Opioid Use and Drug Safety during COVID-19

Video length: 33:27

Transcript

[Camille Schrier speaking]

Hello everyone and welcome. My name is Camille Schrier and I’m Miss America 2020. I am here with Dr. Nora Volkow, the Director of National Institute on Drug Abuse, or NIDA at the National Institute of Health. And today we are going to be discussing opioids during COVID-19. Just before we start, you are welcome to submit any questions at any time during our program. We would love to answer them. So, welcome Dr. Volkow. Thanks for joining us today.

[Nora Volkow speaking]

Camille, thanks for having me. It’s a pleasure meeting you. 

[Camille Schrier speaking]

I am so excited to be able to work with you. I am excited to speak with you particularly about opioids and opioid abuse. I spent so much of my time as Miss America educating the public on medication safety and abuse prevention. That is my social impact initiative that I have dedicated my year of service as Miss America to. 

I feel like there’s a real lack of knowledge and information about addiction. And there’s a lot of misinformation out there that exists on substance abuse and substance use disorders and opioid addiction. Do you feel the same way from your perspective? Do you feel that there’s a lot of misinformation out there?

[Nora Volkow speaking]

Yes, indeed, and as you are speaking a lot of things jump into my brain about misinformation. And I think that one of the components about drugs, particularly with opioids and I commend you for taking this on because it’s the most challenging addiction that we have. Because opioids can be beneficial for people that have severe pain and there’s nothing better when you have horrific pain so you cannot ban them from the earth and yet they are also highly addictive. 

So, how do we balance the world in terms of taking advantage of the potential therapeutics for those that benefit while protecting everyone else so that they do not become addicted? And understanding first of all why is it that drugs produce addiction and what happens in our brain when we become addicted it’s fundamental in order to be able to do that. And people don’t really understand still in healthcare, in lay public there’s this sense that people are taking drugs because they want to take drugs. That it’s a choice behavior. So yes, there are many misunderstandings out there.

[Camille Schrier speaking]

That’s so true. And so, you brought up exactly what I wanted to start with, is these are prescription medications. They have intended use and most of these medications - I’m a Doctor of Pharmacy Student. So, I think of the DEA classifications. So many opioids have a C2 on the bottle because they are classified by the DEA as a classification two. They do have prescription use is the point and they have intended medical use.

So, what are opioids used for when they’re used properly? What are the real things that these are treating? What kind of conditions?

[Nora Volkow speaking]

Opioids can lifesaving particularly in circumstances of acute, severe pain. So, if you have a myocardial infarct, the pain has been so bad that if you don’t treat it, the patient may lose consciousness. I was in a horrible car accident and I recall the pain was so incredibly intense, but I wouldn’t lose consciousness and it was horrifying. And then they gave me an opioid and the world changed. So, when you are in those circumstances where you need to manage the pain in order to provide actually further cure to the patient, opioids are lifesaving.

The problem becomes when people start to rely on opioids for management of moderate to mild pain conditions or when they use it for long periods of time where opioids are not so useful because you become tolerant to them. And the more you use them, the longer the period you use them, the greater the risk that you can become addicted. And again, pain is a very challenging condition to control particularly when it’s severe, particularly when it’s chronic.

So, there are some instances where patients don’t respond to anything else and may require opioids in long-term. So, understanding how to monitor someone when it’s safe, when it’s not safe is one of the key lessons that we’re basically been taught by the current opioid crisis. So, yes, they do have value, opioids but yes, they also can be horrifically addictive.

[Camille Schrier speaking]

That’s so true. That’s one of the best descriptions that’s I’ve really heard about the proper, intended use of these medications because they absolutely do have value but they’re so widely misused. So, let’s talk a little bit how widely are these prescriptions misused? Why are people misusing them and how does this happen?

[Nora Volkow speaking]

Well, people are misusing them, and I can speak on personal experience because when they gave me an opioid in that car accident, I recall I was in a lot of pain and then the pain disappeared. But it’s not just that it disappears. I had this sense of wellbeing that was extraordinary. And I’ve never had that sensation ever just come like that to me. And immediately I realized why these drugs could be so addictive.

They can activate [inaudible] pleasure centers. Why? Because they basically are taking advantage of our own signaling endogenous opioid system and that androgynous opioid system, one of its functions is generate the sense of wellbeing. And our brain has evolved to reach, to seek out a state of wellness and comfort. And so, when you are feeling uncomfortable, you are motivated to do things to get out of it. So, imagine that your brain learns that if you take this opioid you, you just achieve nirvana. 

