Preet Bharara’s new podcast, “Stay Tuned with Preet” on CAFE, is now live. Listen here on Apple Podcasts. 

STAY TUNED: Inside the Opioid Crisis (with Dr. Abigail Herron and Susan Salomone)

Preet Bharara: Susan Salomone, Dr. Herron, thank you for being with us today. This is a tough topic, and it’s an important one, the opioid epidemic in the country. And I think it makes sense to have an extended conversation about it, not necessarily from the law enforcement perspective, which we can do another time, but to hear the human stories of loss and pain involving this issue, and also talk about treatment, and the medical component, and the public safety and public health aspects of it. So, I couldn’t be more pleased to have the two of you here. So, you folks and I, when I was United States Attorney, together did some town halls on opioids and the crisis. Those were very important forums. And I thought, well, it makes a lot of sense, since I don’t have that job anymore, we can still talk about these issues and still educate the public about them, and parents in particular, by virtue of the podcast.

For the listeners, I want to give a sense of what some people are going through. And like I did at our town hall, I want to play a 911 call, placed by the mother of a child who was addicted to opioids, and she found him after he had overdosed. So, for those of you who are listening, I have to warn you, it’s really difficult to listen to. It’s only 90 seconds. It’s a tough 90 seconds.

“Male: 911.

Female: I need an ambulance. My son’s not breathing.

Dispatcher: What’s the address? 107 31?

Female: 107 31. Yes, hurry.

Dispatcher: Is he blue?

Female: He’s white.

Dispatcher: How old is he?

Female: Oh god, he’s dead!

Dispatcher: Ma’am, I need you to calm down. How old is he?

Female: Oh!

Dispatcher: Ma’am?

Female: [Inaudible]

Dispatcher: Ma’am, I need you to calm down. How old is he?

Female: He’s [?20]! No! [Sobbing] No!

Dispatcher: [?Star] police. How old is he?

Female: [Inaudible sobbing]

Male: Hello? Hello?

Dispatcher: How old—how old is he?

Male: He’s 20 years old. Get somebody over here.

Dispatcher: Okay. Is he breathing?

Male: No.

Dispatcher: They’re already on the way. They’ve already been dispatched.

Male: Okay, thank you.

Dispatcher: Has he taken anything?

Male: We don’t know. He has in the past.

Dispatcher: Okay.

Male: Do you need me on the line anymore, sir?

Dispatcher: Yeah. Hold on just a second, okay?

Female: Oh my god!

Dispatcher: You said he’s 20 years old?

Male: Yes.

Female: Nooooo! [Screaming]

Dispatcher: Okay. What’s his name?

Male: Pardon me?

Dispatcher: What’s his name?

Male: Bryan Fentz, F-E-N-T-Z.

Dispatcher: Okay. We’re on the way, okay?

Male: Thank you, sir.

Dispatcher: Uh-huh.”

Preet Bharara: Bryan Fentz died at age 20 of an overdose. And what you were hearing was his mother finding him. The reason I have that call and the reason I played it was not to exploit the tragedy of that family, but because the parents themselves gave that 911 recording to law enforcement some time ago and asked them to use it so their son may not have died in vain. So, on the very sobering note, I want to start with Susan. You also lost a child.

Susan Salomone: Yes. Thanks for having me on, Preet.

Preet Bharara: Absolutely. Absolutely. Tell us about your experience, your son, what happened.

Susan Salomone: Okay. We have four children, four boys, actually. Justin was my oldest son. He died of a heroin overdose on May 29, 2012. But we had lived with his addiction for ten years. He did okay with high school. He graduated, no problem. He went off to Marist College, and his drug use became—escalated. He really graduated to stronger drugs. And we didn’t find any of that out until he reached out for help when he was about 24 years old. He was addicted to pills, Oxycontin. And—

Preet Bharara: Where was he getting the Oxycontin from?

Susan Salomone: The street. He was getting them from the street. And because he was a risk-taker, he liked to feel different, a little anxious. And so, he used medication. He self-medicated. But I wouldn’t say he had major mental health issues. So, he was buying them from the street, and he got addicted. And he went away to a rehab for 28 days, actually. And when he came out, he learned how to shoot heroin there.

Preet Bharara: He learned how to shoot heroin at the clinic.

Susan Salomone: Yes. So, it’s one of the downsides of going to rehab. Sometimes they learn stuff that they didn’t know. They learn where to buy stuff, and they learn different ways to get high. So, he probably learned that heroin was cheaper than Oxycontin.

