How did prescription opioids become a gateway to heroin and fentanyl? When did opioids become the gold standard for pain management, and why did regulation take so long? Chief Medical Officer, Alta DeRoo, joins host William C. Moyers to discuss the opioid epidemic in its entirety, including its origins and escalation, the latest treatment solutions and community responses, and more.
0:00:13 William Moyers
Once upon a time in America, alcohol and alcoholism seemed the primary worry in society. For a while cocaine grabbed the headlines. Crack cocaine too. And crystal meth, marijuana, and LSD have generated plenty of attention. But in recent years, opioids have dominated the headlines and with good reason. More people than ever before have died of accidental overdoses, most caused by opiates. Hello everyone and welcome to another edition of Hazelden Betty Ford's podcast series Let's Talk. I'm your host, William C. Moyers, and joining me today, the Chief Medical Officer of Hazelden Betty Ford, Dr. Alta DeRoo. Welcome, Dr. DeRoo.
0:00:55 Dr. Alta DeRoo
0:00:56 William Moyers
Tell us opioids. What impact have they had in addiction in America?
0:01:02 Dr. Alta DeRoo
So traditionally when we think of opioids and somebody coming in for treatment for a substance use disorder, we think heroin, morphine. And so their treatment can be very predictable. With Buprenorphine, Naloxone, that is one of our go-to medications. But now, opioid treatment is going towards Fentanyl. And it's insidious. We don't know where it is, we don't know where it's gonna appear, who might be using it. They know that they're using something but they're not sure if Fentanyl is in their substance that they're using. So, that makes it challenging for us when we wanna use a tool or a medicine like Buprenorphine/Naloxone because Fentanyl leaves the body slower—
0:01:39 William Moyers
0:01:40 Dr. Alta DeRoo
—Than other opioids. And so the treatment of it is tricky. It's a little unpredictable. So we've had to alter our treatment of how we would treat somebody with withdrawal and Fentanyl.
0:01:51 William Moyers
But let's talk about opioids in general in terms of the Twelve Step, abstinence-based approach that has been our cornerstone since we began in 1949. Can we treat or can you treat opioid dependency with a Twelve Step abstinence-based model?
0:02:10 Dr. Alta DeRoo
Absolutely! You can treat it with an abstinence model. There are some folks that are very successful with not using any type of medications for opioid use disorder, without using any MOUDs. And may just engage in Twelve Step facilitation, AA meetings, that type of thing. That can be done with the counseling support and coping skills. However, the cravings creep in and people may want to curb those cravings with a medication. There was a really nice study that was done that showed that those who don't use any type of medications for withdrawal after about a year about only 25 percent will still be abstinent.
0:02:52 William Moyers
0:02:53 Dr. Alta DeRoo
So, we like to couple the Twelve Steps—
0:02:55 William Moyers
0:02:55 Dr. Alta DeRoo
—With the recovery part, with the counseling, and the coping skills. That's important. But then, on the medicine side, we like to help that person in recovery with curbing those cravings.
0:03:07 William Moyers
When it comes to cravings for opioids, how is that different than cravings for alcohol or other drugs?
0:03:15 Dr. Alta DeRoo
So the cravings can be the same. It's a desire to want to use it, you know. But we just have a very effective tool for those cravings with Buprenorphine/Naloxone.
0:03:23 William Moyers
0:03:23 Dr. Alta DeRoo
But the cravings, they're the same type of cravings, meaning wanting to use that drug. Or wanting to use that substance. When a person has coped all the time with that substance, that's gonna be the go-to thing. So it's curbing that desire to wanna revert back to those habits.
0:03:42 William Moyers
Mmm-hmm. Mmm-hmm. How did opioids get to be so prevalent in society?
0:03:50 Dr. Alta DeRoo
Yeah. So, boy that is a great question. So, going back to the early 90s, there was the fifth vital sign. The fifth vital sign was the everybody had to treat pain. You had to treat pain and it was enforced by a Joint Commission back then. And doctors, like myself at the time who were doing large open surgery cases, open abdominal cases, were taught this drug, this medicine, is not addictive. So please feel free to give your patients as much as they need. And young doctors like I was—
0:04:24 William Moyers
0:04:23 Dr. Alta DeRoo
—Back in, you know, when this was happening, we didn't want our patients to suffer. And we wanted them to be treated with opioids. And we wanted to stay compliant with what the Joint Commission expected of us. We found out later that these opioids were addictive and everybody has probably seen it within the tabloids and within media that they were addictive. So what you saw after 2010 was this rapid increase in opioid overdoses because now people had become dependent on those opioids from doctors, people getting prescriptions, were now turning to the streets. And they were getting synthetic opioids. And those synthetic opioids is your Fentanyl.
