What’s Behind The Sharp Rise In Heroin Use In The U.S.

MS. DIANE REHM

10:06:53
Thanks for joining us. I'm Diane Rehm. The number of Americans who say they've used heroin is 80 percent higher than just five years ago. In recent months, hundreds have died in heroin overdoses from Maryland to New York. Joining me in the studio to talk about the death of Philip Seymour Hoffman and the surge in heroin use and addiction around the country, Dr. Wilson Compton of the National Institute on Drug Abuse at NIH.

MS. DIANE REHM

10:07:29
Joining us from a studio in New York City, Barry Meier of The New York Times. And by phone from Philadelphia, Jeff Deeney of The Atlantic magazine. I do want to urge you to join us in this conversation, 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. Thank you all for joining us today.

MR. JEFF DEENEY

10:08:04
Thank you.

MR. BARRY MEIER

10:08:04
Thank you for having me.

DR. WILSON COMPTON

10:08:07
Thank you, Diane.

REHM

10:08:08
And, Barry Meier, let me start with you. Just what do we know about Philip Seymour Hoffman's death on Sunday? I know that the autopsy has not yet been released. But how much do we know?

MEIER

10:08:31
We know just what the police said -- reported thus far, which is that he was found in his -- a studio that he was using as an apartment apparently with a hypodermic needle in his arm, that in that studio the police found approximately 50 bags of heroin, a number of -- several dozen hypodermic needles, and a number of bottles of prescription drugs.

MEIER

10:08:59
So it's not clear at the moment whether the overdose involved a extremely large amount of heroin, whether that heroin was laced with additives, including this rather dangerous heroin that's now circulating, which is mixed with the prescription opioid Fentanyl, or whether there were other substances involved, including alcohol and/or prescription drugs. So that all remains to be seen. And maybe when that information becomes available, we'll know more about this unfortunate situation.

REHM

10:09:36
I gather he had been in rehab for quite a while, had been -- said he had a relapse in May of 2013. Is that correct?

MEIER

10:09:53
That's correct. And I think his experience -- some of your other guests can speak more forcefully about this. This is quite typical. Individuals who become addicted to opioids, usually to prescription drugs or to heroin, can go for many, many years clean and in rehab, and then some episode or series of incidents will set them down the path to addiction again. I guess the sort of overarching issue that we're confronted when a high-profile person or a really terrific artist, like Mr. Hoffman, dies is the reality that addiction is a disease.

REHM

10:10:36
Mm.

MEIER

10:10:36
And until we start addressing addiction as a disease, we're going to see tragedies like this, as well as, you know, untold hundreds of overdose deaths that take place among individuals who are not well known, who are not artists, but nonetheless die because of overdoses.

REHM

10:10:57
And before we get into the question of disease and dealing with a drug abuse, such as heroin addiction, as disease, Dr. Compton, explain just how heroin works on the body.

COMPTON

10:11:19
Heroin is an opioid drug, so it's from -- originally from opium poppies, and it's processed from the morphine that is taken out of the opium poppies. And it was originally produced in the late 19th century as a treatment for morphine or opioid addiction. That's how the company started it, but it turned out to be more addictive on its own.

COMPTON

10:11:41
It's in the same family of drugs as many of the painkillers that we use routinely in medical care. So you've already heard about the medication Fentanyl, which is an essential medication for both surgery and sometimes for long-term pain. But we also think about Oxycontin and Percodan and Vicodin and Hydrocodone and all the other painkillers that are necessary for medical treatment.

REHM

10:12:01
And just how addictive is heroin?

COMPTON

10:12:06
Well, heroin's one of the most addictive substances that we know. All substances that are abused can be addictive. It's remarkable that people don't think marijuana's addictive, and yet something like 9 percent of people that start smoking marijuana will end up being addicted to it. For heroin, it's more like about a quarter from the studies that we've seen so far.

REHM

10:12:27
Are you seeing an epidemic of heroin in this country now?

COMPTON

10:12:35
Absolutely. When we think of an epidemic, how do we define an epidemic? That means more cases than you would expect in a given period of time. So when you see an increase in the number of cases year after year, that's the definition of an epidemic. And so you've already described an 80 percent increase in the number of people using heroin. We've seen more than a doubling in the people entering treatment for heroin. We see an increase in the number of emergency room mentions. And certainly overdoses have been increasing in many parts of the country.

