The Opioid Prophet

Heller senior scientist Andrew Kolodny was one of the first physicians to sound the alarm on the nation’s deadliest drug crisis ever. Now he’s battling powerful interests to stem the opioid epidemic.

Andrew Kolodny
Mike Lovett
Andrew Kolodny

In 2003, as a new employee in New York City’s health department, having just completed a psychiatry residency at Mount Sinai, Andrew Kolodny was given a singular charge: Reduce the city’s drug-overdose deaths.

The size of the task felt overwhelming. “How can a psychiatrist in Lower Manhattan prevent somebody from doing too much heroin in the South Bronx?” Kolodny says. “It seemed sort of impossible.”

Still, he was game to try. Buprenorphine, a milder, safer alternative to methadone, then the standard opioid-addiction treatment, had recently come on the market. He started visiting medical clinics across the city to persuade physicians to use buprenorphine to treat heroin-addicted patients. “They’d look at me like I was crazy,” he says. “They said, ‘Why would we want to treat addicts? Why would we want them coming into our office?’”

Kolodny decided to open his own clinical practice in Manhattan, assuming he’d be treating addicted men from poor, predominantly minority neighborhoods. But a funny thing happened. Patients came to see him from as far away as New Jersey and New York’s Westchester County and Staten Island. They were mostly white and middle-class. And they were addicted to prescription painkillers such as oxycodone (OxyContin) and hydrocodone (Vicodin), not heroin.

“That was my first clue we had a really serious problem with prescription opioids,” Kolodny says today, sitting in his office at the Heller School for Social Policy and Management, where he is a senior scientist.

One of the first doctors to recognize what has become the deadliest drug epidemic in American history, Kolodny is now arguably the country’s most outspoken expert on a crisis that continues to grow. Opioids — including prescription drugs, heroin and the synthetic drug fentanyl — claimed more than 49,000 lives in 2016, according to data from the Centers for Disease Control and Prevention (CDC), up from 28,647 in 2014.

Over the past decade, Kolodny has broken ranks with many physicians by insisting the epidemic is not one of drug abuse but of addiction, borne of the overprescription of extremely addictive painkillers to patients suffering from back and nerve problems, and other kinds of chronic pain. His stance has put him at odds with pharmaceutical companies that manufacture opioids (as well as some pain-patient advocacy groups that receive funding from them), which claim problems with opioids are limited to people who abuse them.

But as the sheer magnitude of the opioid crisis swamps the nation’s medical system, and devastates families and communities alike, Kolodny’s warnings are finally being heeded.

Opioids in every medicine chest

When Kolodny arrived at Brandeis in December 2016, the Heller School’s Institute for Behavioral Health (IBH) already had a national reputation for opioid policy research. IBH director Connie Horgan believed Kolodny would lend a clinical perspective that would give greater urgency to the institute’s research, and made him co-director — alongside senior scientist Peter Kreiner — of IBH’s newly created Opioid Policy Research Collaborative (OPRC), which studies responses to the crisis.

More than 100 people attended the OPRC’s official launch celebration in mid-November. The HBO documentary “Warning: This Drug May Kill You” was screened, followed by a panel discussion moderated by Cynthia McFadden of NBC News and remarks from U.S. Representative Katherine Clark, from Massachusetts’ 5th District. The panel also included Marylou Sudders, Mass­achusetts secretary of health and human services, and Dr. Myechia Minter-Jordan, president and CEO of the Dimock Center, a Boston community health and human-services organization.

BAD MEDICINE: Audience members at the Opioid Policy Research Collaborative launch event watch the HBO documentary "Warning: This Drug May Kill You."
Mike Lovett
BAD MEDICINE: Audience members at the Opioid Policy Research Collaborative launch event watch the HBO documentary "Warning: This Drug May Kill You."