0:05:08 William Moyers
0:05:09 Dr. Alta DeRoo
Or heroin. So, even though somebody may be getting a prescription for Oxycodone or Oxycontin, when that was not available to them anymore, they would go into withdrawal. Or maybe even seeking pain and then that's when they would turn to things like heroin, which was out on the street, and then more recently, Fentanyl.
0:05:23 William Moyers
0:05:24 Dr. Alta DeRoo
So that's what contributed to the dramatic rise.
0:05:27 William Moyers
Because in the "old days," before the 90s, people who were dependent on opioids were typically dependent on heroin. And that came, that dependency came generally in the inner cities, right?
0:05:40 Dr. Alta DeRoo
0:05:41 William Moyers
There was an association with that. The opioid epidemic really was driven by doctors legitimately prescribing pain meds.
0:05:49 Dr. Alta DeRoo
Right. Yeah. [nods]
0:05:50 William Moyers
That's ironic. Why don't doctors know more about that? [grins]
0:05:53 Dr. Alta DeRoo
Oh they do! They know much more about it. And there are actually—there's oversight now as to how many opioids doctors can prescribe. There's databases, we get reports on how many opioids that we prescribe. And so doctor prescribing patterns are kept in check now.
0:06:09 William Moyers
Okay. But medical schools were not doing a very good job for a long time in educating docs around addiction in general and specifically pain meds, right?
0:06:17 Dr. Alta DeRoo
Yeah. We're getting better. We're getting better—
0:06:18 William Moyers
Yes. Yes. Yeah.
0:06:19 Dr. Alta DeRoo
—And I, you know, it's the idea of opioid use disorder or a substance use disorder is within medicine, but we've learned it after medical school. What we're trying to do also within Hazelden Betty Ford Foundation is reach into those medical schools and invite those students into our campuses. Where they learn all about treatment including Twelve Steps, counseling, and then they also meet with our physicians and have academic sessions with our physicians where they learn about the treatment of addiction. Because there's a board certification in Addiction Medicine that is open to them.
0:06:53 William Moyers
Mmm-hmm. [nods] Mmm-hmm. Before you got your certification in Addiction Medicine, you were an OB/GYN.
0:07:00 Dr. Alta DeRoo
0:07:00 William Moyers
And you've delivered thousands of babies over your career.
0:07:02 Dr. Alta DeRoo
Yep. Yeah. [smiles, nods]
0:07:03 William Moyers
Tell us, addiction and pregnant women, specifically opioid addiction in pregnant women, what are the issues? What are the challenges?
0:07:12 Dr. Alta DeRoo
Probably some of the biggest challenges is the stigma associated with that. When a woman gets pregnant, she is seen as living up to higher standards than somebody who's not pregnant, right? So, if you have a person who's pregnant, they're responsible for themselves and the baby. Being this vessel to nurture their baby. And so going into treatment, they're often faced with stigma amongst healthcare providers. So, there are initiatives out there to decrease stigma and I think we're making headway on that.
0:07:40 William Moyers
0:07:42 Dr. Alta DeRoo
Also, another medication that is used for those suffering from SUD, Buprenorphine/Naloxone, there aren't a lot of OB/GYNs like myself that are able to prescribe. Right? So we would encourage more OB/GYNs and women's healthcare providers to get a certification to prescribe Buprenorphine/Naloxone. A life-saving medication. And safe for the mom in pregnancy.
0:08:07 William Moyers
Once upon a time we talked about "crack babies" [uses air quotes]--
0:08:10 Dr. Alta DeRoo
0:08:10 William Moyers
—That was the 80s, that probably wasn't true. Right?
0:08:14 Dr. Alta DeRoo
[chuckles, grins] Right.
0:08:16 William Moyers
Are there such things as opioid-dependent babies?
0:08:20 Dr. Alta DeRoo
So yeah, so the baby is a passenger in the mom.
0:08:25 William Moyers
0:08:24 Dr. Alta DeRoo
—And they are passively dependent. Right? These opioids will get to babies. There's no addiction that's assigned to babies. Baby doesn't meet the DSM-5 criteria for addiction. [smirks] But the baby's gonna withdraw.
0:08:36 William Moyers
0:08:36 Dr. Alta DeRoo
When baby is cut off immediately from mom's opioid supply that may be coming in, and then there are gonna be withdrawal symptoms, treatable withdrawal symptoms that babies can recover from. And live healthy, normal lives.
0:08:49 William Moyers
Mmm-hmm. What about the mom who is dependent on opioids, she may have had treatment but she's still struggling, she's pregnant, and she goes into overdose or she has an overdose—
0:09:01 Dr. Alta DeRoo
0:09:03 William Moyers
—Whether it's a first responder or a friend or a doctor, NARCAN is often used—
0:09:09 Dr. Alta DeRoo
0:09:09 William Moyers
Talk about what NARCAN does and is it safe in pregnant women?