REHM

10:13:06
And turning to you, Jeff Deeney, I know you have personal experience with heroin. How long were you addicted? What made you stop using the drug?

DEENEY

10:13:21
Well, I had a period when I was younger where I was using heroin for about two years until I got clean at the age of 21. I had a period of abstinence and then later, in my 20s, relapsed and became a user of Oxycontin, which had become much more popular in the black market during the time that I had stopped using drugs.

DEENEY

10:13:45
So I've been, you know, experienced with both. And I've, you know, experienced what it's like to both, you know, purchase them in the black market to stop using them. And the last time I went to rehab was 2004 for Oxycontin addiction. And just about two weeks ago, I celebrated 10 years clean.

REHM

10:14:10
I'm glad for that.

DEENEY

10:14:11
Thank you.

REHM

10:14:11
Can you talk about what led you to heroin in the first place?

DEENEY

10:14:18
I think that I was kind of a reckless kid. And I was going to college at the University of Chicago on the south side of Chicago. And there were drug corners, you know, in close proximity to the school and a lot of drug users sort of circulating around campus. And, you know, when I was young, that was attractive to me.

DEENEY

10:14:43
That was actually the difference between my stint with heroin and my stint with Oxycontin is Oxycontin tends to trade -- it's a little more expensive 'cause it's harder to get. It trades, you know, more off street than, you know, typically what you would think of in terms of open air drug markets for drugs like heroin and crack.

DEENEY

10:15:06
And so when I relapsed and I picked up Oxycontin, you know, part of that really was a conscious decision on my part that I didn't want to go back to places like North Philadelphia where I bought drugs before, where there was just an incredible risk in terms of risk of assault, risk of arrest, risk of, you know, robbery, risk of getting ripped off and getting, you know, a product that's either fake or potentially poisonous. And so, you know, Oxycontin, at that time for me, actually kind of kept me from going back into that heroin feed.

REHM

10:15:47
But Oxycontin did what for you by comparison to what heroin did?

DEENEY

10:15:55
Absolutely the same thing, almost the -- an identical feeling, you know, relatively equal in terms of potency, just more expensive because the supply is much more limited. So, for instance, an 80-milligram Oxycontin, which I used to sort of start my day out with, would cost $40 on the streets as opposed to, you know, a $10 bag of heroin. And they're comparable in strength.

REHM

10:16:27
And just before I go back to Dr. Compton, what was your reaction, Jeff Deeney, to the amount of drugs found in Hoffman's apartment?

DEENEY

10:16:43
Oh, yeah. Well, he was definitely on a major binge. You know, he had about seven bundles of dope from the most recent report. A bundle is how -- on the streets, heroin packages will be, you know, rubber-banded together in stacks of either 10 or 12 or 14, depending on what the, you know, the buy of the day is.

DEENEY

10:17:04
You know, you'll get, you know, 11 bags for the cost of 10. You know, you get little price breaks for buying in bulk. And so, you know, that's a lot of heroin. I mean, somebody who's out buying, you know, seven bundles at a time and keeping it around the house is probably using an incredible amount of drugs.

REHM

10:17:24
And in The Atlantic piece that you wrote yesterday, you talked about tainted heroin that's linked to perhaps as many as 30 deaths in Philadelphia. That tainted heroin, how would you describe it?

DEENEY

10:17:46
Well, it's a batch of drugs that's just mixed up on the streets where, you know, I guess Fentanyl is a simple enough molecule that it can actually be manufactured on the street and then mixed in with heroin. But, you know, it's very imprecise. I mean, you know, Fentanyl is usually measured in micrograms.

DEENEY

10:18:07
And, you know, these are not pharmaceutical companies preparing these batches of heroin to put on the street. And so there's a just an incredible unpredictability right now in terms of the street supply. If you're a heroin user and you're going to buy a bag of drugs, I mean, you never know what you have in it. But right now it's extremely unpredictable and dangerous.

REHM

10:18:26
Hmm. Jeff Deeney, he is a social worker and recovering heroin addict, contributor to The Atlantic magazine. Short break, your calls when we come back.

