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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.

Interviewer: I think most of us at one time or another may have joked that, "We're addicted to chocolate," or, "I'm addicted to that TV show," but those addictions aren't real addictions. We're going to examine addictions next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Elizabeth Howell is with the University of Utah Hospital. Let's talk about addiction for a second. Now everybody jokes about, "I'm addicted to chocolate." That's not really addiction, is it?

Dr. Howell: Not really. I mean, some of the same brain processes are involved, but chocolate doesn't usually cause people to lose their family and their house and their life. It's a compulsion maybe to eat chocolate . . .

Interviewer: Sure.

Dr. Howell: . . . but it's not something that's going to kill you.

Interviewer: So let's talk about true addictions. I was doing a little bit of reading, and it just really was strange to me that if somebody is truly addicted, they can't look out for their own well being, they can't make decent decisions, because a lot of times people, you'll hear them say, "Well, wow, why didn't they just make a better choice than doing drugs?" But they really don't have that ability, if I understand correctly. Is that accurate?

Dr. Howell: Well, yeah. You have some choices about some things, but I think the main thing to remember is that when you're actively addicted, and you're using drugs or alcohol or both, that your brain is not working right. I mean, it's not the same as having a brain that is sort of firing on all cylinders at the same time.

Interviewer: Yeah. Is it the actual addiction, or is it the drugs, or a combination of both?

Dr. Howell: Both, really.

Interviewer: All right.

Dr. Howell: So the drugs actually, they alter how you perceive the world and how you see things, but they also do something that's very important, which is they activate the process in the brain, which is the addiction process, that really distorts how people think. So in Pennsylvania, there's kind of an epidemic of people mixing fentanyl, which is a very potent opioid, with heroin, and a lot of overdose deaths have happened because of that. And if you're someone in the public, you'll say, "Wow, that's really scary. If I were a heroin addict, I wouldn't be using anything right now . . .

Interviewer: Yeah, sure.

Dr. Howell: . . . because I'd be afraid I'd kill myself."

Interviewer: Yeah.

Dr. Howell: But if you're a real active addict, what you think is, "How did they get the good stuff?"

Interviewer: Really, that's the thought process?

Dr. Howell: That is the thought process.

Interviewer: And they want that.

Dr. Howell: And they want that, because they want something that is so good that it might kill them, and that is the insanity, as they say in the 12-step programs, of the addiction. The insanity of the disease is that your thinking is very distorted.

Interviewer: And that's how they frame in the head, "I want something so good it'll kill me?"

Dr. Howell: Well, it could be, yeah.

Interviewer: Wow.

Dr. Howell: You could get to that point.

Interviewer: So inside the brain, let's say somebody just has an addiction, but they're not currently using.

Dr. Howell: Right.

Interviewer: Is their brain a little different than somebody without that predisposition towards an addiction?

Dr. Howell: There are probably some differences in the brains of people before they ever start using. In the twin studies that have been done using alcoholic families, and alcohol is the easiest thing to study compared to other drugs, if a child was born to an alcoholic father and adopted into a non-alcoholic home, they still had a much higher risk of becoming alcoholic. The highest risk was a child of an alcoholic biological father adopted into an alcoholic home. So the nurture part, the environment, did play a certain role, but by far the biggest risk for addiction is genetic.

Interviewer: Does the brain physically get rewired because of addiction?

Dr. Howell: I don't know if it gets completely rewired, but there are certain genes that are turned on or off, depending on the different genes, when you start using.

Interviewer: Okay.

Dr. Howell: And, like you say, they're kind of laying there dormant.

Interviewer: Sure.

Dr. Howell: It's like a room with the lights off, but when you turn the lights on . . .

Interviewer: By taking a drink or doing a drug.

Dr. Howell: . . . right, then certain genes could be turned on or turned off. And the way that this happens, it's not like the first time you ever use that all the changes that happen, by the time you've been using for 20 years, are there. They happen over a period of time and in sort of wave of different changes in the brain, different parts of the brain, different systems of the brain, and it's quite complicated. I don't know if you would call it rewiring, but it's definitely a re-engineering of the brain.

Interviewer: So we've talked a lot about addiction. I want to talk for a moment now, and kind of wrap this up with, if somebody is a loved one of somebody who is addicted, help them be in the mindset of the addicted person so they can better help them.

Dr. Howell: I would try to imagine it as thinking of something that you feel like you have to have for life, like it's something that you need to survive. And when you're in the throes of addiction, the person who's addicted really feels as if that is the most important thing in life, that it is actually more important than food, or their children, or whatever, and that the drive to use is so strong that their behavior seems insane, because it is. Because what you can't control is the craving and the mental obsession and the compulsion. Now people obviously get into recovery, and they stop using, so we could get into this is it really a disease, can you really control it sort of debate, but what you can't control is what your brain is telling you. That's like saying if you're diabetic, I will not let my blood sugar go up.

Interviewer: Yeah.

Dr. Howell: You can do as much as you possibly can to keep your blood sugar from going up, but you can't always control that, because that's a physiologic process that is independent. And that's what the addiction is. Once it gets started, it's an independent physiologic process that can be managed, but it can't be just gotten rid of or controlled.

Interviewer: Or cured.

Dr. Howell: Or cured, yeah.

Interviewer: It's always there.

Dr. Howell: Right.

Interviewer: So what could somebody do to help that person? Because I don't think this is a do-it-yourself sort of a thing.

Dr. Howell: No, not really. And what we tell family members first is get informed and find out what you need to know about addiction and take care of yourself, because many times a person comes in for addiction treatment, their family has been trying to help them, but they've been doing it sort of in a backwards way. They're well-meaning, but they've been kind of enabling the person. They've been covering up for them. They've been bailing them out of jail. They've been doing this and that. And so you don't want to do that.
People need to experience the consequences of their addiction, and sometimes it's the only thing that will wake them up, because your brain is all changed, it's not working right, and you need a big wake-up call, and sometimes that needs to be letting people "hit bottom." Where you don't want somebody to hit bottom is if they're in danger of dying and hitting bottom, but if they're going to go to jail, or whatever, then I would let that play out, and then have a plan that, "Okay, we'll help you get out of jail," if that's what's happening, "if you will go to treatment."
There are some medications that can help, although we don't have enough, and then there are also many psychological, psychosocial treatments that include psychotherapy and changing behavior, more behavioral therapy, going to 12-step meetings, or some kind of support group.
The other thing you have to make sure of is that anything else that is involved that may be impacting the addiction is being treated. So if someone's depressed, they have post-traumatic stress disorder, or they're bipolar, or whatever, some sort of mental illness or mental disorder gets treated appropriately without addicting medications.

Interviewer: Yeah.

Dr. Howell: Yeah, because that's where I see a lot of people getting into trouble, is they have anxiety, so they're put on something else, like a benzodiazepine that's addicting, like Xanax or one of the others, and that's only going to make the problem worse. And the other thing that you need to do is make sure that besides that you're treating the psychiatric or mental problems, that you're also treating any physical problems that are going on. Somebody could have hyperthyroidism or something that could be triggering them to drink.

Interviewer: Sure.

Dr. Howell: I mean, there are a number of things. So the physical and the mental you want to take care of, and make sure that whatever treatment program you're looking at has the ability to check for those things and treat them, if appropriate.

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