Ask the Expert – An Interview with Dr. Andrew Kolodny

Naloxone the opioid overdose antidote

Dr. Andrew Kolodny was kind enough to be interviewed by Jacquelyn Ekern the Founder & President of Addiction Hope about the increased use of Naloxone or Narcan as an opioid overdose antidote.

Mrs. Ekern: Naloxone or Narcan use is increasing, and some have found repeated overdoses by the same person. What should be done immediately after an overdose reversal with Narcan?

Dr. Kolodny: Making naloxone, an opioid overdose antidote, more available in the midst of an epidemic where opioid overdose has become a leading cause of death in the United States is a no-brainer. Naloxone should be available anywhere somebody could experience an overdose.

It should be just as available as Auto defibrillator devices are. We should have naloxone in schools, college dorms, drug treatment programs, even in a Starbucks because people are overdosing in the bathrooms of Starbucks, and it should be available to the family members of people who have an opioid addiction as well as the household members of patients receiving high doses of prescribed opioids.

We should be doing everything we can to see that Naloxone is nearby if someone is experiencing an overdose. I think the United States has been doing a very good job of improving access to Naloxone and many cities and counties are distributing Naloxone for free.

Naloxone InstructionsFirst responders and policemen are carrying Naloxone in many municipalities, and in many areas, it’s been made available over the counter in special settings.

So, all of that is great, and we’re doing an excellent job of expanding access to Naloxone. Yet, overdose deaths are continuing to skyrocket.

We’re doing a better job than anyplace else in the world in making Naloxone available, yet, we have far more opioid overdoses than anywhere else in the world. So, making Naloxone much more available is great, but it’s not making much of a dent because when you rescue somebody with Naloxone, if you don’t see that they are able to access effective addiction treatment after you rescue them, then you just have to hope someone’s around with Naloxone the next time they overdose.

Many overdoses occur in people’s sleep or when they’re alone, and there’s nobody else around who can rescue them with Naloxone. They can’t give it to themselves. So yes, we’ve done a good job with Naloxone, but it’s not enough. It’s necessary but not sufficient.

Mrs. Ekern: If someone has an opioid use disorder and is treated for this, should the friends and family carry and be trained in the opioid overdose antidote Narcan reversal?

Dr. Kolodny: If someone has opioid use disorder, it should be in their home the same way that someone with allergies would have an EpiPen in the house. We understand that opioid addiction is a chronic disease, and people are prone to slips and relapses. So, yes, it should be with family members even if their loved one is in recovery.

Mrs. Ekern: Do most treatment facilities encourage that and help supply and prescribe it?

Dr. Kolodny: Very few treatment programs are ensuring that their opioid-addicted patients have Naloxone in their homes. I think many rehabs indulge in a fantasy that patients are going to walk out of their program and never use again.

Of course, you know that’s not at all what usually happens. What’s usually happens is that people will relapse or slip especially if they’re not receiving effective outpatient treatment.

Mrs. Ekern: How would you suggest, if someone did have Naloxone at home, they would treat the individual? Do they need to catch them immediately and administer the opioid overdose antidote?

Dr. Kolodny: Yes. As soon you see that someone is experiencing an overdose, you immediately administer Naloxone and then call 9-1-1.

Mrs. Ekern: The recent overdose of Demi Lovato and others raised an issue about post addiction treatment abstinence and if moderation of drug use is possible. If someone is an addict, can they use other drugs moderately and not risk a relapse?

Dr. Kolodny: I really don’t think there is such a thing as an “addict,” and I don’t like the term- not just because it’s stigmatizing. The term is also misleading. It implies that a certain type of person is using drugs because they want to get high from them and may not care about who they hurt along the way.

I Received Naloxone badgeOver the years, there’s been this notion that that so-called “addicts” have antisocial personalities, and none of that is true.

Some people became opioid addicted taking opioids because they liked the effect and that’s how they got addicted. But once addicted, they are not taking opioids for fun. Once addicted, they continue using because without opioids they feel very sick.

There are also many people who become opioid addicted taking opioids exactly as prescribed by doctors.

Once somebody becomes opioid addicted, what drives their continued use more than anything else isn’t a desire to get high, it’s not pleasure-seeking that drives them to continue to use, which I think the term addict implies. What drives continued use once somebody has become opioid addicted are avoidance of the negative symptoms, the dysphoria they experience when they stop taking the drug.

