EXTRA: The Opioid Tragedy — How We Got Here
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这是我们2020年系列的更新，我们与医生、研究人员和成瘾者讨论了危机的根本原因——以及禁欲与减少伤害之间的紧张关系。来源：盖尔·多诺弗里，耶鲁医学院急救医学教授及主任，耶鲁-纽黑文健康急救服务主任。基思·汉弗瑞斯，斯坦福大学精神病学与行为科学教授。斯蒂芬·劳德，雪松康复的首席医疗官，田纳西州阿片类药物减轻委员会主席。妮可·奥唐奈，宾夕法尼亚大学成瘾医学与政策中心的认证康复专家。让-玛丽·佩龙，宾夕法尼亚大学急救医学教授。艾琳·理查森，餐厅经理。资源：“美国健康药物政策的方向——安全屋的案例”，作者：埃文·D·安德森，利奥·贝莱茨基，斯科特·布里斯和科里·S·戴维斯（《新英格兰医学杂志》，2020年）。“布洛芬去监管化与阿片类药物使用障碍的主流治疗”，作者：利奥·贝莱茨基，凯文·菲斯凯拉和莎拉·E·韦克曼（《美国医学会精神病学杂志》，2018年）。“急诊科启动的布洛芬/纳洛酮治疗阿片类药物依赖”，作者：盖尔·多诺弗里，帕特里克·G·奥康纳，迈克尔·V·潘塔隆，马雷克·C·查瓦斯基，苏珊·H·布施，帕特里夏·H·欧文斯，史蒂文·L·伯恩斯坦和大卫·A·菲林（《美国医学会》，2015年）。“布洛芬-纳洛酮疗法在疼痛管理中的应用”，作者：露西·陈，凯莉·燕·陈和简仁·毛（国家卫生研究院，2014年）。“在马里兰州巴尔的摩，当前和前注射者中街头获得布洛芬使用的流行率及相关因素”，作者：贾奎琳·阿斯滕博斯基，贝基·L·根伯格，米琳达·吉尔斯皮，克里斯-艾琳·约翰逊，格雷戈里·D·柯克，舒尔提·H·梅赫塔，查尔斯·R·舒斯特和大卫·弗拉霍夫（美国国家医学图书馆国家卫生研究院，2014年）。“奥施康定的推广与营销：商业胜利，公共健康悲剧”，作者：阿特·范·齐（美国国家医学图书馆国家卫生研究院，2009年）。额外内容：“为什么阿片类药物流行仍在蔓延？”系列节目，由Freakonomics Radio制作（2024年）。“阿片类药物悲剧，第1部分：‘我们让整整一代人上瘾’”，由Freakonomics Radio制作（2020年）。“关于电子烟危机的真相”，由Freakonomics Radio制作（2019年）。 </context> <raw_text>0 See terms at discover.com slash credit card.

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Hey there, it's Stephen Dubner. We just finished a two-part series that looked at the very long-lasting opioid crisis. It's horrible. It's absolutely horrifying.

We learned why the opioid epidemic has endured, and we learned about the billions of dollars in settlement money and how that should be used. Don't spend any money on anything some other funding stream covers. Today, we wanted to play for you a bonus episode. This is an update of a piece we published in early 2020, a piece that was also about the opioid crisis. As you will hear, the crisis seemed to be leveling off back then, but as it turned out,

It wasn't. It continued to worsen, especially during the pandemic, although there are signs that now it really is leveling off. In this episode, we spoke with some University of Pennsylvania physicians about an addiction treatment that they thought should be universal.

They can get it as part of routine medical care, just like they might get their insulin for their diabetes or their blood pressure medicine. So is this treatment now universal? That's probably a no. You'll also hear a bit more from Stephen Lloyd, the Tennessee physician who was featured in our new series. And stick around to the end of this episode for an update on the team at Penn Medicine. As always, thank you for listening. ♪

This is Freakonomics Radio, the podcast that explores the hidden side of everything with your host, Stephen Dubner. Jean-Marie Perron is a professor in the Department of Emergency Medicine at the University of Pennsylvania. I'm an emergency medicine physician and medical toxicologist, which means I was trained in poisonings and overdoses. And more recently, I've started to do addiction medicine work.

Peron has seen the opioid crisis up close as a researcher and a practitioner. So we have about 1,000 or 1,200 patients who visited our three hospitals last year, and about 400 of them were overdoses.

Have you ever used opioids of any sort? No. Had a couple kids and broke my leg and broke my wrist. I didn't have opioids for any of those three things. Were you offered in any case? I broke my leg in Canada, interestingly, I would say right in the middle of the opioid crisis. And they said, you know, do you need anything? And I said, you know, I'm fine with ibuprofen. Skiing? Mountain biking.