Preet Bharara: It is.

Susan Salomone: And it was a better high. So, when he came out after 28 days, I think that night, he was high, to tell you the truth. Around the dinner table.

Preet Bharara: And what did you and your husband do then?

Susan Salomone: Well, we were—see, the things we’ve learned over the last five-and-a-half years are amazing, but we were at a loss. We really didn’t know what to do. So, we kicked him out. And we kicked him out of our house. We asked him to leave the house, that he couldn’t live in our house anymore because he was obviously not committed to being clean. And at that time, we heard a lot of people tell us that they have to be ready to be clean in order to get clean. So, he moved into an apartment. He continued to use. And we then became very frightened for him, and we went to his apartment when we couldn’t reach him, and he was there. And we brought him home. And shortly after that, he went—he was using heroin. He went into a research study at Columbia Presbyterian Hospital. And the research study was for a medication called Naltrexone. And he was in that program for six months, and he did very, very well with it. He had about six to eight months clean from that program, and he was on a shot called Vivitrol, which is a 30-day opiate block. I’m sure the doctor will talk about that. And he was doing great. He had a great job, and he was so proud of himself. In October of 2011, he started to slip, which means that he started to use again. We didn’t know at the time what he was using at that point. But again, we were at a loss as to what we do. What do we do now? So, what did we do? We didn’t do anything. We said, you have to stop using. He wouldn’t stop using. So—

Preet Bharara: Had you thought about another clinic?

Susan Salomone: No. We didn’t think about—he wouldn’t go to treatment. He wouldn’t. You’d be surprised what they’ll say to you. Like, I could teach that class. That’s a very common one that we hear. We work with families now. So, in October, he ODed, and he had an anoxic brain injury, and that means there wasn’t enough oxygen to the brain. At that time in 2011, Narcan was not being distributed to local citizens. It was only EMS, only fire departments, only police departments. Not even the police had it on them, actually. And the EMS came, and they gave him the Narcan, which is an antidote to an opiate overdose, and it didn’t work. So they took him to the hospital, they put him on a respirator. The next day, he started to come to. They took the respirator off, and we found out he had an anoxic brain injury, which was very, very severe. He couldn’t write, he couldn’t type, he couldn’t play his guitar, which was really his favorite thing to do. It was his way of comforting himself. He would never be the same after that. He had a movement disorder as well, so he couldn’t even hide it. So, he said he wanted to move into a group home, which was five minutes from my house. It was transitional living. So he moved in on May 15^th, and he died of an opiate overdose, heroin overdose, on May 29^th.

Preet Bharara: How did you find out about that?

Susan Salomone: The police called my husband and said, “We found your son. He died in the place he was at.” My husband called me. I was a teacher then. I was teaching in the Bronx. And he said, “Your sister is coming up to see you.” She works in the school also. And I just knew. For him to send my sister up to get me. So, he did die there. And I know that he couldn’t have shot up himself because he had a movement disorder. He couldn’t have cooked it. There’s no way he could have cooked it. So, he had someone cook that and help him get high.

Preet Bharara: Did you ever find out who that was?

Susan Salomone: No. And we didn’t even look.

Preet Bharara: But you did decide to do something.

Susan Salomone: I wrote an article called “Saving Justin.” It went into our local paper, the Mahopac News. And I got a call on June 14^th. So that was 15 days after my son died. I can’t even believe it when I think of the timing on this. And the call—the person who called me, he said, “I buried my son this morning.” I said, “Well, we really should get together.” And his name was Lou Christiansen, and his wife is Carol Christiansen, and they came over. And they told us the story of their son Eric, who was a narcotic police officer. He was a narcotics detective, and he got addicted to painkillers that were prescribed by a doctor for back pain. And he went to his mother. Carol always tells this story. He came to his mother Carol and said to her, “Mom, I think I’m addicted to painkillers.” And Carol said, “How could you be addicted? They were prescribed by the doctor. You know, you’re not addicted.” Anyway, he was addicted, and he went to treatment in April, came out, started using again, and went back to treatment in June. Came out, and died of a heroin overdose. We started an organization called Drug Crisis in Our Backyard that night at our table. Our mission is to bring awareness of the rampant use of heroin and opiates in our community, to recognize this is a brain disease, to stop the stigma associated with it, to help families who are dealing with this in their homes right now, and to advocate for legislation that creates better transitional housing, for one thing, and easier access to treatment. That’s our mission, and we have been on it for six years now.