So, we really don’t have “addicts”. We have people suffering from the disease of addiction. With regard to moderation, I think when we talk about moderation it really depends on the drugs that you’re talking about and the individual.

So, for a drug like alcohol, most of the population is able to consume alcohol repeatedly without becoming addicted to it. About 10% of the population develops alcohol addiction, and when we look at that 10% that becomes addicted to alcohol, although we haven’t identified the specific gene or genes, we do know that alcohol problems run in families, and we have a good understanding that genetics play an important role for the unique subset of people who become alcohol-addicted because most of the population doesn’t develop alcohol addiction.

For the 90% of us that don’t become addicted to alcohol after using it, moderation is extraordinarily important. Risky drinking, meaning drinking in a harmful way, is a very common problem. There are many health and social problems that can stem from risky drinking.

So, moderating one’s alcohol use is really something we should do. All people who consume alcohol should try to moderate their use.

Opioids are different. Opioids are more like nicotine. Opioids are highly addictive drugs. Almost anyone who repeatedly exposes themselves to a highly addictive drug is going to be at high risk for becoming addicted.

It’s not like alcohol where 90 percent of us use it without becoming addicted. The people who can use a highly addictive drug repeatedly and not get addicted are the exception rather than the rule.

Naloxone Nasal SprayWhen I talk about highly addictive drugs, I’m talking about nicotine, heroin, oxycodone, hydrocodone, these are highly addictive drugs, and I don’t believe that they can be taken on a daily basis with little risk of addiction.

Trying to use highly addictive drugs moderately is not a safe thing to do. If you try to use heroin, oxycodone, hydrocodone or nicotine moderately, you’re playing with fire. It’s very easy to become addicted to those drugs, and once somebody becomes addicted, it becomes next to impossible to use moderately.

Mrs. Ekern: In the case of patients that have opioid use disorder, can you describe how methadone helps patients and what the drawbacks of methadone use are for these individuals?

Dr. Kolodny: The first-line treatment for opioid addiction, the treatment that is most likely to help most people with opioid addiction is opioid agonist treatment, and by opioid agonist treatment, I’m referring to buprenorphine and methadone.

These are the treatments that strong evidence tells us are effective. Opioid agonist therapy decreases the individual’s likelihood of experiencing an overdose and increases the likelihood that they will function and have a good quality of life.

That’s true with buprenorphine and methadone. Methadone, I believe, is second line to buprenorphine. Buprenorphine should be considered first because it can be prescribed from a doctor’s office and filled at a pharmacy.

The patient doesn’t have to visit a clinic every day to obtain it. They’re able to treat their opioid addiction in a setting of privacy and dignity rather than having that individual line up at a methadone clinic.

The reason we can treat opioid addiction with buprenorphine that’s prescribed by doctors and dispensed at pharmacies, unlike methadone which has to be administered under supervision to people in special clinics, the reason we can do this with buprenorphine is that it’s much safer than methadone.

Buprenorphine is a unique opioid. The term we would use to describe it is Partial Agonist. This makes it much more difficult for people to overdose from it. There’s a ceiling on its effect even if a patient takes a large dose.

That’s not true for methadone. Methadone can easily cause death when too high a dose is taken. So, for methadone, unless the patient is very stable, it should be administered from a methadone clinic under supervision.

There’s one other advantage to buprenorphine over methadone which is that buprenorphine is less sedating. Patients usually feel more alert. Some patients on methadone will complain of feeling tired from it.

So, buprenorphine is safer. It causes less sedation and can be prescribed in primary care settings. People can have their opioid addiction treated the same way their other medical problems would be treated. Those are the advantages of buprenorphine.

How Naloxone WorksAll of that said, there are some patients who do need methadone, and for whom methadone is a better option.

For example, a patient that hasn’t done well on buprenorphine, or a patient with a chaotic lifestyle may benefit from the structure of the daily visit to the clinic.

Those would be examples of patients for whom methadone may be the better choice. It’s very good that we have methadone maintenance right now because access to buprenorphine is inadequate. If we didn’t have methadone maintenance programs, I believe that the national overdose death rate would be much higher than it currently is.

Mrs. Ekern: Can you describe how Naltrexone, also called Vivitrol, can help patients and what the drawbacks might be?

Dr. Kolodny: Extended release Naltrexone, has much less evidence to support its use. The clinical experience when treating opioid addiction with Naltrexone shows very high dropout rates.

Most patients don’t stay on it very long. Many patients will quit taking the drug after one or two injections. It’s a monthly injection.