But anyway, I would... So you brought it on yourself. I did bring it on myself. But I would definitely say that I would have a super high threshold for anyone in my family, anyone I know. I mean, I advise against it sort of across the board. Because it's just too easy to... You just don't need to go there. So opioid deaths in the U.S. have leveled off, maybe started to decline a little bit. What are you seeing here in Philadelphia? Yeah.

So they did decline a little bit. I think what is important about the national data is that the deaths that have declined the most are the oral pills. And that's probably the result of deprescribing and a little bit of a result of prescription drug monitoring programs preventing the co-prescribing of benzodiazepines with opioids, maybe a little bit more public awareness, like I shouldn't drink when I'm taking back pain medication. ♪

Another potential driver of the slight decline in deaths is the widespread availability of Narcan, an emergency nasal spray of the drug naloxone, which can stop an overdose as it's happening, wherever it's happening. Perrone has administered Narcan herself a few times. The most recent was riding the subway home in Philadelphia after a night out.

And somebody called and said, does anyone have Narcan? There's a man down. And I do carry Narcan. And so I ran five or six subway cars up and there was a man on the ground. Getting CPR was blue, cyanotic, was pulseless, really on the brink of death or defined as dead already maybe. And so we continued CPR. I got my Narcan out. I gave him one dose and he didn't really respond. And then I gave him another dose. And then I thought,

you know, we needed to do mouth-to-mouth. And then I thought maybe some of the Narcan was still stuck in his nose. And so I sort of scrubbed

scribbled his nose a little bit and kind of irritated him a little bit more. And then he took like one teeny tiny breath. And over the course of the next, you know, 90 seconds, he started to wake up. And then about 10 minutes later, EMS came. I was like, you guys just saved this guy's life. You're saying you guys, but you were the one that came. Well, no, but they had started CPR. They had called someone for help. They had called 911. I mean, they'd done so much. You know, we simulate resuscitations like that in the hospital. And this group of, you know, people just

got it all together, did all the right things. So it was really impressive. I mean, it was probably 25 or 30 people at the end of it all. And it was like this amazing, I call it my Philly moment, because it was like winning the Super Bowl when everyone was in the streets and everyone just had this amazing bond. And it was just, it was incredible. Brought tears to my eyes then, and it brings tears to my eyes when I talk about it. So that story had a happy ending. Many overdose stories do not. And Narcan can only do so much. It doesn't treat the underlying addiction.

The patients who come to the emergency department after receiving Narcan from an overdose, about 6% of them are dead at the end of one year and 10% of them are dead at the end of two years. So there is no other medical condition that we currently treat in the emergency department that has that kind of mortality. So from your perspective, I'm curious, you're an ER doc and people come in for help when they're in a desperate state already, right? They're not typically coming to you to say,

I've been thinking long and hard about my life and I want to make a graduated change, right? So what can you do for them? What was the treatment, let's say, five years ago when the problem was starting to really turn into a horror? And how does the treatment differ now?

So that's a great question. Five years ago, an overdose patient hopefully got some compassion in the emergency department and a little bit of a conversation about why they may have overdosed that day or what we can do to help them. Maybe as of four or three years ago, they would have been discharged with a box of Narcan or naloxone so that if they were exposed to another overdose, somebody could use that on them or they could use it on a friend or colleague.

I think fast forwarding from there, what we've realized is that giving them kind of a crumpled piece of paper that said you should stop using drugs doesn't really work. They are in a cycle of using and fighting withdrawal every three or four hours. And so that doesn't lend itself to getting your phone out and making an appointment for Monday morning to see an addiction specialist.

This appointment model was failing in other hospitals, too. We were on the front lines just seeing patients being brought in, sometimes being just dropped off at the door and thrown at the emergency personnel. That's Gail D'Onofrio.

I am professor and chair of emergency medicine at the Yale School of Medicine. She is also chief of emergency services at Yale New Haven Health. So like Perrone, D'Onofrio is a practitioner and a researcher. So our study in JAMA in 2015 was looking at different models of care for opiate use disorder. JAMA is the Journal of the American Medical Association.

And in 2015, ER practitioners like D'Onofrio weren't having much success treating the many opioid addicts they'd started to see. So she and her team set up a study. It included 300 patients divided into three treatment groups.

In the first group... We'll try to motivate them to get care, and then we'll refer them to the centers of care that we had here at Yale or in the community. This was the standard treatment at the time, the crumpled piece of paper model that Jean-Marie Perron mentioned.

The second group of D'Onofrio's patients got a bit extra. They got motivational enhancement, which we call the brief negotiation interview. That was a 15-minute conversation talking about their addiction and the circumstances that led to it. And then those people got a facilitator referral. Not just a crumpled piece of paper. So we actually called the place ourselves, and if it was at night, we'd call them in the morning and said, we refer this person to you.

And then the third group... They got also a motivational enhancement brief intervention, but then they were started on buprenorphine.

So, buprenorphine is an opioid agonist, which means it activates the opioid receptor just like heroin and oxycodone. Jean-Marie Perron again. I think everyone knows methadone, and methadone is our historically opioid agonist treatment that we use for patients with opioid use disorder and the only treatment we really had for a long time. But methadone has issues.