You learn it immediately and that in an unconscious way will drive you wanting to seek the same experience. And that’s what we call conditioning and that’s why drugs are so malignant. They condition us to them making us their slave. So, you have this automatic desire even without realizing that you are remembering that sensation. You just have this motivation and drive to take it and that’s why these drugs can be so addictive and so malignant.

[Camille Schrier speaking]

And that was not something that I really understood before I became a Doctor of Pharmacy Student. That we had this endogenous opioid system that already existed in our body and that endorphins are really our body’s natural substrate for that opioid receptor that we are then hijacking with opioid drugs. And that was just so interesting for me to learn. And so, my biggest question for you is, you talked a little bit about tolerance to these medications. What is the difference between that physical tolerance and physical dependence and the actual compulsion of addiction?

[Nora Volkow speaking]

And this is actually one of the misunderstanding even among physicians. One thing is physical dependence and one the other thing is addiction. Physical dependence will happen to anyone of us who you give an opioid repeatedly. And it is linked to a certain extent with tolerance so that means you need higher and higher doses to achieve the same effect. And as physical dependence develops which can actually develop after a few days or one day of exposure to opioids, the cells in your body compensate.

Such that when you remove that opioid, they have a hyper response and you have hyperalgesia, increased pain, increased anxiety. And it’s very, very, very uncomfortable. When they gave me opioids, they admitted me to the hospital. They put me there for two days. And I left the hospital and I said no more opioids and I went cold turkey. And I recall feeling horrible that night. It wasn’t the pain; it was a restlessness. It was just this not being in my skin. And then I realized that that was physical dependence. And then two, three days later, it was completely gone as if nothing had happened. 

So, it’s short lasting and in general it basically just wanes off. You just have to go slowly down. My error was to just cut it abruptly. You do it slowly and then the physical dependence disappears. Addiction is much more complex. Addiction entails longer lasting exposure and it involves memory and strengthening processes that create that conditioned responses that would drive automatically your behavior. So, you have learned this unconsciously that that drug provides a sense of wellbeing, so you’ll seek it out. 

And at the same time there are changes in the frontal cortex of your brain which is the one that allows us to make a decision and to be able to carry it through. So, if I say no, I’m not going to eat that dish because I’ve had enough, my capacity to control no more eating is my frontal cortex. But if you remove that, if you degrade that, then I’m not going to be able to control the urges of wanting to eat more. 

So that’s what happens with drugs. You have an enhanced motivation and drive but an erosion of the capacity to self-regulate and to produce inhibition of these desires. So, it’s like, I always like to say very simple. You have a car where you have the accelerator stuck at maximum and you have no breaks. So that’s in terms of the two simple systems that are being generated that drives your behavior. And behind these two systems, there’s another one that other patients that also are very difficult to deal and not everybody realizes is that the more you get exposed to the drug, with the tolerance, the more you require the use of the drug not to get high. 

You stop getting high. But to feel normal. So, you are trying to escape. It leads you to escape this state of dysphoria and stress. So that is the third element in addiction. So, it’s not just the drive, and automatic behavior and the inability to stop it. But this sense of distress and anxiety that wants you to try to escape it and you take the drug to escape it. So that’s in a simple term, the three systems that get damaged when you become addicted to drugs.

[Camille Schrier speaking]

It’s such a complex issue that’s really difficult to understand, I think if you don’t understand the science behind it. And I think that’s why it’s so important that we talk about this. We’re both women of science and I think the understanding those background issues really helps, at least for me, I feel like it helps people bring some empathy to those who are struggling with substance use disorders. Because many times I hear people thinking that it’s really a choice that these people who are fighting this battle are making. 

Why don’t you just stop using drugs? And it’s so much more complex than that in terms of the physical and the actual mental pieces of this that both go together and make the battle twice as difficult to fight. And that’s why I think that it’s really important that we talk about this. But also, we were talking about we have this endogenous system in our body. So, what happens when we hijack that with drugs, and we get into dangerous situations? So of course, we think of using opioids and potentially getting into an overdose situation. Why is that life threatening? What is happening? If this system is already in our body, why is it dangerous?

[Nora Volkow speaking]

It’s very dangerous because first of all, our own endogenous opioids are actually being released as a function of specific stimuli and for a particular short period of time. And they interact with the receptor for very short periods of time. Whereas these drugs have been designed, particularly drugs like fentanyl to have an incredibly high affinity and to attach to the receptor. So, it’s not like you attach and detach. And in the case of overdoses where it is produced by the opioids binding to receptors in respiratory centers in the deep parts of our brain, very close to where the spinal cord is. 