Following the event, President Ron Liebowitz and his wife, Jessica, hosted a dinner. U.S. Senator Edward Markey sent a video message viewed during the dinner. “I pledge my support for your work,” Markey said. “I believe the people here tonight can and will make a difference.”

When Kolodny’s not researching the most effective ways to prevent and treat addiction, he travels the country warning doctors’ groups, the media and policymakers about the crisis. “For years, nobody wanted to hear about it. Now everybody wants to hear about it at exactly the same time,” he sighs.

He’s become an unlikely celebrity. As he talks in his office at Heller, an NBC camera crew keeps interrupting him to line up shots — one crew member swivels around the table with a handheld camera; another shoots through the doorway with her iPhone. “It’s a little distracting,” Kolodny says good-naturedly as the cameraman aims up at him from a kneeling position on the floor. Wearing a puffy vest over his Oxford shirt, his hands awkwardly pushed into his pockets, Kolodny looks every bit the psychiatrist. He exudes a soft-spoken charisma, able to translate policy with passion.

Kolodny grew up on Long Island, where his father was a doctor and everyone assumed he would become one, too. “Jackie Mason used to joke that every Jewish kid’s supposed to be a doctor; or, if their brain doesn’t work too good, a lawyer; or, if their brain doesn’t work at all, an accountant,” he deadpans. After medical school, Kolodny was drawn to psychiatry. “I wasn’t really interested in sticking people with needles or cutting people. You could just talk to someone, which was nice.”

His real interest, however, lay in public health, which had captured his imagination as a kid when he read a book about epidemiologists fighting disease outbreaks. At New York City’s health department, he approached the outbreak of opioid addiction as a puzzle to be solved. The first clue surfaced in a 2006 study by CDC physician Len Paulozzi, which included a neat graph with two rising parallel lines — one the number of opioid painkillers prescribed by doctors, the other the number of deaths from opioid overdoses.

“That was sort of an aha moment for me,” Kolodny says. He naively assumed that, if the graph were true, the policy solution would be straightforward.

Yet almost as soon as Paulozzi’s report came out, pain organizations funded by pharmaceutical companies challenged it, placing the blame for the rising epidemic not on overprescribing doctors but on addicts and criminals who steal or divert legitimate opioid prescriptions to abuse them. The pain organizations argued a reduction in prescribing would penalize pain patients for the bad behavior of drug abusers. Federal agencies fell for this argument.

“Almost everything coming from the federal government was focused on ‘How do we keep kids from getting into grandma’s medicine chest?’” Kolodny says. “Nobody asked, ‘Why does every grandma now have opioids in her medicine chest?’”

Kolodny might have been persuaded by the pain groups if he hadn’t been seeing firsthand the impact of the drugs on patients, many of whom had been legitimately prescribed opioids for pain and were unable to stop taking them.

One opioid survivor, Betts Tully, was prescribed OxyContin in 2001 after two back operations. The medicine never completely eased her pain, so her doctor kept prescribing more — increasing her dosage from 20 mg to 280 mg over six months. Kolodny read about Tully’s ordeal in an Op-Ed she wrote for the Journal of the American Medical Association.

“I was no longer working or talking to friends and family,” she says. “All I did was stay in bed.” When she stopped taking the pills, withdrawal symptoms made her feel even worse. Because the drugs muddled her mind, she couldn’t see the problem clearly. It took an intervention by her daughter for her to get help, then two years of gradually reducing the prescription drug to get all the opiates out of her system.

Kolodny accompanied Tully and other patients to U.S. Food and Drug Administration meetings to advocate for tighter controls on the drug companies. Wherever he went, he found pharmaceutical company representatives with their own patients, begging policymakers not to take measures that could reduce what they said were needed pain medications.

An epidemic of overprescribing doctors

Purdue Pharma, which introduced OxyContin in 1995, aggressively marketed the drug, says Kolodny, deceiving doctors on the safety and effectiveness of its long-term use. (In February, Purdue announced it would no longer market opioid drugs to doctors.)