Methadone is dispensed from federal treatment programs and the patient has to go there every single day to get their dose. And the opioid agonist methadone works by being a very long acting opioid and acting at the opioid receptor and in high enough doses it thwarts the use of other opioid agonists.

Buprenorphine is different. First of all, it can be prescribed from a doctor's office, so the patient doesn't have to go to a methadone clinic every day. They can get it as part of routine medical care, just like they might get their insulin for their diabetes or their blood pressure medicine. And it's intended to be less stigmatizing to get it as part of routine medical care.

The other thing is that it's a partial agonist at the opioid receptor, so it doesn't continue to activate it the way methadone does. So there's what we call a sealing effect, which makes it much safer so that there isn't as much respiratory depression and there isn't as much risk of opioid overdose and death. It's really hard to overdose on it.

It's hard even if a child takes a pill of their adult family or friend and off a table that they will die from it because it does eventually just reach that ceiling effect. So buprenorphine, which is itself an opioid, would seem to offer a safer and more flexible treatment for opioid addiction. But how effective is it?

That's what D'Onofrio was really looking for in her study at Yale. And so what we found...

was that those patients that were in the buprenorphine group were two times more likely to be in formal treatment at 30 days in one month. That was a huge improvement over the two other groups in the study. So about 37% of patients in the referral group were in treatment, and about 45% in the brief intervention group, and then almost 80% in the buprenorphine group.

So they were able to double the rate of engagement of patients who showed up for a follow-up meeting. When Jean-Marie Perron of Penn saw the Yale study, she was impressed and excited.

And that is so critical to, you know, getting people into treatment. And that medication stabilizes the cycle of withdrawal that patients are experiencing. So it's really important to not say you can come in tomorrow for your first appointment, but here's a medication. The next 12 hours won't be the hell you think it's going to be if you start on this medication now. So that sounds like a wildly useful drug that I'm sure every hospital and medical board and state legislature must be in favor of.

dispensing more of this antidote, yes? That's probably a no. I think there's a lot of good people in theory who do want to do this and expand our treatment. I think the logistics of learning how to administer buprenorphine sounds more complicated than it might be, and that is a barrier. What do you mean by the logistics of administering it?

So, first of all, in order to write a prescription for buprenorphine, you have to get something called an X-Waiver, which means that you have to take an eight-hour training program and you have to apply to the DEA to get a special waiver. Does the same sort of waiver licensing process apply to prescribing medical opioids in the first place? It does not. So, I can, in fact, treat your opioid use disorder with buprenorphine.

So why the extra level of regulation for buprenorphine?

It's complicated. But when we went from the late 60s, when we started methadone and, you know, we had people who needed treatment, but we weren't going to let just any doctor prescribe it. And so that's why methadone was restricted to these federal treatment programs. But then when we said, well, you know, in 2000, buprenorphine became available and was approved in the United States. But we weren't just going to let every doctor put out a shingle and start administering buprenorphine.

Buprenorphine is most commonly administered in a name-brand drug called Suboxone, which also contains Naloxone. Buprenorphine was invented by the pharma firm Reckitt Benckiser in 1966, one of many synthetic opioids designed in the 20th century. They were meant to treat pain but be less addictive than opium itself.

But as it turned out, most of them were addictive. That is the foundational problem of the prescription opioid crisis. In the 1990s, Reckitt Benkiser recognized buprenorphine's potential for treating opioid use disorder. And it spun off its buprenorphine division into what is now a subsidiary company called Indivior.

Several years ago, another drug company thought about getting into the buprenorphine market, Purdue Pharma, which makes OxyContin, one of the most widely abused prescription opioids. A Purdue memo at the time called buprenorphine an attractive market, but they never did jump in. Today, Purdue is the target of thousands of lawsuits charged with having downplayed the addictive nature of OxyContin. Just how influential was Purdue in the opioid universe?

Consider this startling development. The World Health Organization recently retracted its two main guidelines for using opioids to treat pain. Why? Because the guidelines, it has now been discovered, were unduly influenced by opioid manufacturers, including Purdue's international subsidiary.

And yet, at this moment, OxyContin is still legally and widely dispensed as a useful painkiller that is also easily subject to abuse. Suboxone, meanwhile, is much harder to abuse, but is also harder to get. What do medical professionals who treat opioid addiction think of this? Here's what one doctor wrote on the Health Affairs blog.

Buprenorphine has the potential to be a transformative tool in healthcare practitioners' fight to reduce deaths from opioid overdose, but that the ex-wavering process is onerous, outdated, and hampers our ability to help patients manage and recover from opioid addiction. An editorial in JAMA Psychiatry made the same complaint

and noted that easing the restrictions on buprenorphine in France helped drive down deaths from opioid overdose there by nearly 80%. If extrapolated to the United States, the authors wrote, this translates to more than 30,000 fewer annual deaths from opioid overdoses. ♪

So globally, the statistics are tremendous, no doubt in the evidence there. Do you see the waiver requirement for buprenorphine as a sort of over-correction, over-response to the medical community's own embrace of opioids in the first place? Like, we messed up big time, and at the very least, what we're not going to do now is mess up in the same direction, even though this might be a different direction?

