified to give the federal waiver. "We need to step up and stay aggressive so we can help treat [opioid addiction]"

Just Going to Leave This Here

On this episode's Just Going to Leave This Here, Troy wonders how the new marijuana breathalyzer is going to be used the cops and Scot is finding a new appreciation for bodyweight exercises as he tries to fit exercise into his busy schedule.

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