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Interviewer: We know here in the United States, the opioid crisis and the addiction to those drugs is a real concern. But when it comes to the medical side of things, what is opioid addiction?

Joining us today is Dr. Elizabeth Howell. She is an Associate Professor of Psychiatry and the Director of Addiction Psychiatry and Addiction Medicine Fellowship at University of Utah Health and Huntsman Mental Health Institute. Now, Dr. Howell, just to kind of start out, like, when it comes to your perspective, what is opioid addiction?

Dr. Howell: Well, everybody has their own thoughts about it. But if you want to look at the official definition, we would look at something called the DSM, the "Diagnostic and Statistical Manual 5th Edition" of the American Psychiatric Association, and they have 11 criteria. And if you have two or more of those criteria, you have either mild, moderate, or severe opioid use disorder or other use disorders. But I think a simpler way to think about it, because I don't think the general public goes around memorizing the DSM-5, is to think of it as loss of consistent control over use of a substance, continued use in the face of adverse consequences, compulsivity or craving. And then the other part can be denial, and it doesn't mean that you don't know there's a problem, but you're not in touch with how many ways the use of the drug is affecting your life.

Interviewer: So those are behavioral things that we're looking for.

Dr. Howell: Right.

Interviewer: But when it comes to, say, biologically, physiologically, I guess, what is going on when we get into this? Because I've heard that it's not actually the drugs that are causing the addiction.

Dr. Howell: Right. The addiction is actually in the brain. And, you know, there is no addiction without a brain, so we don't know in the field if there's something different about people who get addicted before they ever use or if the drugs cause the brain to change or both. And that's a big mystery. There's actually a really neat study that we're part of at HMHI, called the ABCD Study, that may shed some light on that. But for now, we don't have the answer to that. So what we do know, though, is once people have started using regularly is that the brain is different and it doesn't react the way that the brain of someone who doesn't use drugs reacts.

So, for example, people tell me all the time, "I don't understand why they don't just quit using because I can have a drink and then stop." But the point is that that person's brain is very different than the person's brain who is unable to stop when they start. And there are a lot of different brain changes that happen, and it's interesting because you can actually track some of these brain changes to specific behaviors. So, for example, you know, being out of touch with the consequences of your actions, or not having strong feelings about anything except drugs, those can all be traced to different parts of the brain. So it is behavioral, but behavior comes from the brain and addiction and drug use change how the brain reacts to normal things in our lives.

Interviewer: When we say that the brain is different, I guess, does that mean that there are certain people that are more susceptible to addiction? Does that mean that, you know, is it nature? Is it nurture? Or are certain people just born that way? Do people, you know, grow up leading towards addiction?

Dr. Howell: It's really both. About 40% to 60% of the risk is genetic. That's only 40% to 60%. Some of the other risk comes from life experiences or, you know, where you grow up. If you grow up in a family where everybody else is drinking, of course some of that is genetic, but it is also environment and you are exposed to that. But also, trauma is a huge risk factor for addiction. Trauma, traumatic experiences in childhood, especially, can change the brain in a way that you're much more susceptible to either wanting to use, or when you do use, losing control over your use.

Interviewer: Thinking of those patients, you know, or maybe a loved one is listening right now and they have someone in mind, what kind of treatments are available? Because, I guess, one of the things I want to ask first before you get fully into the treatments is, is there a cure for opioid addiction?

Dr. Howell: There's no cure, as I think of a cure. There is treatment. And this is very similar to other illnesses that we treat in medicine. So, for example, if you have high blood pressure, there's probably no cure. You can definitely treat it. You can do things. You can lose weight. You can exercise. But even people who are very thin and very athletic can have high blood pressure. It's a medical condition. You can do everything you possibly can with your life and you could still be suffering from addiction. You might try everything. You still have, for whatever reason, a very high risk of continuing to be unable to control your use, having craving, etc.

But the treatment that we have tries to at least arrest the process. So for opioid use disorder, one of the most effective treatments we have is medication for opioid use disorder, and this can be kind of controversial for some people, but methadone, buprenorphine, naltrexone, are all different medications that they work in different ways a little bit, but they do help people stabilize so that then they can get their lives back together, and then the behavioral treatments can work a lot better when your life is more stable.