REHM

10:20:01
And welcome back. We're talking about heroin addiction, something that indeed killed Philip Seymour Hoffman over the weekend. Here in the studio, Dr. Wilson Compton. He's deputy director of the National Institute on Drug Abuse at the National Institutes of Health. Also joining us from New York City, Barry Meier. He's a staff reporter for the New York Times, author of "Painkiller: A Wonder Drug's Trail of Addiction and Death." And from Philadelphia, Jeff Deeney. He's social worker and recovering heroin addict. He's a contributor to the Atlantic magazine.

REHM

10:20:59
During the break, Dr. Compton, you were talking about the similarities in the effects of Oxycontin and heroin.

COMPTON

10:21:11
Yeah, I think we've already heard a little bit about the painkillers and that the high is very similar. And chemically the brain responds almost identically to heroin, the street drug, as it does to the pharmaceutical agents that might come from the pharmacy or somebody's medicine cabinet. So our brains don't distinguish between these different opioids very much. They all have the same impact on the central nervous system on the neurotransmitters in our brain that respond to these drugs.

REHM

10:21:39
What happens in the brain when these drugs or these medications are taken, either injected directly into the bloodstream or taken orally?

COMPTON

10:21:55
Well, as a physician, the beneficial effects are there's reduced pain, a reduced perception of pain, relaxation of blood vessels so that it can be very helpful. If somebody's having a heart attack, one of the first things you do is give them morphine when they come to an emergency room. But when people are using it to get high for intoxication, it does a number of things. For one thing, it produces a very rapid onset of euphoria, excitement, reward. Sometimes it's experienced as a warm sensation throughout the body. Some people also feel sick and nauseated, so there can be side effects right away, too.

COMPTON

10:22:27
But over time people develop a habit to that, so they enjoy it. And they want to do it again. So what we find is that the behavior patterns get set up over and over. People form memories, and their judgment changes. Their decision making changes. So they make decisions that they never would've made elsewhere in their lives because of the drug seeking and the pleasure that these drugs start out with.

REHM

10:22:49
And once they start out, does their tolerance grow?

COMPTON

10:22:55
Absolutely. Anybody that takes these substances on a regular basis will develop tolerance. That means that it takes a larger amount to have the effect their looking for. That actually can be one of the problems when people are in treatment or drop out of treatment is that they haven't been using the drug. They go back on the street, and they may not realize that the same amount of drug that they used before on a regular basis could be fatal on another occasion.

REHM

10:23:20
Jeff Deeney, was that part of your experience?

DEENEY

10:23:26
Well, actually, this is part of my experience as a social worker all the time. In Philadelphia, I actually think the most common overdose scenario is when addicts come out of the county jail, and, you know, they were arrested. They had a period of involuntary detox inside prison. They immediately return to the corners where they were buying and using before and just use the amount that they were using when they went into prison, not realizing that that short stint inside reset their tolerance. And that's a very, very common way for people to overdose in North Philadelphia.

REHM

10:24:06
Barry Meier, what's your view on the Oxycontin and other drugs that people have used to substitute for heroin?

MEIER

10:24:19
Well, as your other guests have pointed out, these are essentially the same drugs. They go into the same class of drugs. They have the same effects. They produce the same tolerance. And I think if you go back -- while we're talking about an upsurge in heroin use now, if you go back over the past decade, you've seen sort of an ebb and flow of these drugs. As one becomes available, people tend to flock to that. If there's a crackdown on that drug, they go to another drug in the same class.

MEIER

10:24:47
I remember, about seven or eight years ago, there was a spade of deaths involving methadone. Because of the crackdown on Oxycontin, people were being prescribed methadone. They were trading that out on the street or getting it on the street. So essentially you've got this large class of drugs, and people go from one to another depending on their cost and their availability.

REHM

10:25:11
Barry, where is most of this heroin coming from?

MEIER

10:25:17
I believe most of it is coming from Mexico. It starts out there and then is brought into the United States and distributed, you know, along the I-95 corridor here on the east coast. And it's prepared and adulterated in various ways, as we're seeing now in Pennsylvania and in Maryland with the Fentanyl-tainted heroin.

REHM

10:25:40
Surely it's not just on the east coast, though, is it? Isn't it in other parts of the country as well, Barry?