Preet Bharara: I know you have been. And it’s very important work. Here’s a sentence that you wrote in the article that you mentioned. You know, there are a lot of people who don’t have resources and who don’t have support groups. And people think that that’s why they have their problems. But as you point out about your son, you wrote, “He had everything he needed—a job, a sponsor, a program, a therapist, a supportive family, and many clean friends, but he couldn’t shake the addiction.” What advice do you have for people, given all that you’ve learned and all that you’ve gone through, who are having this problem in their own families?

Susan Salomone: Well, I’d say don’t give up hope. I lost hope. And they feel it. When you lose hope as their parent, the person they really need emotional support from—when you lose hope, they lose hope. And I learned from watching my son try to get clean that if a parent thinks it’s painful when their child relapses, they have no idea how painful it is to the person himself or herself that is addicted. They feel so defeated. Their self-esteem is destroyed, and they feel that they really cannot do this. And many of them can’t do it, and there are a lot of suicides related to this that doesn’t even come into the count when you start to look at the deaths surrounding opiate addiction and drug addiction. There are so many suicides that aren’t even in that number.

Preet Bharara: Yeah, the number of deaths are significant underreported, everyone thinks. Let me bring in Dr. Herron. Doctor, thank you for being here as well.

Dr. Herron: Thanks for having me.

Preet Bharara: Could you explain to folks what your specialty is?

Dr. Herron: I’m an addiction psychiatrist and an addiction medicine specialist.

Preet Bharara: And why’d you choose that line of work?

Dr. Herron: Not what I thought I was going to do. I’ve always been interested in behavioral health. When I went into residency, I started doing research because I thought that seemed interesting to do research, and I found my people. I loved working with people with addiction. I liked all the different interfaces of medical and behavioral health, and all the components that went together.

Preet Bharara: How come? How come you like working with people with addiction?

Dr. Herron: You know, I think that what people don’t realize, and what people always say to me when they hear what I do is, “Oh, it must be so hard.” And of course, there are parts about it that are hard. But there’s also a tremendous capacity for change. And people can get better and can recover, largely through their own behavioral choices, which is not something that’s true in most other diseases, right? A lot of other things we have, cancer cells are growing, or your blood sugar is doing what it’s doing, and you’re not capable of just doing something yourself and taking on action that can make you better.

Preet Bharara: So, an opioid addiction does not have to be terminal.

Dr. Herron: No, it’s chronic. And I think that’s the part we don’t think about enough, right, is that addiction is a chronic brain disease. And whether you are actively using or not, you still have the disease of addiction. But it doesn’t mean you need to die of an opiate overdose. And there are many people who are alive for 30, 40, 50 years in recovery now, and those people are incredible success stories. So, it doesn’t have to end this way.

Preet Bharara: Can we take a step back and go through some terms?

Dr. Herron: Absolutely.

Preet Bharara: And some of the medicine? Because we’re bombarded with sound bytes about the opioid crisis, and people have stories of pain. We’ve heard some today. But I’m not sure that everyone appreciates what some of these things mean. So first, most basically, what’s an opioid?

Dr. Herron: So, an opioid is a group of medications an illicit drugs. So, it includes things like heroin, which is the most well-known illicit group, member of the group, and also things like prescription painkillers. Fentanyl, oxycodone, hydromorphone. So, things you might get if you got—

Preet Bharara: Percocet as well?

Dr. Herron: Percocet’s a brand name, but yeah, it’s something you might get if you got a wisdom tooth taken out, if you had chronic back pain.

Preet Bharara: What are some other brand names?

Dr. Herron: Oxycontin, Dialudid are some of the most popular. Roxicet. So, people often will use street names for things, like Oxys, Roxys, that trade on that sort of brand name.

Preet Bharara: They’re all in the same family.

Dr. Herron: All in the same family. And to your brain, they all very quickly undergo a metabolism where they act the same way. We have opioid receptors in our brain. They’re there for pain relief. We also have something called endorphins, which are natural opioids that help us when we have—when we exercise, or that are part of the pleasure center of the brain. These drugs and medicines all act on that part of the brain to produce pleasure and relieve pain.

Preet Bharara: So, can you describe the physiology of addiction? So, not everyone gets addicted.

Dr. Herron: No.