I think it lingers because of some of those concerns. But if we go back to 2000, we didn't really have any kind of opioid crisis in 2000. So it was really approved in the absence of a big surge in opioid use at the time. I think not repealing it at this point is probably multifactorial. People are worried about suboxone diversion. So the same substance that we want to prescribe is also available on the street. And we acknowledge that. But it's not used on the street

to get high, it's used for patients to treat their own withdrawal symptoms when they're unable to get other medications. So I think that's part of why there's been some resistance to taking away the X waiver. I think it also is going to take an act of Congress, which is fairly hard to accomplish.

And I think that repealing the X-Waiver isn't entirely going to, you know, open the floodgates for prescribers who want to prescribe buprenorphine. There's still some education and some stigma that needs to be addressed before more people are going to be willing to prescribe buprenorphine.

This situation has changed somewhat since we first published this episode. In 2023, President Biden did sign a bill eliminating the federal requirement for doctors to obtain an X waiver to prescribe buprenorphine. But some states still have their own restrictions on prescribing the medication. And that isn't the only thing that's keeping buprenorphine from being used more widely.

If you look at residential treatment programs across the country, most of them, over 70% of them are still abstinence 12-step based programs. That is Stephen Lloyd, a physician in Tennessee who specializes in addiction. Lloyd himself was addicted to prescription painkillers for years. Basically, I took pills all day long. When I got out of bed in the morning, I had withdrawn during the night, so I was sweating. I felt like an 80-year-old man and I was in my early 30s.

Lloyd went into a detox program and then a 30-day residential rehab facility, which got him turned around. Today, he's the medical director for a network of addiction treatment centers.

I'm a big believer in medication-assisted treatment, and we know that the most effective thing that we can do for opioid addiction is actually medication-assisted treatment with the use of drugs like buprenorphine, methadone, and naltrexone. And I've taken heat from this in the local treatment community as well as the treatment community statewide and even nationally.

Can you just describe where that pushback and that reluctance is coming from? Well, unfortunately, Stephen, the pushback comes from people in the recovery community. And one of the problems with addiction medicine is that most of the people that work in the field or a lot of the people that work in the field had the issue themselves. That's how they got in the field, like myself. But they believe that the only way to get healthy is how they got healthy. So it's totally anecdotal.

As Lloyd noted, most addiction treatment programs do stress total abstinence, including 12-step programs like Alcoholics Anonymous and Narcotics Anonymous. How successful are such programs? That is a famously difficult question. Solid data are hard to come by. After all, anonymity is a feature of such programs, and there are all kinds of possible selection biases.

Alcoholics Anonymous claims that 75% of its participants stay sober, but academic studies put the success rate closer to 10% or even less. That said, one Stanford study compared addicts who quit with the help of AA versus those who quit on their own and found that AA nearly doubled the success rate.

Stephen Lloyd's argument is that abstinence is the chosen path for the recovery community, but that medical professionals embrace MAT, medication-assisted treatment. You've got the World Health Organization. You've got NIDA. That is the National Institute on Drug Abuse. Everybody who looks at this says the role of medication is paramount. It should be the cornerstone. Yet it's so hard to get people into those programs because of the stigma associated with it. A lot of times it'll be from parents.

I've had numerous parents talk their kids out of medication because they said they were trading one drug for another. And then a few months down the road, I get the call that they've overdosed and died. And I can't tell you how heartbreaking those calls are. If I say to you, I don't like the idea of the pharmaceutical industry being able to be the chief beneficiary of medication-assisted treatment because they helped drive this problem in the first place. It's a little bit like, you know,

I set a house on fire, then I'm the hero who calls in the fire to the fire department. I don't like the optics of that. I don't like the economics of that. What do you say to that argument? I say I agree with you a million percent. It makes me choke every time I think about it. But I don't have a better option.

I don't have anything else that's going to stop my patients dying at the rate that MAT does. I can't stand it. I read somewhere recently that several years back, Purdue Pharma tried to acquire the marketing rights to buprenorphine, which just absolutely is unconscionable to me. And so I would agree with you 1000%. I wish there was a better option. But right now there's not. And so I can't let my feelings get in the way of trying to help my patients and help them stay alive.

Could you describe for me the underlying causes of opioid addiction? I guess what I'm looking for is if you could break it down between a physiological addiction or craving as well as the psychological and environmental drivers.