MEIER

10:25:50
Oh, yeah, absolutely. I was just referring to sort of we -- there's a sort of trafficking corridor along the east coast that I'm familiar with. But heroin is a problem nationwide and globally as well. I guess one of the things I found very interesting about the situation involving Mr. Hoffman, apparently the police found the drug buprenorphine in his apartment. And that is a drug that's used essentially as a replacement for an opioid, for people who are going through drug withdrawal or is used essentially as a maintenance drug in place of heroin or in place of Oxycontin as an addiction treatment.

REHM

10:26:35
Dr. Compton.

COMPTON

10:26:37
Well, it's certainly a curious finding. I look forward to learning more about it. If a considered heroin addict take buprenorphine unexpectedly, it actually can precipitate withdrawal because it has sort of mixed effects. It's not a full agonist, meaning it's not a full -- fully active in the opioid receptors in our brain, but it's partially active. So for some people, it can actually start them in withdrawal if they take it unexpectedly.

COMPTON

10:27:01
It certainly is one of the newer treatments. And one of the key messages that I think we need to get out there is that treatment can be very effective for heroin addiction and opioid addiction generally. And we need to think about medications as treatment as being a mainstay of what we can do to help people recover their lives.

REHM

10:27:18
We have an email here from Terry who wants to know how -- pardon me -- how someone actually can overdose, Dr. Compton.

COMPTON

10:27:34
Well, unfortunately, overdose is remarkably easy, and it's unexpected. Very few people intentionally are trying to kill themselves. Of course, there are some people that do that on purpose and are committing suicide. But, for most people, it's an accidental overdose. So they use either a larger quantity, or, as was already mentioned, heroin may be mixed with other substances that can make it more potent and more likely to stop your breathing.

COMPTON

10:27:58
The essential factor is that opioids have an impact on our brainstem. That's the part of the brain that's sort of in the upper part of the neck and lower part of the head where breathing and heart rate are controlled. So when there's too much opioids in the body, we stop breathing. We just -- it slows down over and over until you turn blue and eventually die in just a very short period of time.

REHM

10:28:21
How long?

COMPTON

10:28:22
Oh, it can be just a matter of minutes. If we stop breathing, we have only several minutes when we need to be resuscitated. Fortunately, if medical care can be received at that time, there are potent blockers of opioid receptors. So if you show up in an emergency room or an ambulance driver comes or a policeman or even a family member that might have this Narcan or Naloxone available, it can be administered readily and reverse the effects within seconds and wake people up.

REHM

10:28:50
Now, what about Oxycontin, same thing?

MEIER

10:28:54
Absolutely, but all of -- as you've heard from all of us, these drugs are the same chemical class. So the blocking agent -- if somebody's overdosed, it's quite possible to revive them if you're there in time. Many of these cases are somebody's by themselves in which there's no one there to revive them.

REHM

10:29:12
Now, Jeff Deeney, in your experience, how often do these addicts come very, very close to overdosing?

DEENEY

10:29:23
I think it's really easy. And I actually agree with the other guests that I've seen some suggestions on the Internet that Philip Seymour Hoffman committed suicide intentionally. And I actually don't think that's the case. I think that he was an addict who was habituated to a pretty large dose of the drugs because, you know, if you have a full-blown addiction and you have the kind of resources that he had in terms of money to spend on your addiction, an addiction will generally grow to accommodate whatever amount of resources you're going to throw at it.

DEENEY

10:29:57
So it's not inconceivable that he would do something like put five dime bags of heroin into a single shot, which they say that they found five empty bags next to him. That's a really, really big shot. That's really dangerous. But if you're an addict who's heavily habituated and you're doing two or three bags at a time, you might not think that that is so completely reckless to do. But at the same time, any time you bump your amount up from what you're used to doing in order to catch a bigger high, I think you risk overdosing pretty much every single time you do that.

REHM

10:30:38
Dr. Compton.

COMPTON

10:30:39
I think what Jeff is describing is the way the brain distorts their thinking, that, when somebody's addicted, they make decisions that are really quite foolish. So in another setting, they may understand the risks, but when somebody is on a run and is using drugs regularly, they make decisions that are quite different and quite dangerous like that.

REHM

10:30:58
Jeff Deeney, I wonder what led you into rehab. And then what part of that rehab broke down and drove you back into drug use?