Preet Bharara: Millions of these pills are prescribed, and we’ll get to whether or not that’s too many. But a lot of people take them. I took them briefly after I had a head injury. Some people get addicted, some people don’t. What’s the difference?

Dr. Herron: So, addiction is a chronic brain disease, but it also has a behavioral component, and I think this is the part that’s hard. So, you can have the genetic makeup and the setup for addiction, and if you never have exposure to these drugs, then you don’t ever know that you have the disease of addiction. And of course, lots of people can take them even chronically for chronic pain and for other things, even for years without developing it. For some people, this use triggers something in their brain where they start seeking that pleasure over and over again, and at some point, it converts, where it is not so much about pleasure-seeking anymore and becomes more about relief of discomfort, relief of anxiety. And the use, if you look at many people with longstanding opiate addiction, they’re long past being high or enjoying it anymore. They’re using at this point to not be sick.

Preet Bharara: Well, that’s the frightening part of this, right? As Susan was pointing out, a lot of people begin innocently. And you go and you get back surgery, or you have some other kind of operation, and the doctor prescribes you, as was thought appropriate, some kind of opioid, and you take it, and the next thing you know, you’re addicted. What is an overdose, and what happens during an overdose?

 

Dr. Herron: So, one of the things I want to say about opioids that makes them so particularly problematic and why this epidemic is so time-sensitive in a lot of ways compared to some other drugs is that opioids have the capacity to kill you from even a single use, which is arguably not true for certain other drugs. It’d be very difficult to have a marijuana overdose, for instance. So, there’s other problems for long-term marijuana use, but not in the same way. Opioids, among their good things like pain relief, also shut down the respiratory drive, so they actually tell your brain, you don’t need to breathe as much. And when you take high amounts of opioids, it can shut down the drive so much that you stop breathing. So, people die from respiratory depression, lack of oxygen.

Preet Bharara: That’s what a typical opioid overdose is.

Dr. Herron: Yes. An important thing to remember, though, is that that’s not instantaneous. It’s not what we see in the movies, where somebody puts a needle in their arm and they’re dead in 30 seconds. And what happened with Sue’s son is it really illustrates the point. There is an opportunity in many cases to intervene medically during that time.

 

Preet Bharara: Let’s talk about one of those interventions, because Susan, you mentioned it.

Susan Salomone: Yes.

Preet Bharara: A more recent drug that is much talked about by elected officials and law enforcement agencies and first responders. Talk about what that is.

Dr. Herron: Yeah. So, an incredible advancement that we’ve had is a medication that existed, which is—the brand name is Narcan, or the generic name is Naloxone. It’s an antidote. It reverses opioid poisoning and is used by first responders, but now in some states, including New York, can be used by lay people to reduce the consequences and reverse an opioid overdose.

Preet Bharara: So, but at what point can Naloxone be used, and when does it cease to be effective?

Dr. Herron: So, people have to still be alive. It won’t reverse someone who’s dead. So, if someone has completely stopped breathing, if they’ve ceased brain function, if their heart’s not working, Naloxone’s not going to reverse that unless you’re in that first 30 seconds or so that that happened. But if someone’s unconscious, breathing very shallowly, maybe has a weak pulse, is unresponsive, there is an opportunity to be able to administer this medication and potentially reverse it and save their lives.

Preet Bharara: What would happen if you administered Naloxone to a healthy person?

Dr. Herron: Absolutely nothing. I could give it to my two-year-old. It does nothing if you’re not high on opioids. It’s completely safe to take. I could give it to you right now and nothing would happen.

Preet Bharara: I’ll pass for now. But I’ll just sip my water. So, should everyone have Naloxone in their home?

Dr. Herron: I think everyone should have Naloxone in their home.

Preet Bharara: Like EpiPen.

Dr. Herron: Except even more, because you’re only gonna use the EpiPen on somebody that has the allergy in their body. This could be on anyone that took an opioid, including an accidental overdose. So, if a kid got into medication out of your medicine cabinet, Naloxone could be lifesaving.

Preet Bharara: Is there any concern that people will assume more risk because they think there’s this lifesaving, reversible drug that they can take?

 

Susan Salomone: I’ve heard that. I’ve heard that complaint. If it save a life, I mean, I think that the more people that have Narcan, the better. And people that say that really don’t understand this disease. I think that it’s a lifesaving medicine that should be used. And if it can save a life, then that’s what it’s being distributed for.