0:09:14 Dr. Alta DeRoo
Right. Great question. So NARCAN is a medicine that is usually in the community injected up the nose. It's a nasal spray. There are other formulations of it. But if somebody in the community were to have an overdose, it's readily available from EMS. Anybody can get it from the pharmacy. You don't need a prescription; you can get it over the counter from the pharmacy. In our states. And so, when you're giving this life-saving medication up the nose like a nasal spray, there's nobody that can't get it. Right? There are no contraindications that we know of it.
0:09:48 William Moyers
Mmm. Mmm-hmm. [nods]
0:09:50 Dr. Alta DeRoo
And the alternative is that person's gonna die. [chuckles] If you don't give it, that person's gonna die anyway. So we wanna be proactive to give it to everybody including pregnant women. There's a lot of hesitation to give the medications to pregnant women. What will I do, will I hurt the baby, will I hurt the mom? Well, if you think a couple steps forward, if you don't treat that mom, and she's not breathing, that's gonna compromise baby. If she becomes anoxic or not getting enough oxygen, and that baby's not gonna get enough oxygen, they may both die. So you're not gonna hurt Mom or baby by giving NARCAN. So please, give it to that pregnant person if you find her as an overdose—
0:10:24 William Moyers
0:10:24 Dr. Alta DeRoo
—Just 'cause she's pregnant is not a contraindication to it. You'll be saving two lives! [smiles, nods]
0:10:26 William Moyers
Mmm-hmm. Mmm-hmm. I wanna talk about the treatment, go back to the treatment for a second. I remember when Hazelden Betty Ford or Hazelden at the time before we merged with the Betty Ford Center, about a decade or so ago, we began to introduce medication into our treatment regimen for opioid-dependent patients. And there was a lot of blowback from the recovery community around that. People even saying that those using medication were not sober, were not recovering—
0:10:54 Dr. Alta DeRoo
0:10:54 William Moyers
What's your response to that?
0:10:56 Dr. Alta DeRoo
So I've heard that. I've heard that. And I've been in those rooms.
0:10:58 William Moyers
0:10:58 Dr. Alta DeRoo
I've heard that and I've heard people talk about that, right? And that's just change. That's people who were taught recovery by apprenticeship, and this is what I've done, and this is how I'm gonna help you. And you should try it my way. And, you know, this is what worked for me. And a lot of this Twelve Step with a sponsor and AA is this apprenticeship model. But then in comes science and medicine.
0:11:21 William Moyers
0:11:21 Dr. Alta DeRoo
And we can use that too. And that just augments the treatment. Because somebody's getting a medication like Buprenorphine/Naloxone, that just helps them with their cravings. There may be this misperception that a person is "using" [uses air quotes] or they may be getting some type of euphoria or high—
0:11:36 William Moyers
Yes, yes, yes. [nods, smiles]
0:11:37 Dr. Alta DeRoo
—And they don't. Something like Buprenorphine/Naloxone is almost—it only acts on the receptors partially, it's called a partial agonist.
0:11:45 William Moyers
0:11:46 Dr. Alta DeRoo
So a person is not gonna get high from this. They're not gonna get euphoric. And so this just may be a misunderstanding in the recovery community about what Buprenorphine/Naloxone is.
0:11:55 William Moyers
0:11:56 Dr. Alta DeRoo
But we highly encourage our patients to be in those rooms—
0:11:59 William Moyers
0:11:59 Dr. Alta DeRoo
—Of AA and NA. And if you wanna keep it private, keep it private. But, you know, I definitely have heard those things and I think it's because of not much education or a misunderstanding about how the medication works.
0:12:11 William Moyers
Yeah. And I think there is an easing of that resistance, if you will, as we continue to see people finding recovery even while using medication. Let's talk a little bit about treatment in the five minutes that we have left. Do you have to "go to treatment" [uses air quotes] for opioid dependence to get well?
0:12:32 Dr. Alta DeRoo
No. You don't. There are many people who some just stop on their own. Some don't need anything. We see this with alcohol, we see this with opioids. People have a really good family structure and can white-knuckle it—
0:12:43 William Moyers
0:12:44 Dr. Alta DeRoo
—And not have to go to treatment. But then for those that can't do that, you can go to your primary care physician. You can talk to them about Buprenorphine/Naloxone. You can get the counseling. So you can do that on an outpatient, you know, basis.
0:12:57 William Moyers
0:12:58 Dr. Alta DeRoo
Any physician who chooses to get the training can prescribe Buprenorphine/Naloxone. It does not have to be an Addiction Medicine physician.