The drug works by blocking your opiate receptors which means that not only are you blocking exogenous opioids from having an effect, (by exogenous opioid I’m talking about opioids you would take like oxycodone, heroin) it also blocks endogenous opioids. Some patients don’t feel well while on it, which may explain why we see such high dropout rates.

Naltrexone may actually increase the risk of an overdose death. Patients who miss their injection are extremely sensitive to opioids. So, even moderate use can potentially cause death.

We do not have good evidence to tell us which is the right medicine for which type of patient. We don’t have good evidence to tell us this kind of patient should get buprenorphine; this kind of patient should get methadone, or that kind of patient should get Vivitrol.

We don’t really know, but I believe that patients who have moderate to severe opioid use disorder should be receiving either buprenorphine or methadone.

I think Naltrexone may be appropriate for patients with mild opioid use disorder, who have not been addicted for very long. But I’m very concerned that Vivitrol is being aggressively promoted and used in people with severe opioid addiction who would be better off on buprenorphine or methadone.

Naloxone Saves Lives

I’m talking mainly about the criminal justice system and drug courts. There is a bias against treating opioid addiction with buprenorphine and methadone.

The makers of naltrexone has taken advantage of the bias and may play up fears about buprenorphine in the marketing of their product.

Mrs. Ekern: What ingredients in a treatment program make a five-year positive outcome more likely for someone struggling with opioid use disorder?

Dr. Kolodny: I think the good outcomes and may have less to do with what specific elements of treatment and more to do with the patient’s individual characteristic.

A patient who develops opioid addiction later in life after having had stable employment and having established significant relationships, for example a middle-aged person who becomes addicted to pain medication prescribed them by a doctor, may do very well with little more than buprenorphine prescriptions. They do not require much additional psychosocial support.

An individual who develops opioid addiction earlier in life, or one who transitions from prescription opioids to heroin and the addiction happened earlier in life before they really matured, that individual is going to be harder to treat and may experience more relapses and slips. That individual is also more likely to require psychosocial support in counseling in combination with a medication like buprenorphine or methadone.

Mrs. Ekern: In addition to medically assisted therapies, some of the treatments that you’re recommending sound like more supportive therapeutic options, Do things like cognitive behavior therapy or dielectric behavior therapy help?

Dr. Kolodny: Yes, they do. I think more for CBT than DBT, but yes, CBT is a very important component especially if the patient is interested in coming off of buprenorphine or methadone.

There are many people who can do well while on medication, but when they try and come off, if they’re not receiving Cognitive Behavioral Therapy, if they’re not learning how to identify triggers and respond appropriately, if they’re not learning how to respond to cravings, they will be very high risk for a relapse.

So, it’s critically important when patients are trying to come off of medications to seek treatment.

On behalf of Addiction Hope, we would like to thank Dr. Andrew Kolodny for taking the time to speak with us and for doing so much in promoting the saving of lives from opioid overdoses.

Dr. Andrew KolodnyDr. Andrew Kolodny is one of the nation’s leading experts on the prescription opioid and heroin crisis. He is Co-Director of the Opioid Policy Research Collaborative at the Heller School for Social Policy and Management at Brandeis University. Dr. Kolodny previously served as Chief Medical Officer for Phoenix House, a national nonprofit addiction treatment agency and Chair of Psychiatry at Maimonides Medical Center in New York City. Dr. Kolodny has a long-standing interest in public health. He began his career working for the New York City Department of Health and Mental Hygiene in the Office of the Executive Deputy Commissioner. For New York City, he helped develop and implement multiple programs to improve the health of New Yorkers and save lives, including city-wide buprenorphine programs, naloxone overdose prevention programs and emergency room-based screening, brief intervention and referral to treatment (SBIRT) programs for drug and alcohol misuse.

*Special thanks to Dr. Mark Gold for sharing his Ask the Expert Series with Addiction Hope.

The opinions and views of our guest contributors are shared to provide a broad perspective of addictions. These are not necessarily the views of Addiction Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Addiction Hope understand that addictions result from multiple physical, emotional, environmental and genetic factors. If you or a loved one are suffering from an addiction, please know that there is hope for you, and seek immediate professional help.

Published on August 29, 2018
Reviewed by Jacquelyn Ekern, MS, LPC on August 29, 2018
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About Baxter Ekern

Baxter Ekern is the Vice President of Ekern Enterprises, Inc. He contributed and helped write a major portion of Addiction Hope and is responsible for the operations of the website.