And there is a center there that allows us to breathe automatically without having to think about it. Of course, I can think about it and I said I’m going to stop to breathe for just 20 seconds but then there’s a point that it overrides and most of the day I don’t ever think about it. And opioids bind to receptors there and basically inhibit that center. And so, what happens if you are taking a high dose of an opioid, heroine, fentanyl or a high dose of morphine, the receptors bind there, and your respiration goes slower and slower and slower until you lose consciousness. 

And the drug is still bound there until you stop breathing but you’re unconscious and you don’t realize that you are no longer breathing. And so, there’s no oxygen going into your body, there’s no oxygen going into your brain and that’s why you die. And so that’s exactly where the overdoses are coming. Now even though when you are taking it, people know that there is a risk of overdoses. They realize that and now with the very potent drugs that are out there like fentanyl they know that the risks are even higher. 

And so, the question that we all ask ourselves trying to understand why is if they know these extremely high risks why are they still doing it? And I think that the answer is because it’s more powerful than their own abilities to self-regulate and to exert the best judgement. It overpowers their judgement. And you say well, how can something like that overcome your judgement? And I always like to think about it in terms of, we have in our brains the capacity to fall into a state where you have to overcome your judgement. 

So, say for example you are starving, and you haven’t eaten anything. And so, you see this food that’s contaminated, and you say okay, if I eat it, I’m going to get sick. But the hunger is so strong that you overcome that judgement and you eat that food and you get sick because there’s a point where if you don’t eat the food, you’re going to die. And in a way, and this insight was given to me by a patient that described addiction. 

He said, it’s almost like if you don’t have air and you need the air so badly, that’s exactly the intense drive to get it, that if you don’t you are not going to survive. So, it turns the drug into a deprivation state that you need to overcome in order to survive. And that’s why people take such gigantic risks and are willing to end up with an overdose because their brain has now shifted to that stage of perceiving the experience as one of survival and deprivation.

[Camille Schrier speaking]

That is so scary to think about but it’s the reality for so many people. And I think increasingly more people as time progresses. I know that this has been an issue throughout history for a long time because opioids have been around for a very long time. But really have become I think, more prevalent within my lifetime ever since the mid ‘90s and have become more prevalent in our national news today. This has kind of become - you know we’re in COVID. We’re in this pandemic situation right now. 

But I feel like we’ve been fighting especially epidemic within our country of opioid addiction and abuse for so many years. So, in terms of the National Institute on Drug Abuse, what are you all doing to help combat this? What are steps that the federal agencies are really kind of able to make to make change in this?

[Nora Volkow speaking]

Well, we as an agency fund research and that research that can help us, for example, understand the changes in the brain of people that are addicted. Research that can help us understand why are certain people more vulnerable to drugs and are more vulnerable to become addicted? Also, to help us research for development of medications that can help a person achieve recovery. What are the behavioral and social components that are necessary to ensure that that person will succeed? 

So, all of these are scientific questions that as an agency we basically fund researchers so that they can guide on the one hand, policy but also the way that we treat people. And one where I hope also, what you’ve been describing is, the attitude of people, the ability to feel empathy. You were speaking about it and I said the notion about we can feel empathy on someone having cancer or Alzheimer’s disease. But a lot of people reject people that are addicted, and they basically discriminate them and mistreat them. And that is the constant issue because people that are addicted, to start, no one likes to be discriminated. So, they don’t seek out treatment help because they don’t want to be discriminated.

And then they incorporated that discrimination into their own self, so they have this self-loathing because they feel that they are weak and that this isn’t under their control. And so, one of the aspects that people don’t speak very much about is that the risk of suicide are much higher among people that are addicted. And it’s in part that self-loathing that comes from saying how is it possible that I cannot control my own desires? I’m so week at that and that desperation can lead people to actually say I don’t want to live anymore like this. And so…

[Camille Schrier speaking]

That’s difficult. And thinking about that really dark piece of addiction, there is hope. There’s absolutely hope for people for recovery. So, what are some steps that people can take to lead themselves towards recovery? And many people have achieved long-term recovery. So how does that function in terms of the brain changing the way the pathways are working? And how are people able to achieve that?

[Nora Volkow speaking]

Oh, absolutely. And I’m glad you’re bringing it up because the brain has the ability to heal itself. Our body can heal itself. It’s fantastic but that’s something that we have. And so, the issue is what is necessary to help you achieve that healing? And medications can be incredibly helpful in the case of opioid addiction. They’re quite affective but it many instances it may not be sufficient if you want to actually achieve complete recovery. Why? Because one of the factors that leads people to actually take drugs is isolation. 