DEENEY

10:31:15
Oh, the first time I went to rehab, I was just a really sad case. I mean, I had been homeless for a little bit. I mean, I had absolutely no money. I had no way to make any money. I was a very poor hustler. I was not sort of built for the streets. And so it didn't really take an awful lot of time to produce the kind of excruciating pain that just sort of motivated me to go seek help. The second time around, it really was when I hit the point where I couldn't afford the pharmaceutical drugs anymore because, as I mentioned, the Oxycontin is very expensive compared to street heroin.

DEENEY

10:31:58
And I had a job and was able to supply that for a time period. But when I started to run out of funds, having been someone who was an injection drug user previously, I knew that if I started running out of money that I was going to have to seek out cheaper alternatives. And I was going to have to go back to trying to buy heroin. And I was older, and I really wasn't interested in the risks, the things that excited me about it in terms of, you know, being in neighborhoods where people were shooting at each other.

DEENEY

10:32:33
You know, that was exciting to me at 19. You know, it's less appealing at age 29. And so it was a turning point for me where it was either, you know, am I going to pick heroin back up, or am I going to get clean and deal with this? And, you know, clearly, I made the right decision. You know, it's just gotten worse since I've been off the streets.

REHM

10:32:57
And you're listening to "The Diane Rehm Show." Dr. Compton, what puts addicts who've entered recovery at risk for relapse?

COMPTON

10:33:13
Well, it's an unfortunate situation that people do relapse. What we would like are treatments that get at the underlying addiction, but we don't have those. We have the ability to help people enter recovery and regain their lives. But what happens when people relapse is -- are a number of factors. It can be stress in their lives, whether that's social stress or emotional stress or physical stress.

COMPTON

10:33:34
One of the main predictors of relapse though is sampling the drug itself. So people think, oh, I'll just have one, and that might be safe. But it turns out that even a very low dosage can prime the body and prime the brain to want more and more.

REHM

10:33:48
And what about the relationship between drugs and alcohol?

COMPTON

10:33:53
Well, certainly there are cross effects among the different substances. It's not at all unusual for a heroin addict to also have problems with either the stimulants like cocaine or amphetamine. And alcohol would be very typical. We also see tobacco use being an extraordinarily common addiction among substance users. And it turns out that the tobacco is what will kill an awful lot of them.

REHM

10:34:16
Barry Meier, I wonder whether you think we have lost the so-called war on drugs.

MEIER

10:34:25
Well, certainly the death of someone like Philip Hoffman seems to put that into perspective, as well as the deaths of other people who are less well known. The question becomes, if we are forcing people essentially to go out on the street and buy drugs that are lacking in purity, that are essentially dangerous to satisfy their addiction, what are we accomplishing?

MEIER

10:34:54
To what degree are restrictions on these drugs preventing people from getting addicted to them or, on the other hand, causing people to die from overdoses? So I think that's the essential question that an episode like this raises. What's being served here and what is the -- what are the pluses on the public health side and what are the losses on the public health side?

REHM

10:35:19
A writer, Eugene Robinson, has an op-ed in this morning's Washington Post on Hoffman's death saying, "Prohibition is not working. It's time to try something new." Is he right, Barry?

MEIER

10:35:40
There -- it's certainly time to try different approaches. And one approach to addiction treatment in the case of folks who fail at addiction treatment is providing them perhaps with drugs that will satisfy them. That will keep them alive until we can get them into the type of treatment that will work or come up with different treatment strategies that will work. I mean, there are thousands of people that are dying every year from drug overdoses. And I don't know how the current strategies of dealing with drugs and the war on drugs is helping that in any way, shape, or form.

REHM

10:36:20
What do you think, Dr. Compton?

COMPTON

10:36:23
Well, certainly the -- I think the whole metaphor of a war on drugs is misguided and that we need to be thinking of this as a health condition and approaching it from a health perspective. So when we think of it as a war, that means that we ought to lock people up and be thinking in terms of law enforcement as the main approach. That hasn't worked very well.

COMPTON

10:36:41
We know that when you simply lock people up and don't provide treatment and don't help them with rehabilitation and don't help them with recovery when they come back out of jail or prison, we are dooming them to relapse, more crime and more drug use.