So, really, treatment has to be a combination of things, and it doesn't happen overnight. There isn't a magic medicine, a magic bullet as people call it, to treat any kind of addiction, especially opioid addiction. And the medications only work when you're taking them. Once you stop taking them, your brain is still different and you can start having craving years after you ever used an opioid. And that's the disease if we want to call it a disease, or that's the difference in the brain is that the brain is always going to be seeking the drug even when the other parts of the brain know that it's destroying someone's life.

And I hear this from patients all the time. "I know this is killing me. I don't want to use, but I can't stop." And that's the terrible conundrum that people have when they're in the middle of their addiction and they want to stop. So our treatments are really to help them be able to stop safely and then try to get their lives back together and hopefully heal up some of the brain changes that have happened over the course of their addiction so that they can live a life without being addicted.

Interviewer: So now that we know a little bit more about opioid use disorder and how some of the physiological things that actually comes with this type of addiction, if there is a listener that either themselves or someone in their lives, you know, might be going through this kind of struggle, where do they start to get this treatment, to get this kind of, you know, get on the road to recovery or, I guess, remission if this is a disease?

Dr. Howell: You know, sometimes you can go to your primary care doc or provider and get some help. There are more and more primary care providers who are prescribing medication for opioid use disorder. But then there are others who don't or they don't feel comfortable with it, or they don't know that much about it. And so, then, you would go preferably to an addiction specialist of some kind. The fellowships that I run, the Addiction Medicine and Addiction Psychiatry Fellowships train physicians who finished a residency in a primary specialty to be addiction specialists and to be able to treat regular opioid use disorder and other addictions, but also how to be specialists for people who have really complicated problems, because often we see the patients who've been through many different kinds of treatment and nothing has really taken hold for them and we need to get a little bit more sophisticated or refined about how we're treating their specific addiction. And the medication is only part of it. By no means is it the only thing that you have to do. You can't just throw a medicine at somebody and expect that their opioid use disorder is going to be just fine. It doesn't work that way.

So what you would do is if you, you know, you could start with your primary care provider. If they are not knowledgeable or comfortable, then, you know, one of the things that you can do is you can call, actually, our University HMHI crisis line and they can often help people get connected to treatment because you may need to go in the hospital. It may be that severe. And yet you may just need outpatient treatment, and they can help people sort that out and figure out what's needed.

We also have a recovery clinic over at HMHI, and it's staffed by addiction psychiatrists and addiction medicine specialists and therapists and other staff. And our trainees also work there, and they can help with evaluations and recommendations for treatment. And if you can get treatment at HMHI, fine. If not, if your insurance doesn't cover it there, then we can help send, you know, refer you out to wherever you can get the treatment with your insurance coverage.

Interviewer: And for a listener who might not be in the state of Utah, I assume that there are similar crisis lines in other places of the world?

Dr. Howell: Right. Yeah. So if you're not in Utah, it varies drastically around the country, but there's generally a community crisis line. And the other thing is that there is a 1-800 number through the Substance Abuse and Mental Health Services Administration. But there is a website, and I think it's called "Find Treatment Now" that you can look up and find all kinds of treatment options within your ZIP code and within a certain range from your home.

Interviewer: And for listeners who might be interested in, say, those different resources, they'll be linked in the episode description, if you want to click on your app or on the website. Now, Dr. Howell, I guess the one last thing I kind of want to ask to kind of wrap this up is, what kind of hope do family members and people suffering from this disorder, you know, have when they get into treatment?

Dr. Howell: You know, most people come in to treatment and their families are pretty hopeless feeling. And I'm not trying to sugarcoat addiction. It is a disease that can be fatal, but it's not uniformly fatal. Even without treatment, a lot of people get better over time. But especially with treatment, it can accelerate that process.

There's two things that, I think, are important for opioid use disorder. One is if you are someone with opioid use disorder or you care about somebody who has opioid use disorder, you should definitely get a naloxone overdose reversal kit because the one thing I can't do is help somebody who's dead. And if you die of an opioid overdose when we could have prevented that with naloxone, it's really tragic and unnecessary. So once again, this depends on your community. In Utah, we have utahnaloxone.org and they can facilitate you finding a place that you can get a free naloxone kit to have on hand. And clearly, if you're the person overdosing, you're not going to be able to give yourself naloxone, so it's helpful to have it and for everybody in the family to know how to use it, where it is, etc. I have one in my bathroom. I have a sticker on my door at the house that says, "I have naloxone." And pretty much any addiction provider I know carries some of it around because we never know we could just be walking down the street and come upon somebody who needs to have an overdose reversal. So I would look into that and that's the first thing.