And so, if you have become addicted and you’ve withdrawn and you’ve lost your friends, you’ve lost your job, you lost your purpose in life. That makes you very vulnerable for relapsing. And so, when addressing the issue of addiction, we have to recognize that the disease there are the changes produced by the drug itself in the brain. But as the brain has changed, that person has changed his entourage or her entourage in his life in a way that has isolate them in ways that are very dangerous. So being able to recognize that we need to provide social support systems and that are meaningful.

And that provide that person a mission to feel that they are appreciated, that they belong, that they are excited about doing something, is one of the key components for people to be able to achieve recovery. So it is. We always like to sort of say, it’s okay, it’s a magical thing. Here I have an antibiotic and I’m cured. There are very few things that are like antibiotics and I wish we had something like that. But addiction actually produces downstream changes that require attention. So, the way that we communicate is addiction is a chronic disease and therefore it requires chronic continuity of care and treatment. And it also requires support. 

And when people say, well what can I do and I always say right now, as I’m looking at COVID and how you see people struggling. The issue that there’s something that’s unifying us and that’s the opportunity to be able to do something that helps someone else. That is very reinforcing. 

And I think that we all can help by being there, by providing support, by not tolerating discrimination. By reaching out and giving a hand.

[Camille Schrier speaking]

Absolutely and I think to talk about isolation, I think COVID has brought more isolation to us all than what is normal for even the most social of us and those of us who are [inaudible]. So how is the isolation of COVID really affecting those in terms of opioids and we have so many different substance abuse disorders. I’m sure that just because we have a stay at home order doesn’t mean that those that are facing these issues that that just stops for them. So how is that affecting those types of people?

[Nora Volkow speaking]

Well, we’ve been reaching out to the communities, diverse communities to try to answer that questions because of course, since we’re very aware how important social networks are, to find out what’s happening. And we’re hearing patients are relapsing and people that have been in recovery for a long time are relapsing. And there are people that were taking drugs are increasing and escalating their drug taking. There’s also been a lot of word that there has been an increase in overdoses. So COVID has been very stressful and stress has been one of the factors that contributes to drug taking and to relapse so unfortunately that we are expecting that we will see an increase in overdose deaths this year as a result of COVID. 

And the issue then is what is it we can do to help in these circumstances? And there’s been sort of technology has enabled us to advance in such a way that now we have virtual interactions like the one that we’re having right now. That can be brought for example, into a network that provides support for a patient that is trying to achieve recovery. Or that gives them access to a physician that can give them a behavioral intervention so they can prescribe them medications to help them prevent them from overdosing and staying away from opioids. So, all of these technological advances have provided some level of buffering. 

How affective it is definitely much better than not having it, but we don’t know how effective it’s going to be in the long-term because we haven’t been able to evaluate it long-term. But certainly, it has been very helpful to have access to these technologies. And I’m very grateful that you are doing this because I think that one of the aspects that we all learn is we all learn from others and communicating and feeling that others care for the issue. That it’s not just something that people want to ignore. That there is attention to it, that you are taking the time and saying this is something that we should all try to help with.

[Camille Schrier speaking]

Absolutely and I think sometimes it gets overshadowed by other things in the media. COVID is a huge issue going on right now, but it has kind of silenced that piece of the opioid epidemic that’s been in the country. So, I think that it’s important that we continue to talk about this because it’s not something that just goes away.

We did have a question come in for you. How can we strike a balance between misuse and providing opioids for those who need them? I think that’s a wonderful question. It’s such a difficult issue. And so, what is your recommendation on that?

[Nora Volkow speaking]

Well obviously a lot of doctors are struggling with this question because they realize that in some instances patients with chronic pain need opioids. And I think that one of the lessons that we’ve learned all along is that to start with, we need to provide information to patients about what means by physical dependence, what means by addiction? How can they recognize if they are becoming addicted to it? And also, that the doctors can recognize so that they can intervene. And believe it or not, in many instances they are unable to recognize if a patient is becoming addicted. That’s one of the issues.

The other component is that as a society we’ve grown up with the sense that you shouldn’t have any discomfort. And that medicine should take care of anything away. And that’s unrealistic. And so, when you say to people okay, you have pain and I’m going to give you a medication, you will still have pain but my goal is for you to do your everyday life activity even if you have pain. As opposed to creating the expectation that pain will disappear. And that’s an important message that we all should learn because it has led to over medication for pain and other disorders. 

