Confronting Opioid Addiction

hi everybody welcome to kaiser Health News and California health lines Facebook live chat about opioid addiction treatment options and access to those treatments if you have a question please go ahead and feel free to post it on our Facebook page I'm Emily BAE's our I'm a columnist at California Health Lian and kaiser Health News and this is Bryan Rinker Brian's a contributor who has written some really dramatic stories about opioid addiction what we're going to be discussing those today in addition to being a journalist brian has a master's degree in public health and he has some personal experience with heroin use Brian let's start by you telling us a little bit about your personal experience yeah yeah besides being a reporter I do have a personal experience with heroin use for most of my 20s about nine years I was an IV heroin user about five of those years I used heroin every single day and I did a lot of things that heroin users do I lied I stole my kind of manipulated everyone I loved and cared about me and I ended up going to jail I went to rehab I've tried a variety of different types of treatments during that time to get me off heroin and yeah for many years when did you stop and and what was the the bigger epidemic or was there an epidemic at that time yeah so during that time like from the moment I started using heroin to the moment I stopped which is about to that the end of 2008 I wasn't I didn't really get into the opioid prescription pain pills but during that time like the number of prescriptions and the number of overdose deaths opioid-related overdoses sky rocker they quadrupled during that time that I was a heroin addict and then after that things just got even crazier people started switching to heroin and then we started to have these really high annual overdose death rates yeah that's right I think 2016 is the recent year we have statistics for and in that year more than 42,000 Americans died from opioid drug overdoses do you know the numbers or what the situation is in California yeah so in California it's kind of considered to not be as as hard a heart of hate as some of the other parts of the country but still like in 2016 there was a little more than 2000 opioid-related overdoses still a lot of people and and some of the rural counties and rural areas in California have overdose death rates that are comparable to some of the places like in West Virginia and other Midwest and East Coast places so speaking of overdoses I'm gonna ask another personal question have you ever overdosed yourself yeah I mean I did a lot of my using by myself and I I think that I overdose all the time and just came to and just wasn't really aware that I had overdose but I do have a there was a specific time where I did some heroin and I just kind of fell fell to the ground and I remember waking up or I remember opening my eyes and I had my friend who was sitting on top of me and he was slapping me and I couldn't hear him and I couldn't feel the slaps but I knew that he seemed to be freaking out and I was like thinking why is this guy freaking out so bad and you know I'm just chilling and then I kind of came to and he told me that I had turned blue and thought he thought I was gonna die so you had no knowledge that you had overdosed it sounds like it was just like going to sleep and then I kind of just woke up you know now it was just one of the lucky ones I got to wake back up yeah thank goodness you know right now in the news we're hearing a lot about this drug called naloxone and this is an overdose reversal drug antidote to overdose is essentially did you have naloxone did you carry it with you at that time no it wasn't I didn't really know about it back then it wasn't as big news as it is today but I knew that paramedics in the area that I lived carried it and if they could reverse an overdose pretty easily and that there was no reason till that like your friend died of one because you could just call any one one and they'd come and revive them but today you know they give it out and a needle exchanges to heroin users like I was and the Bay Area is one place that they do it right and I know that in more than 40 states including California naloxone is available without a prescription so you could go to a pharmacy theoretically you know Walgreens or CVS or something like that and buy it without a prescription yeah I've heard that too I've never actually gone in and bought any but it makes sense like if you have loved ones that are using opioids or you're hanging around people that you think may have an overdose to carry that with you and to go get it and yeah for a heroin user might be a little too much money to go and pay for it if you're kind of struggling every day to like survived on the street and get it high so it seems really important that they give it away for free at these needle exchanges um and I was also like I live in San Francisco in the Tenderloin district and there's a lot of drug use and and I was thinking that it makes sense for a lot of businesses and places that have that are open to the public to carry it as well I mean that's interesting that business owners would carry it I I I remember speaking to a an addiction medicine specialist a couple weeks ago who told me that in San Francisco alone since you mentioned that last year about 1200 people were revived due to naloxone and not by paramedics or doctors or policemen it was by you know regular folks so it is clearly saving lives and the Surgeon General came out recently to and said that everybody should be carrying it so so let's move on to the treatment options there are three fda-approved medications for treating opioid addiction and they are methadone buprenorphine and naltrexone two of them methadone and buprenorphine are actually opioids themselves today we're not really going to get too deep into the details or we aren't at this moment actually but if you have questions about them please feel free to post them on our facebook comments feed here but that raises the question again about you Brian tell us about your treatment how did you get off of heroin yeah so during the years I tried a lot of things to get off heroin and I at one point I did do methadone treatment and I had talked my parents into paying 500 bucks which gave me about a month of treatment and I had to go every single morning to the methadone clinic between I think the window was like 6 and 8 a.m. and you know I wasn't the best I wasn't the best patient I would what I a said I could drink alcohol that was ok but I couldn't do other drugs and so what I would do is I would just drink a lot and then I would show up at the early in the morning I get my dose and I'd go home and I'd usually pass out wake up and then figure out how I was gonna score heroin a night that only lasted a month but even if I wanted to keep going which I don't think I did I would have been able to afford it like my mom was she didn't even really know what she was giving me that money for and I just couldn't come up with five hundred bucks a month to do the methadone treatment and then yeah then the other one which is people nor fina or suboxone which is the brand name I actually never had been prescribed it by a doctor but I would bite off the street there was always there's a big market on the street for those drugs and it was always kind of like you buy it and stash it away for that time when you when you wanted to get clean off or when it does stop using heroin oh so people would buy it for as a way to to get off of heroin kind of like a self self treatment plan you know what's rarely worked right and it sounds like methadone just didn't work for you well it didn't it didn't seem to work for me then okay and then I'm sorry so if methadone and buprenorphine didn't really work for you you did what did you do to get off of heroin yes I mean like the only the only times really that I had any any time where