But the second thing is that there is hope for recovery, and I'm always meeting people who are in recovery, who've had severe addictions. I was in another part of the state recently and I was working with a guy on a community event, and he said, "I'm so-and-so and I used to be a heroin addict and, you know, I was . . ." and he told me all about the things in his life that were tragically going wrong. And he made a big change in his life and got into recovery. And I don't know all the specifics, but it's five years later, he's not been using for a while. He's taking care of his children. He's got his own business and he's really successful and he's very happy. So that's what I see can happen. And if you only see the tragic part, you see people in the emergency room or in the hospital with all their complications or you see people who are destroying things in their lives, you feel hopeless. But you never really get to see all the people that do well. And that's one of the nice things about our addiction care system that we have is that we get to see people on both sides, and we're not trying to sugarcoat the tragedies that can happen, but we definitely know people can get better and live productive lives.

Dr. Jones: Ten years ago, our clinics were filled with moms doing meth when they were pregnant and it broke my heart, but times have changed and drugs have changed, and we're going to talk about the drugs we unfortunately send to our babies when we're pregnant today on The Scope. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: So, as we think about the drug epidemics that we're facing now in this country, we think about heroin, and we think about opioids, but I grew up in the era of cocaine, not personally, of course, and so clearly there have been some changes, and it's important because babies that are exposed to these drugs in utero withdraw differently, and some drugs last much longer. So we need to know what's available to the moms, what are moms taking these days, so that we can best take care of the baby. So today in The Scope Studio, we're talking with Dr. Gwen McMillin who is Professor of Pathology and Medical Director of Toxicology at ARUP Laboratories, which is our big national testing lab.

Thanks for joining us, Dr. McMillin.

Dr. McMillin: Happy to be here.

Dr. Jones: So tell me a little bit. You and I are of an age where we've seen things come and go in popularity in the drug business, but what have you been seeing in laboratories from substances that came with the baby after the baby was born? What were babies exposed to?

Dr. McMillin: Well, you're right. Drug use patterns have changed over time, and they are also geographically distributed, so some drugs are more popular in some parts of the country than others.

Dr. Jones: Can you give me an example of that?

Dr. McMillin: So I know that in San Diego, California, for example, methamphetamine was a very, very large problem. That has somewhat abated, and now I would say cannabis or THC-containing products are probably a much bigger problem.

Dr. Jones: Okay. So how about here in Utah? Have you seen a change over the last handful of years? I know we have . . . when people come, women who are pregnant come into our clinic, and we always ask about drugs that they might be using, I think things have changed, if they'll tell us.

Dr. McMillin: Definitely. The opioid epidemic that is affecting many people in this nation has also affected people in Utah, and a larger number of pregnant women are using prescription opioids like oxycodone or hydrocodone. If those moms are treated during pregnancy, then sometimes the drug is switched to one that may be safer, such as buprenorphine. Buprenorphine has recently been accepted as probably the safest opioid replacement for pregnant women.

Dr. Jones: And is it safer for the baby?

Dr. McMillin: It seems to be. There are studies that have shown that the likelihood of a withdrawal syndrome and the severity of that withdrawal syndrome seems to be less with a buprenorphine-exposed baby than with a methadone-exposed baby, or certainly with heroin and the prescription opioids like oxycodone and hydrocodone.

Dr. Jones: So there are reasons for mothers to be truthful.

Dr. McMillin: Absolutely.

Dr. Jones: We've done a Scope on being truthful to your doctor. Be truthful about what they're taking so they might actually have some changes made in the way they're cared for during their pregnancy that might help them and their baby, and it's also important for them to know what the consequences might be for them. So what are we seeing if about 1 in 10 -- that's a big number -- 1 in 10 babies are exposed to drugs of abuse or drugs in this state which might be abused, because it's certainly legal in Colorado in terms of cannabis? So what kinds of things were you seeing in ARUP? ARUP has samples from all over the country, right?

Dr. McMillin: Correct, yes. We receive roughly 50,000 specimens a day from all 50 states.

Dr. Jones: Wow! But that's not 50 baby specimens?

Dr. McMillin: No, no, not that many baby specimens, but we are doing thousands a month of umbilical cord tissue and meconium testing.

Dr. Jones: Okay, specifically to test to see if the baby's been exposed?