In 2010, to counter misinformation about opioids, Kolodny, other like-minded doctors, and patients founded Physicians for Responsible Opioid Prescribing (PROP). PROP exposed Big Pharma’s marketing efforts by publicizing how pain groups funded by pharmaceutical companies promoted aggressive prescribing as safe and effective.

TEAMWORK: The panel discussion at the OPRC launch event.
Mike Lovett
TEAMWORK: The panel discussion at the OPRC launch event.

Meanwhile, peer-reviewed studies were contradicting the safety and efficacy claims. Researchers found that, although opioids could be used to treat short periods of acute pain, pain patients on opioids did not do well over the long term.

In early 2014, actor Philip Seymour Hoffman died from an opioid overdose at age 46, spurring a public reckoning with the drugs’ prevalence. Even then, however, the federal government response was muted.

Kolodny compares President Barack Obama’s neglect of the opioid issue to Ronald Reagan’s lack of action on the AIDS crisis in the 1980s. “I don’t think the opioid crisis was on Obama’s radar,” Kolodny says. “He started to do the right things at the very end but never spoke about the problem publicly until his last year in office.”

Gradually, Kolodny shifted his focus from raising awareness of the crisis to researching how to fight it. “To bring the epidemic to an end, we have to prevent more people from getting addicted,” he says. “And, more than anything, that means cautious prescribing.”

In 2015, Kolodny used a grant and support from IBH to look at the prescription patterns of doctors in New York state, studying data from the state’s Prescription Drug Monitoring Program (PDMP), which tracks all opioid prescriptions.

Years earlier, Kreiner had established the Prescription Drug Monitoring Program Training and Technical Assistance Center to help improve state PDMPs through a combination of academic research and on-the-ground consultation with former PDMP administrators. In 2011, the CDC approached him about combining prescription data from multiple states.

The CDC was “a little blindsided by the intensity of the opioid problem,” Kreiner says. “A big part of that was the lack of timeliness of getting good data.”

Currently, Kreiner’s database contains data from 12 states. He’s used the information to develop a set of 43 measures of risky patient and prescriber behavior that could increase the risk of addiction.

As of now, 50 different state laboratories struggle with how to monitor and control opioid prescriptions. Some states have passed laws requiring doctors to check PDMP databases before writing a new prescription. Others have limited the number of days before a patient can get a refill. “People are trying things without really knowing what’s going to work,” Kolodny says.

“We have found no effect for even the most comprehensive laws on daily opioid dosage,” says Kreiner.

Perhaps that’s because states that limit the number of days before refills don’t specify limits on the dose, allowing patients to still get dangerous amounts. By drilling down deeper on the relevant data, the Prescription Drug Monitoring Program Training and Technical Assistance Center may be able to help states create more-effective laws.

‘It really is Kryptonite’

At the same time, states are investing in treatment for those already suffering from opioid addiction. “The genie is out of the bottle,” says Kolodny. “Doctors’ starting to prescribe cautiously doesn’t mean patients’ addictions are going to go away. It means building out a treatment system that doesn’t exist yet.”

Even before prescriptions began declining in 2011, young people were turning to the black market to buy heroin, often a cheaper alternative to OxyContin. In recent years, opioid overdose deaths among heroin users have risen rapidly. The heroin supply, which often has fentanyl mixed into it, has become more dangerous.

Although evidence shows the best treatment combines counseling with drugs like buprenorphine or methadone, abstinence-only programs predominate at treatment centers. “It’s easier for people who are addicted to buy heroin than it is to find a doctor who will treat their opioid addiction with buprenorphine,” Kolodny says.

LONG WAY TO GO: President Donald Trump has signed a memorandum declaring the opioid crisis a public-health emergency, but the fight remains poorly funded.
Andrea Hanks / The White House
LONG WAY TO GO: President Donald Trump has signed a memorandum declaring the opioid crisis a public-health emergency, but the fight remains poorly funded.

