yes there is a crisis in the united states the largest drug problem in history with over two hundred fifty thousand deaths attributed to opioids dr andrew sachs and dr richard reese are taking on that crisis one person at a time so there are actually three different types of opioids there are the opioids that occur naturally in the opium poppy which humans have known about for thousands of years and used for the medicinal purposes for thousands of years and there are about twenty different other compounds in there but the main ones that have an effect on humans are coding and morphine that they are naturally in nature then there are a whole host of similar chemicals that humans have produced in the laboratory either by slightly modifying the the compounds coding in morphine that occur in the opium poppy or by just synthesizing something brand new in the lab which are in the human brain and control a lot of important functions in our brain in our body so that being said why is that a problem it's natural it is natural just like with all  psychoactive medicines and psychoactive drugs we have natural channels in our brain that can be hijacked by external chemicals and it's a problem powerful and cause that kind of thing and what happens when you use opioids over time is you get taller independent to dose one and then you end up on dose to get taller and dependent on dose two and then moved to dose three etc so you end up on a high dose of opioids which then start controlling your life well they do many things in the brain in the body reducing a pain awareness is one of those important things wait a minute wait a minute you said reducing pain awareness that means that the pain is still there the pain killers i may take are not killing my pain they're just i think seeing my brain cannot recognize it not be as aware of it and not to be so emotionally engaged with the physical sensations of pain but another important thing that opioids do which all substances that humans can become dependent on do is that they indirectly stimulate the brain award system so they make people feel good and give people euphoria and that initially is why people want to go back and take them over and over in many cases and then in some cases there are the situations where someone develops pain gets exposed to opioids and it does reduce the pain awareness and the pain suffering and then they want to continue to use them and then they get into the cycle that dr reese just mentioned where they need more and more and more to get the effect that they were looking for and then you have someone who's got opioid use disorder opioids are a class of drugs derived from opium use was strictly controlled for decades in the united states but they changed for many many years through the last century the amount of opioids used in shall we say in addictive fashion was relatively stable studies in the eighty's and ninety's showed early ninety's showed that there were about three hundred fifty thousand people dependent on opioids in that addictive manner around the united states those were mostly in large cities and they were mostly heroin those are mostly done through injection through needles non prescribed you know heroin bought on the street illegal all that kind of thing what happened in the ninety's is through some faulty research and through a lot of problems with the way doctors and pharmaceutical companies work together we started prescribing opioids for minor pain and for the kinds of things that that when i was in training elysium d was training they said don't use opiates for that only use opiates for acute crash kind of pain so are acute injuries kind of pains or terminal life kinds of pains but don't use them for headache sir bumps needs or sore arms or all those kinds of things and what happened is starting in the ninety's the number of people exposed to strong opiates when up by ten or twenty or thirty times over the next ten years so you had a psychoactive substance opioids we all have natural opiate receptors in our bodies most people in the past before the ninety's didn't ever get exposed to heavy doses of opiates and then through the medical profession pharmaceutical industry we now had a whole batch of people exposed to high dose opiates that's kind of like dragging a sieve through society certain people become tolerant and dependent to that feeling and to those receptor in ways that others don't and those are the people who ended up with  disorders according to the new england journal of medicine in the one nine hundred eighty s less than one percent of patients at boston university's medical center became addicted to pain medication but a decade later doctors were regularly prescribe ing opi i think that physicians were really told that the compassionate humane thing to do was to treat pain with opioids and that people would not become the panda developed a use disorder and that's what well intended physicians believed yes there were a few physicians who were running pill mills and they were just trying to make a lot of money writing these prescriptions but they were few and far between so really i think the whole medical profession was misguided as dr reese mentioned when this idea became current that anyone with any kind of pain that went on and on should be given an opioid it takes two to tango to you know it was not just the doctors but the pharmaceutical companies begin to market they can find there's pain there's money in them they're ill as some be some people have said and so we had this huge amount of prescribing and people who never used to get exposed got exposed one of the first patients i ever had in a study that dr saxon hosted in this area that when we started using buprenorphine which is an opiate system stabilizer and one of the key medicines in treating opiate addiction one of the first patients i had believe it or not this was a twenty one year old kid who was had been an eagle scout and had been like the straight a straight arrow kid that you've ever seen in your life you probably would have hated him when you were in high school because he was so perfect he was given oxy cotto and after a major dental procedure  took it and they gave him thirty days supply of oxy codell which he all took in like three or four days because he took it and all of a sudden it was like this magic feeling that he had this magic feeling of oh my god i've never felt all of a sudden i feel like a double real me you know and he ate them all in about three days call the doctor up and said hey i lost my pills and you know this guy had never lied to anybody as whole life got another  took the whole bottle in about three days and on the one week after that he robbed a pharmacy the robbed three more pharmacies and he came to me through benevolent smart judge who said this is crazy something's going on here we need an expert opinion so this that was just a perfect example and that was like a slap in the face for me just seeing how dramatic that bad prescribe be could expose somebody to something they never would have been exposed before and how when the opiate receptor takes over it really takes over people start doing things they would never do in their life they start lying although they've never told a lie before they start stealing though they've never stolen before so it starts