Well, I don't know how much more I need to break it down. You just did. You know, that's the classic biopsychosocial model that you just described. So that's really the three big components of developing any addiction, in this case opioids. So you've got the – I teach it in terms of a slot machine. You know, when the three sevens come down on the pay line, that's when the money comes out. So the first seven is the bio component, and that's simply genetics. Do you have a family history of any addiction? Yes.

If you do, then that first seven comes down on the pay line. And addiction is about 60% genetic for the most part.

The second part is the psychological component. What kind of household are you raised in? Do you have a high ACEs score, adverse childhood experiences? Were you physically, sexually, or emotionally abused? Do you have that chronic trauma maybe even later in your life? If you do, then that second seven is down on the pay line. And then the third seven is the social component, and that's just the availability. What is widely available?

And the thing that's most widely available and accepted is alcohol. And that's still mostly what we see people abusing and addicted to. But in the late 1980s, early 90s, and into the 2000s, opioids became much more widespread. You and many others call addiction generally a disease. And it sounds like the factors that may determine your likelihood for the disease are pretty much everywhere. So...

Do you see this as a different disease than we typically think about with epidemiology?

Let's take a disease that everybody agrees on, type 2 diabetes mellitus. You know, nobody has a problem with type 2 diabetes being a disease, right? I never hear any discussion about that. Yet, for the most part, it's behavioral, right? Why do people get type 2 diabetes? Well, they don't eat right and they don't exercise correctly. And so we treat that widely with medication to try to decrease the bad outcomes with diabetes. So, you know, I look at addiction as being much the same. If you know about addiction, addiction is a brain disease.

Gail D'Onofrio again from Yale. And we know by looking at scans of the brain that even though I maybe have had treatment and I'm no longer physically dependent, the minute you show me something, whether it's a syringe or it could be just a place that I used, parts of my brain, my amygdala will light up showing that I still have this

I still have this possibility to use if I get back in that situation. I can't pray myself out of it. I can't will myself out of it. So it doesn't matter if I call it a disease or a learning disorder. It is a rewiring of the brain, the reward system and the frontal lobe interaction, and to where the primary focus becomes acquisition of this substance for me to be okay. And so when I look at it in those terms, it looks a lot like diabetes to me. Can you talk for a minute about

If you look at President Trump's first appointment to the head of Department of Health and Human Services was Dr. Tom Price.

He came out early on and said, well, you know, this is simply switching one drug for another. And those of us in the addiction field had serious angst about that. But you have folks in HHS right now that are giving really good direction with regards to medication-assisted treatment and making it more widely available. It is evolving quickly. And I think we're to the point now that some of the stigma is being decreased simply because so many people have died.

Instead of defining recovery as total abstinence from any medication, I want to define recovery in those parameters of, is your life getting better? Are you still going to jail? Do you have your kids back? Do you have a job? Are you a member of the taxpaying citizenship of the United States? To me, those are much more reflective of effective treatment than whether or not somebody's totally abstinent from all drugs because some 12-step group says they have to be.

Stephen Lloyd's philosophy, as well as that of Gail D'Onofrio and Jean Marie Peron, falls under the umbrella of what is called harm reduction. It's the idea that you treat risk not as something that must be driven to zero.

In a recent episode called "The Truth About the Vaping Crisis," we talked about the battle between smoking abstentionists, people who argue that nobody should be consuming any nicotine in any form, and harm reductionists, who argue that vaping may carry risks, but they're almost certainly smaller than the risks from smoking cigarettes. When it comes to opioid abuse, the gap between the abstentionists and the harm reductionists seems to be even wider. </raw_text>