And allowing and teaching patients how to learn to live with their pain and only use the opioids on circumstances where they actually, it is interfering with their everyday activities and when you’ve tried other interventions that can be helpful. As in the management of pain, we’re moving more and more to multi-pronged approaches that emphasize lifestyles. Physical activity for example has been shown to decrease pain. Proper sleep behavior also has been shown to improve on pain perception. And as you know, I think that we all feel pain. 

People feel pain more at night when there are not many other stimuli going on. So, to the extent that you’re focusing and your concentrating in your own body, you’re going to be much more aware of that pain, that if you teach yourself to actually go outside, focus on some other thing. So, these are some of the elements that clinicians are starting to incorporate in the management of patients. But I do realize that there are some patients that in not giving them an opioid when they need it can be very devastating.

[Camille Schrier speaking]

It is difficult to find the balance, but I think that is so incredibly true. But I did want to ask my final question before we end, is for those who are maybe prescribed and opioid maybe for the right reasons. What are the biggest pieces of advice to keep people safe if they are someone or if they have a family member taking an opioid?

[Nora Volkow speaking]

Well number one, you should always take the medications as directed by a physician. And do not increase the dose, do not increase the frequency. 

Do not combine it with other drugs. Tell the physician that’s prescribing you the opioids which other medications you have. Tell the physician who’s prescribing the opioids if they don’t ask you whether you have a history in the past of having been addicted whether it is tobacco or alcohol in yourself or in your family. Because all of those factors increase your risk for addiction itself. So those are some of the very basic questions which should be addressed as a start point. 

Some doctors have agreements where they say well-and the doctor should be also periodically evaluating to see if the medication is still being beneficial and if not, they need to consider withdrawing it. But they need to be evaluating that periodically and there has to be a dialogue and a trust between the patient and the doctor. So, it is changing the way that we’re practicing how we treat pain in our country and it’s also changing our awareness that addiction is not a disease that we can ignore in healthcare, that it’s very prevalent. And as physicians we need to be training people in the health care system on how to manage it. 

Now, Camille, one question. Can I ask you something?

[Camille Schrier speaking]

Oh my gosh, absolutely.

[Nora Volkow speaking]

You’ve been asking me, and I thought to say I think it’s so incredible to have you as Miss America actually representing science. It sort of says yes. 

I mean this is an extraordinary opportunity. And I wonder, do you have your crown? Would you put your crown for us? And so that I [overtalking]

[Camille Schrier speaking]

Actually, it lives on my desk now because I’ve been doing everything virtually. So, it’s right actually here. I’ll put it on for everyone. This is-it’s a really interesting time to be Miss America who’s a scientist during a pandemic. But it’s also interesting to be a Miss America who’s able to educate about really such serious issues. So, I have the opportunity often to go into schools and talk to young people. And to tell a young person how drugs can be dangerous or how alcohol or substances could be detrimental to their health when I have this on my head, gives me a different opportunity to have students look at me and hear that message. 

And so, I’m grateful for the opportunity to be Miss America and be a scientist and have the opportunity to educate on why these medications and particularly drugs of all kinds can be so scary and detrimental to kids. And that will be something I get to carry into my pharmacy career as I continue with that later after my year is over.

[Nora Volkow speaking]

Well, I’m going to tell you something. That crown is your brain. You have an incredible brain and I am glad that I actually, that I had a change to interact with you. So that crown is very beautiful, but your brain is even better.

[Camille Schrier speaking]

Thank you. 

And that’s really the amazing part of this job now is that Miss America can be a woman of science, getting a doctorate in pharmacy. That’s always kind of what Miss America has been but just to be able to bring that to the forefront now especially as we go into a new decade. And it will be the 100^th anniversary of Miss America this upcoming year so I kind of get to bring it into a whole new light. So, I’m excited for that.

And thank you Dr. Volkow for spending the time to help educate people about opioids especially during COVID. I think that it’s so important and to reach out and get resources if you are struggling with something like a substance use disorder or a mental health issue right now. It’s a very difficult time for all of us and to think of that isolation piece and how that can play in to putting you at a higher risk for these types of issues. So definitely reach out to resources. I know there’s resources list right below here if you are interested in reaching out. Thank you so much Dr Volkow for your time. This has been so, so wonderful. And thank you everyone for watching.

[Nora Volkow speaking]

Thanks to you and best of luck.

[Camille Schrier speaking]

Thank you.