COMPTON

10:36:54
So one of the key factors is to bring together the public health and these public safety models. But I am reluctant to simply open up the door to legalization or widespread use because those social constraints really do keep a lot of people from using these substances. So how do we balance these risks and benefits?

REHM

10:37:15
And that certainly is the question. We're going to take a short break here. When we come back, we'll open the phones and hear what you think about all this. I look forward to speaking with you.

REHM

10:40:02
And welcome back as we talk about heroin addiction, the death of Philip Seymour Hoffman. Here's our first email from Paula in Indianapolis. She says, "I believe doctors are partly culpable. For at least 10 years, they've eagerly written prescriptions for narcotic-based pain meds for the simplest of pain. They knew these were narcotics yet prescribed them freely." Dr. Compton?

COMPTON

10:40:38
Certainly we've see skyrocketing rates of the prescriptions of all of these different painkillers, the narcotics that the listener describes. And I think it's incumbent on physicians to make sure that their prescribing patterns are appropriate. We want full treatment of serious pain, which can sometimes require use of these potentially dangerous drugs. But we want to make sure that they're not over-prescribed and then left over in medicine cabinets and elsewhere where they can be diverted into the drug markets.

REHM

10:41:05
But I gather most people -- or is it most people who begin to use heroin start out simply using it as a recreational drug?

COMPTON

10:41:20
Well, it's an interesting pattern. Many years ago, we saw that when heroin wouldn't be available, heroin addicts would resort to pills as a temporary measure. But in the last 15 years, we've started seeing where people are starting with pills and then switching to heroin as an alternative. And that's a very new and dangerous pathway because the resistance to taking a pill recreationally is much lower than people are afraid of heroin. And they don't seem to be as afraid of pills, even though it's the same chemical.

REHM

10:41:49
I gather that would certainly jibe with your experience, Jeff.

DEENEY

10:41:58
Yeah, I think Barry eluded to this earlier, that this spike in the numbers of heroin users we're seeing now is something that we've known about. Public health professionals have known this is coming for a good 10 years. When I went to rehab in 2004 for Oxycontin, what was really kind of disturbing to find was that it was full of young people. I mean, this was just an in-patient facility full of 19-year-old kids who were all hooked on Oxycontin.

DEENEY

10:42:34
And they were mingling in the in-patient facility with older users who were heroin addicts. And the heroin addicts would get in the ear of the young kids saying that, you know, these pills are so expensive. It's a waste of money. Why don't you come with me down the way? I'll show you were the corners are.

DEENEY

10:42:49
And I would see a lot of these kids actually leaving the facility with these older guys to go learn how to cop and shoot heroin. And that right there -- when I got out of rehab and started looking at the Oxycontin problem a little bit more, it really occurred to me that this is going to be a big problem because there's really so many people picking up the pills that it does really seem to have a direct line into the heroin market somewhere down the road for a lot of users.

REHM

10:43:23
All right. Let's go to Judy. She's in Bonita Springs, Fla. Hi, Judy. You're on the air.

JUDY

10:43:32
Yes. I've been enjoying the discussion. Unfortunately, I lost my son Steve to an opiate overdose in 2011. And I'm just trying to do something about it. We've formed a fed up coalition that's working to get some action to end this epidemic. But I wanted to point out several things. One is that there are an awful lot of people who don't begin this path to heroin recreationally.

JUDY

10:44:00
My son had a severe back injury and was prescribed medications, became addicted, went to a treatment center where I do believe he learned about heroin there, got out, relapsed and overdosed on heroin. But I do think that it's not just the physician's fault that they are over-prescribing these medications.

JUDY

10:44:21
It goes even deeper than that. It goes into what the FDA approves and how they label their drugs and also how pharma markets their drugs and how they're allowed to market these narcotic drugs as safe and effective for long-term use when in reality they really aren't. There are obviously exceptions to the rule that it shouldn't be prescribed long term. And definitely they are appropriate for acute pain and for end-of-life care.

REHM

10:44:55
All right. Barry, do you want to comment?

MEIER

10:45:00
Well, I'll simply say that we're in a terrible medical and public health dilemma that's resulted from the overuse and over-prescription of these drugs and the lack of adequate alternate treatment for pain for patients who are suffering those conditions. On the flip side, we've got a problem with addiction treatment as well. We've stigmatized addiction.