Preet Bharara: So, for the people who are listening, and they’re thinking to themselves, do I know anyone who looks like they might have an opioid addiction, but they don’t know for sure, what are the warning signs for them to look out for?

Dr. Herron: People withdrawing, not doing activities that they used to do, giving up things that they enjoyed in order to spend time with drugs or getting drugs, depression, feeling withdrawn.

Susan Salomone: If they’re missing spoons. That’s a big one.

Preet Bharara: That’s a very [crosstalk] one.

Susan Salomone: You’re smiling, but it’s—I looked in my drawer, my utensil drawer one day, and I said, where are all my spoons going? Okay, so that—and also, rubber bands. If they see rubber bands around or any kind of Band-Aids. And one other thing. If you look in your wallet and you say, I thought I had a $20 bill there, when you’re not trusting your judgment, and you intuitively feel that something is wrong, there’s probably something wrong.

Preet Bharara: Yeah. What’s different now than before that’s causing people to take more of these pills? Is there something going on in the culture, or is it just a multiplication of addiction in the normal course?

Dr. Herron: We didn’t used to have these medicines. So, it used to be heroin, and there was only a subset of people that would ever even know how to get heroin or interact with heroin. And that’s only available in certain parts of the country. So, it’s hard in a rural area to get heroin.

Preet Bharara: Although easier, based on my experience.

Dr. Herron: Much easier now.

Preet Bharara: In rural areas in Vermont and other places, there’s an influx of heroin now.

Dr. Herron: Yes, and so—

Preet Bharara: For this reason.

Dr. Herron: Absolutely. But until these medications came to market and became so popular, there were very few choices, and they weren’t readily available until the late ‘90s, early 2000s, which is when you see the explosion. So, the opioid epidemic absolutely tracks along with opioid prescribing.

Susan Salomone: Can I address that?

Preet Bharara: Please.

Susan Salomone: Okay. So, in 1996, there was a patent on a particular opiate. And from 1996 to 2001, that company marketed to doctors in the total of $135 million to tell these doctors, all the doctors, that this drug was non-addictive, and only one percent of the population would get addicted to it. That company, in 2007, pleaded guilty to false advertising and was fined $634 million by New York State. However, the cat was already out of the bag, and the streets were flooded with these pills by then.

Preet Bharara: Tell people which company that was.

Susan Salomone: Purdue Pharma. So, we know this epidemic was started because of money.

 

Preet Bharara: What do you say to the people who rely on pain medication medications? They’re in pain because they have cancer or some other difficult disease. How do you balance this issue of preventing the epidemic of overdoses and dealing with addiction on the one hand, and on the other hand recognizing, which I presume you do recognize, that there is a good faith, legitimate, helpful aspect to these medications?

Dr. Herron: Responsible opioid prescribing is something we now are talking a lot about, but it’s a relatively recent development in medicine. And when I went to medical school, no one ever talked about this at all. That wasn’t that long ago. So—

Preet Bharara: No. You hurt your leg and you went to the doctor, and they gave you a million pills.

Dr. Herron: Right. So, one of the things to really do is look at prescription monitoring programs to see if people are going to multiple doctors; to check your [?ontoxicologies], to make sure people are taking the thing you prescribe them and not diverting it and selling it for heroin instead; to limit quantity and not give someone a month-long supply if you’re doing a first course of medication. All of these things to get access to the medicines for the people who need them, but to not put this out there. The street value is enormously high. If you give someone more pills than they need, the temptation to then divert them or sell them is very strong.

Preet Bharara: So, what’s your advice as a doctor to the average person who is incapable of knowing that they are more susceptible to addiction, and has an operation, and has pain? Separate and apart from what the doctor prescribes, what is your advice to the average person who is in pain after a legitimate medical procedure? Should they just suck it up?