steering the ship no you're no longer steering the ship so the dependency can take place that fast it can take that fast in popular culture of a drug addict looks like a drug addict so the obvious question what does an opioid addict look like we prefer not to use the term opiate addict because we find that that's stigmatizing and we what we really have as dr riess just described so eloquently we have good people who are suffering from a very bad disease so we prefer to call them people  individuals who have opioid use disorder and what do they look like they look like anyone from any strata of society they look like you and me there's no way that you're going to pick them out on the street they're really members of our family people we know people we work with and in the me to that i think the the the pace you know the the public is view the stereotype view of people with addiction is end of the road alcoholic people you know the classic kind of view of that skid row kind of stuff and the same thing with opiate attics people use disorders aren't just that there are still those kinds of folks around but what's happened since the ninety's there were three hundred fifty thousand of quote those kind of folks back in the early ninety's there's now three and a half million plus mostly middle class white people who have become exposed because they're the one seeing doctors they're the ones who had this and then the other pain they're the ones who warned and unfortunately this is true of our society right now pain means opioids if i've got pain i need an opiate and unfortunately bad research in the mid ninet through the purdue pharma basically created the pain vital side and the joint commission on hospital and other regulatory agency said you have to document people's pain and respond to that in any medical visit and so the system got bamboozled and they helped to spread the issue because if you were a doctor and you were seeing somebody and they said i think i need opiates i got really bad back pain and you said well i don't think that's good for you it's not it's not healthy they say yeah but i'm in pain and you're withholding that medicine from me and they're going to go on your yelp site and rate you as a bad doctor so there was a whole lot of forces kind of moving with the medical society to create this monster you mean doctors look at yelp sites and say you know i'm not prescribe enough pain medication so i need to do that's why i will have a higher well it's a sad statement except for that's just a dramatic example of it but when you've got people walking out of your office and you have people reporting you to the medical disciplinary board because you didn't assess or treat their pain right and it says you're supposed to and opiates equal pain you know that that kind of terrible thing went round and round and helped to create this monster well that's got to be incredibly tough on doctors trying to do the right thing do opioids have the same effect on everyone no they don't that's a very important point so there are people who are more susceptible to liking opioids based very much on genetics and we know what's next we have no idea which genes in our twenty three thousand genome sets make people more susceptible and probably also based somewhat on life experiences if people have had stressful life experiences they may be more susceptible most people actually don't like opioids they might take them if they need them in a say in a surgical situation and they'll say this makes me feel woozy and upsets my stomach and i want to get off this thing as fast as i can but then there are the people who are susceptible to them and it looks like that's about somewhere between ten and twenty percent of the people who get exposed to opioids because they're in pain which is the size of turns out to be a sizable number this brings us to the questions of pain and pain management is tolerance to pain genetic is dependence on drugs you know well what we should be doing is for people who have chronic pain as dr reese has mentioned during the ninety's in the early to thousands the reflex response was to give opioids and what we now know is opioids are not a good treatment for chronic pain and there are other treatments that should be used primarily the best treatments for chronic pain are actually forms of psychotherapy that help people just like opioids do to get away from focusing on their pain and start focusing on living their life and enjoying life and minimizing the emotional impact of the pain the problem we have those types of therapies are not not readily available to the average primary care provider or even to the average patient insurance isn't necessarily going to pay for for that so we have a health care system that's driven to find the cheapest easiest solution rather than the best option and let me add to that the i remember i went to one of the first meetings of the state opioid task force back in the early ninety's i think and he was probably there too and they asked neurosurgeons and all these people who back surgeons you know what do you need more of and they said and they all said what we need more of a c b t physical therapy and yoga teachers that's what they want more opioid cognitive behavioral therapy the kind of psychotherapy then he was talking about because that's what helps most chronic pain conditions over time that changes function and improves and in washington state where we're very lucky gary franklin who is head of state labor in industries did studies some years ago showing that people who had back pain injuries the sort of standard muscle spasm back pain kind of stuff that half of americans seem to have who got opioids in the first week compared to people who didn't functionally got worse statistically worse so it wasn't just that it created dependence or anything else it was if they actually physically got worse they were less likely to stay active they were less likely to go back to work those kinds of things who is the pusher in all of this insurance has helped to drive this to because if you're a primary care doctor and you're seeing somebody with insurance  z you'll get paid to see that patient and prescribe a medicine and the medicine will be covered for by the insurance company but if you prescribe ongoing regular physical therapy visits and a psychologist doing cognitive behavioral therapy that insurance company there won't cover it or they'll cover five visits something like that so that you've you've tied the hands of the doctors and we're pretty we're covering the thing that's bad for people and we're not covering the thing that's been shown in research studies many to make them better the makers of our health care system seem like they just don't care about wellness they just care about something they can process on a piece of paper answer that one and again two we don't have a health care system we haven't an organized health care system and why many people have pushed for a single payer now you know we're not communists we're not socialists but what we are is doctors and you won't find many doctors who would say you know the way insurance covers things it creates bad care the united states uses ninety percent of all the prescribed opiates in the world ninety percent ninety percent westernize european countries did