0:13:04 William Moyers
Hmm. And what about people who are using medication to support their recovery—as a rule should they stay on that medication or should they come off of it? [chuckles softly]
0:13:17 Dr. Alta DeRoo
Great question that a lot of the other community has too.
0:13:20 William Moyers
0:13:20 Dr. Alta DeRoo
So, the ASAM guidelines, the American Society of Addiction Medicine, says and we agree at Hazelden Betty Ford that you should stay on this medication for as long as you're providing benefits, right? As long as you're getting benefits from these medications and it's helping you, then stay on the medication. There may be a time though when the patient says, you know, I've got the coping skills that I need, I have the sober community, I have the family support, I think I can start to ease off this medication. There are some patients like that. And we would support them. We also support the patients that just aren't there yet—
0:13:54 William Moyers
0:13:54 Dr. Alta DeRoo
—And they feel like they're benefitting from this medication and may not be ready to come off.
0:13:58 William Moyers
Hmm. What about the role that virtual treatment plays? You and I are here in the summer of 2022, we're on the backside of the pandemic hopefully—
0:14:07 Dr. Alta DeRoo
0:14:08 William Moyers
—But virtual does seem to be here to stay in society. And that includes addiction treatment. How does it work for people who are dependent on opioids?
0:14:17 Dr. Alta DeRoo
Yeah. So, virtual is very good. It was the gift of COVID—
0:14:23 William Moyers
0:14:24 Dr. Alta DeRoo
—It allows us a way to get a person into treatment.
0:14:26 William Moyers
0:14:27 Dr. Alta DeRoo
We can talk to them about the medicines available, there are certain things that we can do to work with urine drug screens to provide that person's support. The thing that may be missing though in the virtual component is the intimacy. And the social intimacy and the feeling of community and that connection that was lost in COVID that we really need in recovery. So virtual is great but it would be great—I'd love to see it combined with some type of group or you know social community. On the other end of that camera.
0:14:55 William Moyers
Mmm-hmm. And can patients who are in virtual treatment, can they still be prescribed the medication if they need it?
0:15:03 Dr. Alta DeRoo
Yes. Yes, absolutely.
0:15:04 William Moyers
0:15:05 Dr. Alta DeRoo
There are guidelines around that but yes, they can be prescribed that medication.
0:15:09 William Moyers
We're about out of time. I mean I have one or two more questions to ask you but there is often times a perception that particularly in the old days when people were addicted to heroin that they never got better. Or that their level of getting better was less than what it should be. Would you just put us all straight once and for all that it is possible to recover from opioid dependence?
0:15:33 Dr. Alta DeRoo
Oh, yeah! Absolutely! Recovery is possible. I've seen many of our patients' success stories, people that come back and talk, alumni that come back and talk to—
0:15:41 William Moyers
0:15:43 Dr. Alta DeRoo
—Our people in recovery, in groups and share their story. Oh I've seen many! Many. Many recovery stories. You know, especially with the counseling, how robust that is, and medications to help. So yeah, there's plenty of help and success out there from opioid use disorder.
0:15:59 William Moyers
And we're glad that you're leading our organization in the charge in terms of treatment and in terms of advocating for recovery. Let me ask you, you're relatively new still as the Chief Medical Officer, what's been the biggest "aha" for you since you took on this role as Chief Medical Officer of Hazelden Betty Ford?
0:16:18 Dr. Alta DeRoo
Yeah. The big "aha" has been how many—seeing how many patients we've touched. How many patients we've touched and then their family. Hearing their family stories. The family stories of gratitude. This is how well my person is. Or, the family involvement where they say, my loved one needs a little help, can we get them back into treatment, is there anymore that you can give us? I've just been astounded at the thousands of people. I can't say millions 'cause I don't really know the number [Moyers chuckles] of lives that we've touched—
0:16:45 William Moyers
0:16:45 Dr. Alta DeRoo
—Just after our initial treatment. Because those people go—they pay it forward, they pass it on.
0:16:50 William Moyers
0:16:51 Dr. Alta DeRoo
So it's amazing how many people we've touched.
0:16:53 William Moyers
Yes. Well Dr. Alta DeRoo, thank you so much for being with us today and touching us here in the studio and with our viewers across the audience of our Let's Talk podcast. We're glad that you're in the position that you are and we're so grateful for your advocacy.
0:17:08 Dr. Alta DeRoo
Thank you. [smiles, nods]
0:17:09 William Moyers
[turns to camera] And thanks to all of you for joining us for this vital conversation about opioids, treatment, and recovery. We hope you'll tune in again to learn more about substance use disorders, treatment, and recovery issues. Remember, treatment works! And recovery is possible. We'll see ya again.