这是我们2020年系列的更新，我们与医生、研究人员和成瘾者讨论了危机的根本原因——以及禁欲与减少伤害之间的紧张关系。来源：盖尔·多诺弗里奥，耶鲁大学医学院急救医学教授及主任，耶鲁-纽黑文健康急救服务主任。基思·汉弗瑞斯，斯坦福大学精神病学与行为科学教授。斯蒂芬·劳德，雪松康复的首席医疗官，田纳西州阿片类药物减轻委员会主席。妮可·奥唐奈，宾夕法尼亚大学成瘾医学与政策中心的认证康复专家。珍·玛丽·佩罗内，宾夕法尼亚大学急救医学教授。艾琳·理查森，餐厅经理。资源：“美国健康药物政策的方向——安全屋的案例”，作者：埃文·D·安德森，利奥·贝莱茨基，斯科特·布里斯和科里·S·戴维斯（《新英格兰医学杂志》，2020年）。“布洛芬去监管化与阿片类药物使用障碍的主流治疗”，作者：利奥·贝莱茨基，凯文·菲斯凯拉和莎拉·E·韦克曼（《美国医学会精神病学杂志》，2018年）。“急诊科启动的布洛芬/纳洛酮治疗阿片类药物依赖”，作者：盖尔·多诺弗里奥，帕特里克·G·奥康纳，迈克尔·V·潘塔隆，马雷克·C·查瓦斯基，苏珊·H·布施，帕特里夏·H·欧文斯，史蒂文·L·伯恩斯坦和大卫·A·菲林（《美国医学会杂志》，2015年）。“布洛芬-纳洛酮疗法在疼痛管理中的应用”，作者：露西·陈，凯莉·燕·陈和简仁·毛（国家卫生研究院，2014年）。“在马里兰州巴尔的摩，当前和前注射者中街头获得布洛芬使用的流行率及相关因素”，作者：雅克·阿斯滕博斯基，贝基·L·根伯格，米琳达·吉尔斯皮，克里斯-艾琳·约翰逊，格雷戈里·D·柯克，舒尔蒂·H·梅赫塔，查尔斯·R·舒斯特和大卫·弗拉霍夫（美国国家医学图书馆国家卫生研究院，2014年）。“羟考酮的推广与营销：商业胜利，公共健康悲剧”，作者：阿特·范·齐（美国国家医学图书馆国家卫生研究院，2009年）。额外内容：“为什么阿片类药物流行病仍在蔓延？”系列节目由Freakonomics Radio制作（2024年）。“阿片类药物悲剧，第1部分：‘我们让整整一代人上瘾’”，由Freakonomics Radio制作（2020年）。“关于电子烟危机的真相”，由Freakonomics Radio制作（2019年）。 </context> <raw_text>0 为什么会这样？阿片类药物有什么不同？它一直受到污名化。我不知道为什么。所以我认为每当你减轻与成瘾相关的污名时，你就增加了人们走出阴影并寻求帮助的机会。广告过后，帮助是如何发生的，何时发生的。我们还与两位正在康复的成瘾者进行了交谈，其中一位现在在宾夕法尼亚大学医院工作，帮助其他成瘾者摆脱困境。

你正在收听Freakonomics Radio。我是斯蒂芬·达布纳。我们马上回来。富有意味着什么？

是拥有更多的故事可以分享或时间可以给予吗？是能够把你的亲人留在身边还是去远方旅行？在爱德华·琼斯，我们相信富有的关键在于知道什么是重要的。你专属的财务顾问将采取全面的方法来制定你的财务策略，以帮助支持对你真正重要的事情。访问EdwardJones.com/findyourrich。爱德华·琼斯，SIPC成员。

T-Mobile在美国最大的5G网络上提供家庭互联网，每月50美元。这就是我如何观看比赛的。哦，是的，那是外面的。

这就是我如何完成购物清单的。嘿，亲爱的，快递到了。哦，太好了。这很简单。这就是我如何提升自己的。是的，双倍积分。只需每月50美元，使用自动支付和任何语音线路即可获得T-Mobile 5G家庭互联网。并且有价格锁定保证，如果我们提高你的互联网费率，你的最后一个月服务费由我们承担。

此外，没有爆炸性账单或年度合同。T-Mobile，这就是你的互联网。今天就访问T-Mobile.com/homeinternet查看可用性。价格锁定的排除条款如税费适用。有关保证的详细信息，请访问T-Mobile.com。在你保持全国可用的后付费语音线路的情况下，价格在每月10美元账单抵免后。需要符合条件的信用。合格账户包括监管费用。此外，未使用自动支付的每月费用为5美元。需要借记卡或银行账户。

Thorn拥有一切，帮助你感到最佳。

在这个夏天，尽情享受你的最佳状态，选择Thorn。访问thorn.com。

谢谢。

正如我们所听到的，用另一种阿片类药物（如布洛芬）治疗阿片类药物成瘾并不是一个普遍接受的概念。但许多聪明而敬业的人支持这一点，包括珍·玛丽·佩罗内，宾夕法尼亚大学的医学研究员和急诊医生。

她和她的团队正在为阿片类药物成瘾创建一种新的治疗方案，其中包括布洛芬或Suboxone。但不仅仅是这样，他们还改变了成瘾者从进入急诊室的那一刻起的治疗方式。这种治疗包括他们所称的温暖交接。

温暖交接是一个相对较新的术语，指的是医院或诊所的患者在出院时已经见过一个同伴或某个将陪伴他们去预约的人，或者他们已经见过将照顾他们的医生或临床医生。因此，患者与其康复的下一步之间有着紧密的联系。温暖交接团队的另一个成员是同伴顾问。

我们的同伴顾问是那些正在康复的人，他们可以立即开始对话，讨论如果他们尝试药物或尝试进入治疗程序或尝试立即参与护理会是什么样子。这一切都是关于参与。这些同伴顾问在医院工作。他们经过认证培训，并且拥有作为阿片类药物成瘾者的第一手经验。

我认为他们是一些最专注的人，不仅如此，他们经历的事情比我这个超级轻松的生活中经历的要多，他们已经走到了另一边，并希望帮助其他人，并且在帮助其他人方面取得了成功。他们很特别。像妮可这样的人。绝对是像妮可这样的人。♪