Dr. Herron: No. And I think undertreating pain, especially in people who’ve had past addiction, is actually a recipe for illicit use, right? So, if people were previous heroin addicts and now they’re afraid to get pain meds, sometimes they’ll go and seek illicit things. I think people have to be honest about why they’re using it, what their pain level is, and they need to feel that they can tell their doctor what’s going on without risk of being thrown out of the practice, of being cut off. So, if you’re starting to notice a problem, if you’re starting to notice you took an extra one just because it helped you sleep or because you felt a little bit anxious, or you’re doing it other than the original indication, people need to stop right then and be responsible to say, “Something’s going on here. Maybe I don’t need this anymore,” and share that with the doctor. And doctors need to ask about that. But if you’re clear in the beginning about the expectations—these are diseases where relapse is expected. And no one thinks that if you have diabetes and your sugar is high that you should hide that from the doctor, or not go back, or not talk about it, or that you’re gonna get thrown out of the practice because your sugar got high. And that’s often not the case with addiction. So, people are afraid to say they slipped. They’re afraid to say they took a pill. We don’t talk about what will happen if there’s a relapse. And so, people avoid coming back. And they think if we talk about relapse as a part of this disease, then people aren’t so unprepared for what happens when that does occur.

Preet Bharara: The problem of stigma attaching to addiction is a tremendously significant one. How do we reduce the stigma?

Susan Salomone: By keeping the conversation going. By having conversations like this often. We have doctors who ask their patients, is this medication appropriate for you? Instead of saying, I’m giving you this medication. How about, is it appropriate? Give the patient a chance to say, I don’t think that’s the right medication for me. That’s how we’re gonna start to change the culture around this. This is a cultural problem.

Dr. Herron: So, we’ve talked a lot about prevention here, and I think prevention is tremendously important. But I don’t want us to forget the hundreds of thousands of Americans that are already affected and will be affected about this, by this, and to say that there are safe and effective treatments for opioids right now. And we actually have the best pharmacologic treatments for opioids of any drug of abuse.

 

Preet Bharara: So, I’ve heard you tick through them for—okay, why don’t you do that for us.

Dr. Herron: So, there’s three—

Preet Bharara: The most promising, and then also maybe what they cost.

Dr. Herron: Sure. Access is a huge issue. So, there are three main medications that are used for the treatment of opiate addiction. The one people know the most is methadone maintenance. We’ve had methadone maintenance in this country for decades now. It’s only available in specially licensed methadone clinics, or what we now call opioid treatment programs. So, people have to go there to receive the medication, and they actually take it right there in the clinic and then bring home to intervening doses until the next time they’re back. That is still an opioid, and people are physically dependent on it, so you can’t stop taking it. You have to keep taking methadone every day.

Preet Bharara: You take it forever.

Dr. Herron: Not necessarily forever, but you would go through withdrawal if you stopped it. You need to take it daily. It’s a replacement therapy, but with a known dose. We know what’s in it, and it prevents all sorts of mortality and other types of morbidity that’s associated with injection use.

 

Preet Bharara: But there are access issues in part because of geography?

Dr. Herron: There absolutely are. There are several types of access issues. So, geographically, for sure, there are parts of the country where it’s not practical. You could be hundreds or thousands of miles from a methadone clinic. There are also issues around insurance, so there are times when people are not able to obtain it because of prescription drug coverage, although it is relatively inexpensive. It’s been off patent for many years.

Preet Bharara: Any downsides or limitations on methadone?

Dr. Herron: So, methadone is a full opioid. It acts to your brain the same way that heroin would. And it can be lethal in overdose if it was stockpiled or taken inappropriately.

Preet Bharara: And so, the second method?

Dr. Herron: The second medication is the other—is the flip side. It’s something called Naltrexone. This is an antagonist. It blocks opioids. So, if you take this, it keeps you from being able to get high from an opioid. So, if I took Naltrexone and then I took heroin on top of it, nothing would happen. It’s an inhibitor. It doesn’t do anything else for your brain, though. So, it doesn’t give you back any of the pleasure or any of the relief of anxiety, or any of the things that might be missing. So, for many people, this can be a hard thing to stay on because you’re not getting any of the sort of positive aspects that came with use.

 

Preet Bharara: How long has that been around?

Dr. Herron: It’s been around for a while. It’s been popular for the last five to ten years and is available both as a pill you take every day, but a little bit more commonly now as an injectable that’s once a month. The problem with that is it only works as long as you take it, so if you stop taking it, the very next day, essentially, you could get high again.

Preet Bharara: It’s like methadone in the regard.

Dr. Herron: Yes, except it doesn’t—there’s no withdrawal because it’s not an opioid. So, you can just stop it and go back to using opioids. And so, retention on that medicine is not good. A lot of people stop taking it.

Preet Bharara: What’s the cost of that?

Dr. Herron: The injectable is very expensive. It costs around $1,000 for a single injection. It’s not covered by all insurance plans, and it varies state to state. But in New York, there’s pretty comprehensive coverage.