MEIER

10:45:27
We've withheld funds from addiction treatment. It's very cloudy as to which addiction treatments actually work. So if we're actually honest about solving these problems, we have to have a much more robust governmental involvement and medical involvement in determining what type of pain treatments work best and also what type of addiction treatments work best.

MEIER

10:45:52
I mean, we've sort of pitted two communities against each other, people who need medical treatment for pain and people who've become addicted. And it's been in the interest of the drug industry and other people to kind of create this dichotomy. They're often part and parcel of the same thing. And we have to use our best scientific medical knowledge to deal with both these problems on kind of separate but equal tracks.

REHM

10:46:21
All right. Let's go to Sheboygan, Wisc. Abby, you're on the air.

ABBY

10:46:28
Hi. I'm actually a methadone maintenance patient. I have Hench-Rosenberg. It's a rare autoimmune condition. So I started getting pain medication for that, never imagining how deeply addicted I would become, how dangerous and dark that would get. But my question is, you know, if methadone maintenance (unintelligible) good for someone like me who is ready to make a change, how do you feel about safe injection sites, alternative treatments, I guess, for people who aren't ready for traditional treatment?

REHM

10:47:08
Dr. Compton?

COMPTON

10:47:10
Well, I think we have medical treatments like methadone that you're on. We have buprenorphine for people that would like to see their general physician and not go to a methadone clinic separately. We have seen experiments to use heroin and supervised heroin injection sites in some parts of the world that appear to be potentially useful for people that either don't respond or are unwilling to seek treatment.

COMPTON

10:47:37
The big concern is that you don't want to encourage additional drug use by -- and discourage people from seeking necessary treatment. So how do we motivate people appropriately to seek care and to stick with care even when it gets tough? And those can be some of the most difficult clinical and medical situations. I'd also say that this begs us to invest more heavily in research to understand the basic causes of addiction and see what we can do to turn the clock back and change the addictive process itself.

REHM

10:48:07
Do some people seem to be more vulnerable than others to addiction?

COMPTON

10:48:13
There absolutely is variation in how vulnerable people are. It depends on combinations of their genetic background. We all know people where addiction runs in their family, that there are alcoholics all over it or, in this case, heroin addiction or opioid addiction in multiple generations. In addition, there are environmental factors, early childhood environments, later family environments and who your neighborhood and what peers you have can really predict who's going to become addicted and who won't.

REHM

10:48:42
All right. Here's an email from Anthony, North Carolina, for you, Barry. "Does Barry really believe there's no correlation between the increased availability of heroin and the continuing U.S. occupation of Afghanistan? Please ask him about this. It seems more than coincidental that the drop in increased availability of Oxycontin and the increase in heroin's availability has no relationship to thousands of U.S. troops traveling to and from Afghanistan, widely acknowledged as the world's largest producer of heroin."

MEIER

10:49:37
Well, I might want to avoid the geopolitics of that question, not because I'm a coward, but because I think that drug markets work like any other kind of market. There's a demand for a drug. There's a demand for a type of high. And when you withdraw one group of products, like prescription painkillers, from that market, other products will, you know, flood in to fill that demand.

MEIER

10:50:10
It almost doesn't make a difference what the source of the heroin is. It could be coming from Mexico. It could be coming from Afghanistan. It could be coming from God knows where. But the fact of the matter is, is that there is an appetite out there for these drugs. There's a demand for these drugs. So as you make one group of drugs less accessible from people seeking those drugs out on the street, other drugs will become available. It's simply a supply and demand problem.

REHM

10:50:40
I have an email here from Jay, who says, "I'm a former heroin and cocaine addict. I found the standard drug rehab method here horrifically ineffective. Then a friend told me about ibogaine, which is illegal in the U.S. and legal in most of the rest of the world, including south of the border. I went to Mexico, took two doses over five days, and it was amazing -- no withdrawal symptoms, and the hallucinatory effect that it left me with gave me insights into myself and afterward had no desire to use." Jeff Deeney, have you heard about this?

DEENEY

10:51:40
Yeah, I have. It's been around for a long time, and I think it's still considered pretty unconventional. What I'll say is I think this gentleman's experience highlights that there's different treatment methods that work for different people. And I think that he's right, that we do need to reexamine our treatment system and look at how effective it is and see what we can do to improve it.