not have this opiate thing and so this whole thing with prescribed opioids getting people dependent who then later move on to heroin has not happened to much of any degree in european countries in other countries around the world who have health care systems that have some direction that decides to pay for things that are more healthy and not pay for things that aren't so healthy because there's some sort of central planning of that in the united states it's driven by the book sixty minutes in partnership with the washington post recently did a great piece on the opioid crisis pharmaceuticals and distributors spent one hundred two million dollars lobbying congress from two thousand and fourteen to two thousand and sixteen to make sure the pill mills stayed open our question for dr saxon reese is did the partnership between congress and the pharmaceuticals create the deadly epidemic we now face well i think it's very complicated and so it's yes the we do have a system where  drug companies can make more money by selling more product and if you have a product that people have a disorder and they absolutely need to have that product obviously your sales are going to go up i think again we've already mentioned that  whole medical community became misguided and then we had the the great recession which caused a lot of people to have dislocated lives and are in a lot of stress and i already mentioned that if you had stress in your life you're more prone to likely opioids and develop problems but if you're employed and you have a job and you have a place to live you have less stress than the person who suddenly loses her or his job and and we just we are we so we  can we have to have some kind of you for your created by a drug to be able to get through i don't think so i think that we're just like human beings everywhere around the world and we happen to have this bad set of circumstances occur in our country and i think it's important now also to talk about some of the ways that we can deal with the problem and get out of the problem yes let's talk a little bit about treatment so when people develop opioid use disorder we have found this and this so this is in contrast to people who just have chronic pain where psychotherapy is very good for them we found that people of opiate use disorder the up withdrawal syndrome that they have when they try to come off opi severe and the effects that opioids have had over time in their brain in their body have changed their brain a body so much that they absolutely need to be on a medication in order to recover from hope you would use disorder and right now  if you have opioid use disorder in the us and you come into treatment the chances are three to one that someone's going to tell you what you need is talk therapy and you don't need medication and we need to turn that around and make sure that everyone w opioid use disorder gets medication as the first line treatment now having talk therapy in addition to that can often be very helpful but we but the the mainstay of treatment for this disorder is medication we have three f d a approved medications that all have been tested in the gold standard for determining if a medication works which is a randomized controlled double blind placebo controlled trial which sounds like a lot of jargon but i can explain that quickly that means that people don't get to choose their treatment they get randomly assigned to the treatment and double blind means that these are the researchers nor the patients know whether they're getting the active medication or the placebo and that way you control for expectancy isn't getting the effects of the medication all of these medications perform better than that than a sugar pill essentially and so the three medications that we have are methadone buprenorphine which dr already mentioned and then naltrexone and each of those have somewhat different mechanisms of action so that gives us a pretty good coverage of potential options to do because well the term addictive is a little bit of a loaded term yes and so cause tolerance meaning that you're going to require to have the opioid and they people do get withdrawal if they come off of them but they're in many ways of very different in their mechanisms of action than some of the people misuse or the people develop a use disorder on and then the third medication the tracks own is an opioid antagonist so it goes to the opiate receptor and blocks it so that people tried to use opioids but the opiates can't get through the receptor and have an effect so if someone is concerned about taking the medication that they would have tolerance and withdrawal with they could use the naltrexone on but they the syndrome of addiction goes way beyond physiologic tolerance or withdrawal it's a hall range of be maladaptive behaviors and we find when in most cases when people get on these medications even if they have physiological effects that are like other opioids the rest of their lives stabilize so they can go back to work they can their their relationships become solid again they don't have cravings to go out and use these other drugs they are out driving their car while they're intoxicated that sort of thing so every other component of what we consider a use disorder can get better even while they're on these medications basically with heavy use over time of street or heroin or pills what happens to this subset of people who are genetically set up for this or otherwise fall victim to developing an opiate use disorder is their opiate system becomes damaged and it becomes damaged in such a way that we don't know actually how to normalize it it becomes damage just like people can be born without diabetes and somewhere along their lives in their teens or twenty's they develop diabetes and their sugar processing system becomes damaged they then need insulin or other medications to stabilize that sugar management system in order to lead a more normal life and no matter how you talk to them that's not going to change so you need a medication to form the basis of treatment then behavioral things on top of that can cause better function and more recovery but without that medication the system they're going to be in trouble the same is true with opiate people people that have developed opiate use disorders have destabilized their opiate system it becomes dysregulation it and again it's steering the ship not the person so all the medications that we give stabilize i call an opiate system stabilizers because without a stabilizer you can talk to your green in the face and that person is off needing to get their so it's an important thing for people to realize because again and again and again and i've run into this some many times we see people who've tried abstinence treatment and talk therapy and gone off to sunrise hills treatment center or whatever and relapsed again and again often dangerously remember what twenty percent of people who relapse after abstinence oriented treatment or after jail or after being in the hospital or whatever when they relapse they relapse seriously either nearly dead or dead or  with brain and lung damage for maybe the rest of their life so recognizing that people need an opiate stabilizing medicine as a basis of treatment is the most important thing for people looking at this show to remember