[This is Part 2 of an interview that began here. Adam Bisaga, MD, is an addiction psychiatrist, clinician, researcher, and professor of psychiatry at Columbia University. This week he published an important new book, co-written with health writer Karen Chernyaev: Overcoming Opioid Addiction: The Authoritative Medical Guide for Patients, Families, Doctors, and Therapists (The Experiment; paperback; 285 pp; $16.95).
In this portion of the interview, Bisaga discusses how his patients became addicted; the role of genetics; choosing a treatment medication; the issue of whether the anti-opioid pendulum has swung too far; Ibogaine; kratom; and stigma. In Part 1, he discusses why opioid addiction is unlike any other; why referring patients with opioid use disorder to most US treatment centers is now unethical; and needed changes in insurance and emergency room practices.]
How do most of your patients become addicted? Medically or recreationally?
Half and half maybe? I see a lot of young adults who’ve been using substances in high school and colleges and came across painkillers and developed opioid use disorder [OUD]. Then you have these people who have been put on painkillers for some medical problem—relatively nonsevere—and continued on those way beyond where the evidence shows they would be useful, and without any monitoring about the adverse effects, and they became addicted.
I certainly see a lot of people who come to treatment who give this history.
Now, they may come to treatment early on, like after one year of using painkillers, or they may already have been using three, four, five years, switched to heroin because it’s cheaper, and come to treatment when things really, really go bad.
So those are the two most common scenarios. And, of course, we see a lot of people who have been addicted for the last 20, 30 years, and have been in and out of treatment over the years. We see those people coming in in their 50s, 60s.
I interviewed someone recently who told me that medical patients were different from addicts. He considered addicts a different category, whether because of genetic predisposition or some sort of priming in adolescence, or some other mental illnesses. What do you think of that perspective?
Clearly there are patients who have some serious pain syndrome that respond well to painkillers. And they will take painkillers as prescribed. And they maintain on opioids for a long time, and they probably don’t have an opioid use disorder. So that’s one group.
Then you get a group of patients who have many problems. They might have gotten an injury, but also are depressed, may not have work, lost a job, have family problems, may have childhood trauma. They got put on painkillers. And they use the painkillers as a way of coping with all the other problems in life.
So they tend to take large doses over long periods of time. They’re not functioning very well, they still have complaints of pain, they don’t really move on with their lives, and they’re probably not all too pleased with how their lives are going.
There’s a lot of patients like that. I’ve read that maybe 10 million maintain chronically on opioids. A lot of those probably meet the definition for opioid use disorder but it’s not diagnosed. They are identified as chronic pain patients. But clearly chronic opioids don’t serve them well. They may live shorter. They are not functioning well. They do not recover from pain. Some probably would’ve recovered if they’d gotten a different treatment. So those patients are different.
And then you’ve got people who are at high risk of addiction. Who have a family history of addiction, who may or may not have all these additional problems, but the primary driver is they have a brain that is primed for addiction. Those are usually people who are impulsive, sensation seeking, low harm avoidance. So when those people get exposed to drugs, whether it’s cocaine or heroin, they are at very high risk of becoming addicted. Yeah, they are different. They probably have a different brain.
Is that genetic?
Yeah. There’s strong evidence, from twin studies, that at least 50 if not 70 percent of it is genetic. Your risk. Your predisposition. It doesn’t mean everybody with both parents who are addicts will get addicted, but definitely this person is at much higher risk than someone from different parents and lives with this same family. Even if they share the same environment, the genetics is the dominant force.
So those are different patients.
But it doesn’t really matter. I think that the treatment and the understanding will still be the same. So I’m not sure how useful it will be—this separating “medical” from “addicts.” Except that I sense here that it’s stigmatizing people who are addicted. And I get a sense that they are somewhat seen like they are in some way responsible for developing the disorder. That they made choices, that they are pursuing pleasures, that they aren’t working as hard as other people, that they are somehow responsible for what happened to them. As opposed to people who got put on painkillers by their doctors and they have no responsibility. I don’t really see the distinction being useful.
How common is it that somebody could treat pain with, say, 60 mg of OxyContin a day for three years, and not have to escalate dose, and be functioning well?
Quite common. It’s not like everyone will lose control. Same with other controlled substances. Like with Xanax, or Adderall. A lot of people can benefit, can be maintained on medication for a long time, without escalating, without impairment, without preoccupation. Which all the hallmarks of addiction.
And I think it’s the same with painkillers. Now the assumption is that it will be easy for the doctor to tell apart the people who are doing well and the people who are not doing well. And that’s an assumption that got us into trouble with the epidemic. First of all, that’s not so easy to tell even for experts, and certainly not for people who don’t have training, like primary care providers. And, secondly, there was no standard treatment [when addiction did occur]. How do you actually help patients out of this situation? There wasn’t really an established strategy for that.