Preet Bharara: One injection lasts how long?

Dr. Herron: 30 days.

Susan Salomone: Or sometimes less.

Dr. Herron: Or sometimes a little bit less at the end.

Susan Salomone: As we’ve experienced.

Preet Bharara: Right.

Dr. Herron: It can start to wear off a bit towards the end.

 

Susan Salomone: Yeah. So, some doctors now are giving the pill. Week three to week four, they give Naltrexone the pill so that the person doesn’t use during that week when it’s starting to wane.

Preet Bharara: And the third method?

Dr. Herron: The last is a medication called Buprenorphine. That’s been around in the United States since 2000, and access to it increased dramatically in 2016. You have to take a special course in order to be able to prescribe it. It used to be limited to only physicians, and Obama opened up legislation in 2016 to allow nurse practitioners and physician assistants, and also to allow doctors to treat more patients with this medication.

Preet Bharara: And how is that different from Naltrexone?

Dr. Herron: This is a really interesting medication because it in some ways sort of hovers in the middle between the two. It is an opioid, but it only acts on your brain part of the way. So, it goes to that opioid receptor in the brain, and it turns it on part of the way. So, it relieves withdrawal symptoms, it helps to prevent craving, but it doesn’t cause the same type of euphoria or side effects that something like methadone or any of the other illicit medications would. This is a still a medicine, though, that would cause withdrawal if you stopped. And so, you do still need to keep taking it or taper off of it in order to discontinue.

Preet Bharara: So, all three medications really require significant duration.

Dr. Herron: Yeah. And I think with opioids in particular, but addiction in general, that is a huge part of what’s missing, is that this is a chronic disease that requires ongoing treatment. The idea that someone could go to detox for a week or go to rehab for 28 days and then never have to do anything else for their disease is unrealistic. And so, for the majority of people to be successful with opioid and to be in long-term recovery, one of these medications is helpful.

Preet Bharara: I don’t know if you can answer this question, but if everyone who died in the last year, and it’s thousands and thousands of people, more people than have died in car accidents and shootings combined, I think, by an order of magnitude—if every one of those people had the ability to get one of these three courses of medication, what would happen to the overdose rate, do you think?

 

Dr. Herron: I think it would go down tremendously. I think a lot of people have tried one of these and failed, and didn’t know there were other options available. They tried them for a time and had trouble, and then they were cut off from their supply. Methadone is inexpensive because it’s been off patent for a long time, but the others are very expensive, so maybe they lost access or prescription drug coverage; their doctor moved out of state; something happened. So, a lot of people have not been given adequate trials with these medications.

Preet Bharara: I wanted to talk about the physiology and I wanted to talk about the personal experiences. I guess we could talk about policy a little bit. How do we make sure that everyone who can benefit from medication because of their addiction to opioids gets it?

Dr. Herron: I think one thing we also want to look at is who’s doing this treatment. So, I’m an addiction psychiatrist. If someone comes to me, they already have an awareness of a problem, right? They’ve sought me out as an addiction specialist. But if you put this into primary care and you teach pediatricians about this and family doctors about this, you allow people to access care in a different model without having to seek out specialty care, and it increases access tremendously. So, the Institute for Family Health, where I work, we do integrated care. If you’re there for primary care and you also have opiate addiction, you can get it from your same doctor, from the same place that already takes your insurance, from the same faces you already know. No one has to know that you’re walking into a specialist’s office. And I think that’s one of the things we want to think about, is who’s doing this work, and not just leaving it up to addiction specialists.

Susan Salomone: Yeah, I think that’s great.

Preet Bharara: But why are we still thinking about it? Why haven’t we done that?

Dr. Herron: A lot of doctors aren’t that excited about treating people with addiction.

Susan Salomone: No, that’s a big problem.

Dr. Herron: So, there’s stigma on the medical side too.

Susan Salomone: It’s a big problem. Doctors do not want to have them sitting in their waiting rooms.

Dr. Herron: And to be fair, there’s a lack of training, so many people don’t know—many people in the medical community don’t know about all of these options, don’t know how to do them, and haven’t been necessarily given the tools and resources to feel comfortable. So, one thing I try to talk to other doctors about is knowing that if you knew there were treatments available, would you feel more comfortable treating one of these people, that having them in your practice, if you knew there was something you could do to help. And many people do feel more empowered then if they understand that there’s medications for this.