Dr. McMillin: Yes.

Dr. Jones: So what are you finding?

Dr. McMillin: So the most common drugs that we are finding are cannabis, as you might expect, so THC-containing drugs, and opioids. And, of the opioids, we do see quite a bit of buprenorphine, methadone, oxycodone, hydrocodone, and then some fentanyl, or meperidine, and sometimes heroin.

Dr. Jones: Wow! So, in terms of cannabis, let's talk of that a little bit, I think because it's legal, people think it won't have any effects on their pregnancy, or it's safe. We know that alcohol, which is legal, is not good for babies, and women largely abstain from alcohol. We know that nicotine, which is legal, is bad for babies, but I'm not sure we've got the word out so much on marijuana.

Dr. McMillin: Right. It is a controversial topic that's the subject of extensive research in many places. I'm aware of quite a bit of research going on in Colorado, for example, right now where mothers are queried about their cannabis use patterns during pregnancy, and both meconium and umbilical cord tissue are tested to help us understand what the extent of the deposition of these different cannabis compounds looks like and what that might mean to babies.

Dr. Jones: Well, so we don't necessarily want to feed these drugs to our babies when they're in our tummies, because then when they are removed from us, we're not going to . . . it's hard to smoke a joint when you're just a newborn. I couldn't get my kid to blow his nose until he was two. It just was too hard for him. We don't want to deliver these drugs to our babies through breast milk. Do you ever test breast milk?

Dr. McMillin: We actually do not test breast milk, and that's because it varies during a feeding, and so to do a good job, one would have to collect all of the breast milk from a feeding, mix it up and then test a portion of that, and even that is just a snapshot based on what mom was doing just prior to the collection, so it's not very informative. But we do use the results of the umbilical cord and meconium testing to help counsel a mother on whether she should be breastfeeding or not, and that's because we know that the THC-type compounds actually concentrate . . .

Dr. Jones: That's the marijuana kinds of compounds.

Dr. McMillin: Yes, the psychoactive compounds in marijuana tend to concentrate in the breast milk, and so maybe several-fold higher in concentration in the breast milk than they are in the blood, which, of course, would potentially expose the baby to a dangerous amount of these drugs.

Dr. Jones: Well, we know that some of the withdrawal symptoms are different, so babies withdrawing from methamphetamines might behave a little bit differently than babies withdrawing from opioids, but some babies withdraw for a long time. It takes a long time for them to get over that. Can you talk to that at all?

Dr. McMillin: Well, yes. Unfortunately, most babies don't get exposed to just one drug, so usually if a mother is using drugs during pregnancy, she's likely to use multiple drugs, and the withdrawal symptoms will look different for exposures to multiple drugs in combination. The timing, as you mentioned, is also variable because, for the withdrawal symptoms to be precipitated, the drug actually has to be eliminated sufficiently that the baby's body needs that drug or wants that drug, and will respond in such a way to solicit that drug.

Dr. Jones: Okay, so let's put it in common terms. If a baby wants the drug, what will the baby be doing? So what does a baby do when it wants its breast milk drug? It cries, it gets irritable, it wags its head around looking for a breast. So what do babies do when they're looking for their marijuana drug or their . . .?

Dr. McMillin: Irritability is a major sign and symptom. There's some well-characterized cries, shrieks, if you will, that suggest a baby is needing drug. There may be seizures which, of course, are really scary. And so, yeah, the baby will get very restless, their vital signs will ramp, so heart rate, temperature, and, you know, it's a pretty characteristic syndrome that . . .

Dr. Jones: That makes it really hard for a new mom, who is having her own sleep disturbances, and may not be at the top of her game, to have a baby who's really hard to soothe, because the breast isn't going to be enough to soothe that baby.

Dr. McMillin: Right. So the ideal scenario is that that these babies who are going through drug withdrawals get identified in the hospital before they go home so they can get appropriate treatment. And, in fact, many of these babies are admitted to neonatal intensive care units and treated with things like morphine, or phenobarbital, or melatonin to help them curb the need, and then they're weaned over days to weeks so that they can go home safely.

Dr. Jones: So what we want is the best for our moms, we want the best for our babies to be, and our best when our babies are born. So, to paraphrase Grace Slick, some pills, some drugs make you larger and some drugs make you small, but the ones you take when you're pregnant should be nothing at all. But thank you, all, for joining us on The Scope.

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