Many chronic pain patients today say they fear that they’re going to be cut off their opioid medication due to excessive societal fear of opioids right now. They feel the pendulum has swung too far the other way.
That’s probably true. The pendulum metaphor, I think, is very apt. And probably in order to have some kind of balance there will be, right now, a little more restrictions in prescribing and, hopefully, we can reestablish some kind of balance.
Clearly, 15 to 20 years ago there wasn’t a well-balanced approach of administering painkillers to a large group of patients, and a large group of people got hurt with it. But this is not to say we should not have medications available for treating severe intractable pain.
When recommending a treatment medication, how do you choose between methadone, buprenorphine, and naltrexone?
You want to decide it in discussion with the patient and maybe the patient’s family. Those are three effective, but very different treatments.
You give them accurate evidence-based information, assuage their fears, address the myths, and then they can make a good decision.
Of course, the reality is often patients don’t have this choice. They go to a program and the program only offers one medication—if they’re lucky. Very, very few programs offer all three medications. Even though the current law [the Controlled Substances Act] states that the provider prescribing medication for opioid addiction should be offering directly, or by referral, all three FDA-approved medications.
Because of this gap in knowledge and practice, a big part of my book is about the medications. I try to really explain the difference between various treatment options. But is it complicated. You do need to spend some time on discussing it. I hope that not only patients and their families but also medical and other treatment providers will benefit from the book.
Some patients want to immediately feel better today, so they want to start on buprenorphine today. Some may feel: “I don’t want to be on any opioids. I want to be detoxed, and want a non-opiate medication to help me prevent relapse.” So naltrexone, a non-opiate, is for them.
Banking family heir Matt Mellon recently died while awaiting treatment in Mexico at a facility that uses a plant substance called ibogaine. Some people use another plant, kratom, to help with opioid withdrawal. What do you think of these?
That’s a longer discussion. The context is that people with addiction have a propensity for magic thinking. They believe there is some magic solution that will take away their problems. And because of that, they are easy targets or victims of unscrupulous prescribers. Snake oil salesmen. Ibogaine may be one of them.
Ibogaine is a story going back to 1960s, but was very popular in the 1980s. There are certainly reports of it’s being helpful, but it can also be toxic. There are reports of people dying in treatment. There’s no way to actually know what you’re getting into because there is no oversight. There was a medication derived from ibogaine that has been in development for a while, but I have not seen well-done clinical treatment trials, and it is not an approved medicine.
Kratom is a plant material that does have an opiate effect. And we know that opiate-like agents are helpful to relieve craving and withdrawal, so it’s not surprising kratom would help with withdrawal. But we also know that if it’s used without medical supervision, it can become problematic on its own. You can become physically dependent on, or even addicted to, kratom.
What we want is to give people access to well researched, well documented, highly safe, highly regulated treatments that are FDA approved.
The last thing I’ll say is that the medications provided by the FDA are still not magic pills. Some people will not respond to them, some will have side-effects or misuse them. But at least we know the chances are good, and if you maybe don’t respond to one medication, we suggest that you try the other one, or, finally, the third one.
I’m all for researching new treatments. But I think we have some highly effective treatments that we don’t use enough. And I think we should focus on that.
You’ve devoted your life to treating addiction. But a lot of physicians don’t seem to want to get involved with these patients. Isn’t that a problem, too?
There’s such a reluctance of providers to treat these patients. In France, there was an opioid epidemic in the 1990s. The government said all physicians should offer buprenorphine to all patients interested. And they had 25 percent of physicians offering this treatment to patients.
In the US, we have about 3 percent of physicians offering buprenorphine. Why is there such a difference?
I would imagine addiction is much more stigmatized in the US. It’s seen more as a nonmedical kind of problem, as a social problem, criminal behavior, a moral problem than it is in western Europe.
In your book you write that, because of the nature of the illness, some addicts are apt to lie and steal. There must be a lot of doctors who just don’t want such patients in their waiting rooms.
But a lot of these fears are not based on reality. Yes, there are patients who are difficult and lying and stealing and they are not pleasant to work with. There are people like that with other medical problems. We tend to think all addicts are like that, but it’s not accurate. This is an idea of addiction perpetuated in popular culture, and maybe perpetuated in medical education. My experience is that physicians who are able to overcome this and open their practices to those patients actually were blown away by how different the reality is from what they expected. It’s almost funny that they say, “This patient is very pleasant and nice. We didn’t expect it.” Like you don’t expect that they’d also be human. And that’s unfortunate, this generalization of others.
But if physicians are willing to open up I think many of them will have a very good experience, will be very glad. You can have a huge impact on people’s lives. Exactly because you are the doctor that gives this patient a different experience than he has received from the rest of the medical care, where they are hated, shunned, rejected.
[For Part 1 of this interview, click here.]