The result is stories like Kevin Flattery’s. A member of an affluent Northern Virginia family, Flattery attended a Jesuit prep school, played varsity ice hockey and graduated from the University of Virginia ready to pursue a career as a screenwriter. Once in Hollywood, however, he began experiencing anxiety and depression. Remembering a long-ago treatment with opiates for a sports injury, he started self-medicating with OxyContin. “Like a lot of people, he seriously underestimated its addictive qualities,” his father, Don, says. “It really is Kryptonite.”

After Kevin became addicted, he sought help from his family, returning on a plane from LA in full withdrawal, suffering from fever sweats and looking like he hadn’t slept or eaten in days. His family was able to get him stabilized with buprenorphine and found a residential drug-treatment program to help him detox. The program advocated complete abstinence, releasing him clean after 30 days. Within another 30 days, he had relapsed and fatally overdosed. He was 26.

“We had to learn the hard way that opioid addiction is a chronic disease that affects brain circuitry and chemistry, and it takes a long time to rewire,” says Don Flattery, who is now, along with Kolodny, a committee member in FED UP!, an advocacy group pushing for an increased federal response to the opioid crisis.

Flattery credits Kolodny with helping survivors deal with the devastating effects of their loss. “He has been an absolute champion for American families in continuing to fight against very powerful interests,” Flattery says.

Others at Brandeis are also leaders in the fight. For the past 15 years, Connie Horgan and senior scientist Sharon Reif have examined medical coverage for treatments as part of a larger study on drug, alcohol and mental-health services. They have found that many health plans either neglect to include addiction-treatment drugs on their formularies or place them on the highest-cost tier. “If a medication isn’t on the formulary or you are going to have to pay out of pocket for it, you are not going to get access to it,” says Horgan.

Health insurers often have an attitude that “use of medication means you are not recovered from your addiction — or that it is just a substitute for heroin — which is far, far from the truth,” adds Mady Chalk, Heller PhD’80, an expert on the opioid crisis.

As awareness of the crisis has increased, a growing number of states are enacting policies to treat opioid addiction. “The more states look at their own data to make decisions, the better we’ll be able to address the opioid epidemic,” Chalk says.

Despite the increasing awareness, Kolodny still gets criticism — sometimes from patients who take opioids and fear losing access to their medicine. A group of patients and a few doctors who lost their medical licenses for overprescribing opioids recently signed a letter addressed to President Liebowitz demanding Kolodny be fired. The university has no intention of firing Kolodny, says Horgan, who notes that IBH gets many letters that praise his work.

For his part, Kolodny expresses compassion for his critics. “I think of them as victims of our era of aggressive prescribing,” he says. “Many will have a hard time ever coming off opioids.” Nevertheless, “we need to prevent more pain patients from winding up in their shoes. Compassionate care for patients with pain isn’t jeopardized by more-cautious prescribing — it demands it.”

Though the tide of awareness has started to turn, the U.S. has a long way to go to solve the opioid-addiction epidemic. Unlike Obama, President Donald Trump hasn’t ignored the problem — in fact, he’s often spoken out publicly about the need to address it. When it comes to Trump’s record of action, however, Kolodny sums up his reaction in one word: “disappointed.”

The Trump administration’s declaration last fall that the opioid crisis is a public-health emergency is wholly inadequate, Kolodny says, since it came without any dedicated funds to fight the problem. Trump’s commission on the crisis issued its final report in November, punting the issue back to the states, with a call for Congress to issue an indeterminate amount of money in block grants.

“Trump certainly gets a better grade than Obama on speaking about the problem,” Kolodny says. “But there hasn’t been any action — none, zilch — from the administration. We don’t need another commission that issues recommendations. We need a plan, and we need funding that addresses the crisis.”

Michael Blanding, a freelance journalist, is the author of “The Map Thief” (Gotham Books, 2014).