Preet Bharara: Susan, how do you think about looking backwards? Your experience with your son and treatment?

Susan Salomone: Families think that they’re gonna send their kids away to treatment or their young adult child away to treatment, and they’re gonna—when they come back, they’ll be better. That’s really what families think. I work with quite a few families. We have a family support group.

Preet Bharara: Right. But what do you tell them is the truth?

Susan Salomone: We don’t tell—first of all, we don’t want to blow them away. But in a family support group, you have the other families who tell their story and how this was not the first time around. This is not their first rotary—rodeo. And so, what do I think about treatment? I think treatment really needs to change. I think that at least for opiates, it needs to change. 28 days does not work. They need treatment that they’re getting in a 28-day program, but then they need continued treatment, just like you would for any other disease. Monitoring afterwards. And we need transitional housing, because people come out after a period of time. First of all, people are not getting 28 days, okay? They’re getting ten days, 12 days, 14 days. It’s barely an interruption of their addiction. Barely an interruption. And they come out, now they’ve been clean for, let’s say, a detox and ten days. They’re clean for 16 days. They come out, they use, and they die. If they don’t die, it’s a revolving door. They’re Narcaned and they’re back in another treatment setting. So, the insurance companies are not happy about paying all this money out for treatment, when in reality treatments are not working because it’s not long enough.

 

Preet Bharara: What do you think is the most important thing for states to do as a policy matter to change?

Susan Salomone: In New York State in 2016, they instituted limited prescriptions on opiates. So, doctors are only allowed to prescribe seven days now without having a face-to-face with the patient again. I think that that should be federal. That would help reduce the use, or at least the number of pills out there. So, that’s definitely one thing. Also, CME for doctors. They instituted in New York State three hours every—

Preet Bharara: Continuing medical education.

Susan Salomone: Yes.

Preet Bharara: Yeah.

Susan Salomone: Every three years. Three hours? It’s not enough. I mean, three hours every three years, that’s an hour a year on addiction medicine.

Dr. Herron: Better than it was before.

Susan Salomone: Oh, that’s right.

Preet Bharara: What did it used to be? Zero.

Susan Salomone: Zero.

Dr. Herron: Yeah. I think that states should help to ensure access to these medications by making sure their insurance companies are offering them, and also look at adequate physician training to be able to prescribe these things.

Preet Bharara: What can ordinary people do who care about this issue?

 

Susan Salomone: Educate themselves. They need to get educated. They need to know what’s happening with their kids, and the education needs to be at a very young age for kids to understand what can happen. And that can be done in a very nonthreatening way.

Preet Bharara: So, I began talking to you guys a couple years ago. And I remember thinking, the problem has been getting worse and worse and worse every year over the last few. And when we walked into the studio today before we started the show, we talked about how it’s gotten even worse since then. Are you hopeful or pessimistic about the future? Where do you see this going in the future, and when might it level off and get better?

Dr. Herron: I am still hopeful about it. I don’t have a crystal ball for exactly what the timeline is. I do feel like over the last few years, this has become so much in the zeitgeist, you can’t really go anywhere without someone talking about it or seeing an article. And it didn’t feel like that even a couple years ago. So, I think we are starting to reach a critical mass where we can’t ignore this problem anymore, but we have at least a generation of people that have addiction that we need to focus on treating before we can really think of prevention efforts making a huge difference.

Susan Salomone: I think that it is gonna get worse before it gets better. There are drugs on the street now that are killing people like that, fentanyl, synthetic opiate. And it’s—

Preet Bharara: Yeah. We didn’t even talk about fentanyl. We have so much to talk about here.

Dr. Herron: You could do days.

Susan Salomone: It is in all—they’re cutting all drugs with it, not only heroin, so it’s a major problem. So, I’m a bit pessimistic, I have to say. I’m hoping that we can turn the corner on this in, let’s say, three years. It starts to come down. Right now, it’s still heading up. And the recent CDC statistics said 20 percent over 2016 for 2017.

Preet Bharara: Well, there’s a lot more discussion to be had, a lot more education to be done, a lot more action to be taken. Susan, Doctor, thank you so much for being here.

 

Dr. Herron: Thank you for having us, and thank you for the attention you’re focusing on this.

Susan Salomone: Yes, thank you very much for keeping the conversation going.

 

Preet Bharara’s new podcast, “Stay Tuned with Preet” on CAFE, is now live. Listen here on Apple Podcasts.