我是妮可·奥唐奈，我是宾夕法尼亚大学急诊室的认证康复专家。那么，妮可，你的故事是什么？你是如何来到这个位置的？所以，从使用到这里，经历了很多工作。我的第一个爱是苯二氮卓类药物，也就是Xanax。这就是我上瘾的东西。我21岁时去过康复中心。第一次我去住院治疗。

而且效果很好。效果持续了大约两年。然后周围有了阿片类止痛药。所以，这就是，为什么不呢？对吧。然后羟考酮当时并不是那么容易获得。所以就像Perk 30s和一些人的处方药。

然后它们非常昂贵，所以更容易获得海洛因。然后发生了什么？你是如何最终戒掉的？我厌倦了拖延戒断，因为那时我所做的就是使用，所以我没有戒断，对吧？所以我意识到，

我每次都将继续处于戒断状态，直到我采取行动，因为戒断是可怕的，没有人想要处于其中。我意识到我的生活就是试图弄清楚我如何获得药物，只是为了停止戒断。最后这并不好玩。这不是派对。没有人快乐。你知道，你只是尽量不生病，勉强维持功能。你有一个妹妹。是的。是的。是的。她比我小三岁，杰西卡。是的。

我知道她死于过量吗？她确实如此。那是2014年12月14日。好的。她使用的是什么药物？海洛因。那时你们的关系如何？我们一起使用。是的。她第一次给我海洛因。所以在我康复的头七年里，我一直在做餐厅管理。然后我失去了我的妹妹。

那时我开始做外展。我需要给她的死亡赋予意义，我需要成为她在活跃成瘾中可能没有遇到的人。奥唐奈让我认识了她一直在帮助的一个人。我的名字是艾琳·理查森。我是一名餐厅经理。我也是一名酗酒者和成瘾者。

我来自新泽西海岸，最近搬到费城。我在这里待了一年多。我已婚。我有一个妻子。我有一个儿子。他刚满三岁。恭喜你。他的名字是什么？他的名字是亨里克，或者说亨里克·马修·理查森，正如他喜欢说的那样。在我们交谈的那天，理查森已经康复93天。她在过量后进入了宾大急诊室。妮可立即来医院见我。

我相信我看到的医生问我是否有兴趣寻求帮助。他说他认识一个我可以交谈的人。然后妮可出现了，来和我谈话。是的。你过量使用了什么？海洛因和芬太尼。妮可帮助艾琳开始使用Suboxone。

我仍在使用Suboxone。你知道，我每天都服用。Suboxone有帮助。我没有渴望。很快，这就开始了。当我第二次回到Suboxone诊所时，他们提高了我的剂量。从那天起，我再也没有对任何阿片类药物产生过渴望。这感觉如何？相当棒。相当惊人。那么，你会将你的成功归因于与妮可的合作多少？

以及拥有一个理解药物本身的同伴，还有其他第三或第四个原因。我是说，它们都起着重要作用。我不想将其分解成百分比或图表之类的，因为对我来说，这一切都是交织在一起的。但你认为没有Suboxone的妮可能做到吗？不，Suboxone绝对是我需要的。但如果我只是使用Suboxone而不做其他任何事情，我会停止服用Suboxone。

我不会继续服用。药物帮助身体部分。然后我所做的其他一切帮助我成为一个新的人，一个新的人类，这是我的目标。所以Suboxone帮助你回到妮可可以工作的水平。确实如此。是的。在我看来，是的。那么，妮可，Suboxone听起来确实是一个很好的解决方案，至少对某些人来说，在某些时候，对吧？你能谈谈...

我想，使用它的广泛性所面临的问题或障碍吗？从我的角度来看，除了医生所经历的摇摆不定和医疗障碍外，我们的经验也是，恢复社区对它有很大的污名。恢复社区传统上是基于禁欲的，这意味着什么都不能。没有药物，没有非法药物使用，什么都没有。为什么？

这只是一个根深蒂固的东西。12步程序有很多传统之类的东西，而且没有太多变化。我不会撒谎。我喜欢12步，我喜欢这个程序，它为我做了很多，但我不在会议上谈论我使用Suboxone的事实。我的赞助人知道。我的密友知道，但我在会议上不提起。显然有不同的12步程序，其中一个明确指出MAT不被视为干净。艾琳，在我们开始录音之前，你告诉我们你有一个朋友刚刚去世。我不知道你想说多少关于这些情况。这是你认识多久的朋友，他是怎么死的？我认识他自从

我开始参加我所称的我们的家庭小组的12步小组，回到二月份。他快要一年没有喝酒了。在18天内，他就会有一年。他，你知道，这就是事情发生的方式，人们停止，然后他们又回去，他们认为他们可以使用以前使用的相同数量，但你再也不能了。如果你回去，你基本上是在自杀。

并不是总是和我很亲近的人，但我知道每周都有一个人死去。但是，我是说，这一个，你知道，我昨天和他在一起。我们在谈论下周的钓鱼旅行，开玩笑。你知道，他妈妈刚在Facebook上和他谈论她对他的骄傲。这真是一个可怕的疾病，你知道。是海洛因吗？可能是海洛因和芬太尼。现在一切都是芬太尼。