DEENEY

10:52:11
What worked for me doesn't work for a lot of people. A lot of people, when they go to rehab, they come out, and they relapse again. A lot of people don't want 12-step recovery. Twelve-step recovery has been amazing for me. But, at the same time, people in 12-step recovery a lot of times have very negative opinions of very scientifically supported interventions like Suboxone and methadone.

DEENEY

10:52:39
And so I think what we've learned over time is that we need a lot of different options. And people need to have choices in what is available to them. I don't know. I think I've read nightmare scenarios of people going to Mexico trying to get ibogaine. And I don't know. I don't know if I have a clinical opinion on that, honestly.

REHM

10:53:03
All right. And you're listening to "The Diane Rehm Show." Dr. Compton, what about you?

COMPTON

10:53:11
Well, ibogaine has been considered as a potential treatment for a number of years. People have been talking about it for quite a while. Unfortunately, it has multiple potential toxic side effects. So it will not be useful as a medication all by itself.

REHM

10:53:23
For everybody?

COMPTON

10:53:25
It's been considered for multiple different substances as a potential treatment, but we might learn from experiences by people like your listener, that perhaps there are chemicals related to ibogaine that might be useful for addiction. And those are the kind of clinical trials that we're undertaking at the NIH right now, is trying to develop new medications because we, unfortunately, have very few effective treatments for addictions.

REHM

10:53:47
All right. To Neal in Dallas, Texas. You're on the air.

NEAL

10:53:53
Yes. I'm on my cell phone. I hope you can hear me OK.

REHM

10:53:55
Sure can.

NEAL

10:53:57
Very good. Well, the first thing I want to say is I really enjoy this segment. And I think that what this shows us is that if we don't change our mentality, we're left with loss. Philip Seymour Hoffman was an absolutely brilliant actor. And hopefully, eventually -- it's hard to say this at this early stage -- if there's any good that can come from this, it will by way of awareness because I think that when we talk about the war on drugs, as some of your callers and your guests have discussed, a war on drugs is really a war on ourselves.

NEAL

10:54:30
These aren't the stereotypical, deranged, drooling addicts in the alleyways. These are our kids, our parents, our neighbors. And I think that we really have to work to change these stereotypes and understanding of who these people are because it's not the evil drug addicts. It's us. It's our families. It's ourselves. Thank you.

REHM

10:54:49
All right, sir. Thanks for calling. That brings me, Jeff, to the question, do you believe that Philip Seymour Hoffman's friends, family would not have known that he had a relapsed?

DEENEY

10:55:07
No. Actually, I think that the media reports are pretty clear that in the days just before he died that his ex-partner, who has a child with him, knew that he was high, that he was acting bizarrely. And I think that he had been in rehab again recently. And I think that honestly the people that might be hit hardest by his relapse and his overdose death are probably people that knew him in recovery. I mean, he was in recovery for 23 years.

DEENEY

10:55:43
I mean, he had an incredible run of clean time from drugs and alcohol during which I'm sure he built a lot of relationships with other recovering people. This is why I personally maintain contact with recovery communities over time because, even though I've been clean for 10 years, I'm not immune to a relapse any more than any other recovering addict is, regardless of the amount of time that you've had away from this substance.

REHM

10:56:14
So what would you say to someone out there who is currently in recovery and tempted by hearing about all this drug addiction out there?

DEENEY

10:56:33
Well, I would say to reach out and use whatever your networks of recovery support are. I think that if it's a really crisis situation where relapse is absolutely imminent, some people do recommend that people start a course of Suboxone as a preventive maintenance intervention. But I personally would probably rely on the people that I have in recovery to…

REHM

10:57:07
Interesting.

DEENEY

10:57:07
…go to meetings, to seek support, to share where I'm feeling.

REHM

10:57:11
Good.

DEENEY

10:57:11
That kind of thing.

REHM

10:57:12
Jeff Deeney, I want to thank you for being with us. Jeff is a social worker, a recovering heroin addict. Barry Meier is with The New York Times, author of "Painkiller: A Wonder Drug's Trail of Addiction and Death." And Dr. Wilson Compton of the National Institute on Drug Abuse. I hope we have helped people. Thanks for listening. I'm Diane Rehm.
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