阿片类药物危机实际上始于处方药，然后转向海洛因，现在是合成芬太尼，这带来了特别高的过量风险。为此，费城目前正在考虑另一个想法。我们都是减少伤害的倡导者。妮可·奥唐奈再次，认证康复专家。所以我们倡导安全注射实践，

针头交换。但我们都在倡导这个安全屋，这是一个让人们安全不至于过量的地方。他们去，使用，

药物进行检测。他们有医疗人员。希望有同伴在那儿引导他们进入治疗，就像我们在急诊室所做的那样。奥唐奈所描述的合法、官方的安全药物使用场所尚不存在，至少在费城还没有。美国已经批准了两个地点，一个在纽约市，已经投入使用，另一个在罗德岛的普罗维登斯，仍在开发中。这样的场所在几个加拿大城市也存在，费城，

安全屋非营利组织得到了许多地方和州官员的支持，但它遭到了美国司法部的反对。如今的形势并不乐观。联邦法院最近在针对司法部的多年案件中裁定反对安全屋。我倡导安全屋的理由是为了像你朋友那样刚刚去世的人，因为他正在康复。对。如果我使用，我会死去。

幸运的是，通过我多年的倡导，我有一个人，我有一个安全屋。如果我不想死，我会打电话给我确保我不会过量。我有这个。这是一个安全网，对吧？并不是每个人都有这个。所以这是我们希望人们能够去的地方，就像你的朋友。如果他在这个地方，他就不会死。

成瘾的对立面不是康复。成瘾的对立面是社区和关系。如果你死了，就无法拥有社区。斯蒂芬·劳德博士再次强调。因此，第一件事是让患者活下来。现在，我们让他们活得越久，就越需要能够让他们参与到支持性环境中，几乎涵盖一切。你对我想知道的，关于非法药物的合法分销商的立场是什么？我很好奇在田纳西州是否有任何朝这个方向的运动。是的。

你真的让我处于一个麻烦的位置。我认为我们必须在这一点上考虑所有减少伤害的策略。因此，我认为每当你减轻与成瘾相关的污名时，你就增加了人们走出阴影并寻求帮助的机会。我支持任何能够让人们达到这一点的方式。

宾大温暖交接计划仍然相对较新。我问康复专家妮可·奥唐奈，她一天能见到多少患者。在一个普通的日子里，我们可以看到多达六个人。我是说，无论他们是因医疗原因住院，还是在我们的住院药物和酒精治疗中，或者他们通过急诊室。而在这六个人中，有多少人愿意至少和你谈谈药物辅助治疗？

老实说，愿意谈论的人并不多。无论他们是否想要东西，这是另一回事。你知道，然后我们进行减少伤害的对话。但没有人真的把你赶出房间，说我不想谈论任何事情。所以如果关于阿片类药物、药物使用、滥用等的一个误解，许多像公共广播爱好者这样的人会听到，如果有一件事他们真的不知道，你想告诉人们什么？阿片类药物使用障碍是可以治疗的。这不是死刑。这不是，你知道，这是一个医疗状况，是可以治疗的。当你这样说的时候，听起来如此简单，但...

现在在政治界围绕这个话题有很多讨论，但从来没有这么简单地说过。为什么不？因为我们喜欢把事情复杂化，而实际上并不需要复杂化。艾琳服用她的药物，她参与，并且她去会议，她做得很棒，她是她儿子的妈妈，对吧？这是可以治疗的。我们不必把它复杂化。

这是我们关于阿片类药物危机的2020年报告。我们最近联系了宾大的团队以获取更新。佩罗内博士告诉我们。自从我们上次交谈以来，我们的项目已经大幅增长。我们在宾大成立了一个新的中心，称为成瘾医学与政策中心，并获得了多个资助以维持我们的工作。

Freakonomics Radio由Stitcher和Renbud Radio制作。你可以在任何播客应用上找到我们的完整档案，也可以在Freakonomics.com上找到，我们在那里发布转录和节目笔记。本集由扎克·利平斯基制作。我们的工作人员还包括阿丽娜·库尔曼，奥古斯塔·查普曼，达尔文·阿布阿吉，埃莉诺·奥斯本，艾尔莎·埃尔南德斯，加布里埃尔·罗斯，格雷格·里平，贾斯敏·克林格，杰里米·约翰斯顿，朱莉·坎弗，莱里克·鲍迪奇，摩根·莱维，尼尔·卡鲁斯，丽贝卡·李·道格拉斯，莎拉·莉莉和陶·雅各布斯。

我们的主题曲是《Mr. Fortune》，由Hitchhikers演奏，我们的作曲家是路易斯·格拉。感谢您的收听。Freakonomics Radio网络。万事皆有隐情。Stitcher。

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