I wasn't using heroin was like when I was in jail and then there was some times when I was in a residential rehab usually those came after being in jail so I would I would sometimes you know kick cold-turkey as they say which is without any kind of medication and go through all those withdrawals and then I would go to rehab and that didn't work either what happened was just one day I just like I was I just had this moment of desperation and I was like I can't do this anymore and and it really wasn't the the only time I felt that like I felt that many times but this time I packed my stuff and I moved back home with my parents who had since left the town I lived in part to get away from me and I showed up and and I just went through the drawers without medication and I started going to 12-step recovery meetings and so you essentially got off of it without the medication it sounds like a maybe to start but then over the long-term yeah I mean I I did and I feel very fortunate and lucky that I was one of those people so Brian's told us a little bit about his experience but you've also covered a lot of stories about people who are struggling with opioid addictions and and one of those you recently wrote about a woman named Heather and she went through this extremely harrowing ordeal a three-day bus ride she was on heroin right and then she went on this three-day bus ride from Chicago to the Central Valley and with drew from heroin during that bus ride and when she landed in Bakersfield explained to us what happened to her yeah so Heather was in Chicago and she just had that same kind of moment that I had which was just like I can't do this anymore I need to go back home and live with my parents maybe that'll help me get off of get off of heroin and and so she thought though the best way to do that would be to go through the withdrawal symptoms on the bus for three days and then show up and and kind of have already gone through the worst of it and then start to like put her life back together and what happened was that she just had this miserable experience on the bus where she just felt trapped for three days just like feeling the sicknesses the anxiety there like cold sweats and she had to like keep running to the bathroom in the back of the bus to to vomit and it sounds like a nightmare and just like the whole mental obsession of probably just knowing like I know what can fix this but being trapped and then when she arrived back home and which wasn't Bakersfield it was in Lake Isabella but she arrived at Bakersfield from the bus and then her mom drove her back home and she found out that like most small rural towns in America it had a bunch of heroin and she just went back to her old ways of so she went through all of that on the bus and then when she got home the temptation was right there but was there I mean could she get into treatment and like Isabella yeah I mean so she arrived in this town and she still was sick so she hadn't even gone through at all so she still felt sick she didn't have any medication to help she didn't have any kind of professional support and the town is a small town and there was really no doctors who are willing to prescribe buprenorphine there was no methadone clinic there's no treatment in general no like residential rehab around there um and so she just very easily fell back into her old ways and but really what changed for Heather was that during that time she found out she was pregnant Wow a lair like she never thought she could have a child and so she really wasn't paying attention to that kind of thing and and she found out at the emergency room in Bakersfield that she was pregnant and that if the doctor told her if she wanted to save the baby she needed to get on methadone and methadone buprenorphine right cuz so tell us a little bit about methadone you said when she got to like Isabel there was no clinic what do you mean by that yeah so methadone there's a methadone clinic in Bakersfield which is about like an hour an hour and a half bus ride from where she lived and what that means is like you can get methadone from these methadone clinics it's the only place you can actually get opioid treatment from and but there's a lot of roles that come with that and so you have to go every single day and if you don't go you can get kicked off the program so you would have to adhere to kind of this really strict structure and when you live really far away it's really hard to get there every day and especially when you're in those moments where you don't have a lot of support where you're you know kind of at your your bottom as they say you know where you don't you're kind of don't have secure housing you don't have secure money and to kind of figure out how you're gonna get that was really challenging and so did Heather the doctor the pregnancy happened there she learned about her pregnancy and and she said that and the doctor told her she needed be on methadone did what happened to or did she manage it yeah so she tried to do it on her own at first and kind of those things I was talking about happen to her and she ended up not making it a few times and they ended up kicking her out of the program and she just like you know she just didn't know what to do you know she was fully addicted to heroin still she was four months pregnant and sorry I got distracted for a second yeah so she's four months pregnant and she's and she's like I don't know what to do and then what happened was her mom stepped in so her mom like went to the methadone clinic it was like I'm gonna quit my job and I'm gonna join my daughter every single day to the clinic until she's able to take the bus herself and they let her back in and and so they started to do that and she was able to start adhere to the program the treatment program and started to get a lot better and did she have her baby and yes she did she had a baby and it was healthy and great had no kind of addiction to any kind of opioids great great is it speaking of methadone isn't there some kind of stigma around the use of methadone I've heard that some people think that because methadone is an opiate itself that you're just exchanging one addiction for another could you address that yeah I could talk about that yeah I've heard that a lot too you know and there is a huge stigma around methadone I mean there's a huge stigma just in general around like drug use and drug treatment and and you know for Heather and her family like they they both had us you know they both thought you know negatively or poorly about methadone and had those similar concerns that I was just treating one a drug for another and it's interesting a lot of heroin users see methadone as that like and don't want to get on treatment because they see it as just exchanging one drug for another and why not just actually feel the the really booming highs of heroin instead and but what happened was though that they they were at a desperate moment where they didn't know what else to do so they were willing to try methadone because there was no other option and a doctor told her that it would save her baby and what happened was they saw it they saw Heather change they saw Heather change and so they both like became proponents of this treatment could you explain briefly a little bit about can you explain a little bit about the fact that methadone and buprenorphine which we'll talk a little bit more about that they are opiate so I mean people who are not familiar with them may not know that they control withdrawal symptoms right that they control cravings could you explain that a little bit or what they're in terror or they reduce the high yeah I mean they help with the cravings and they reduce withdrawal symptoms and and they help people kind of stabilize to have their behavior as well usually stabilizes after they've been on for a long time and that will allow them to then for the long term to address the addiction right okay okay so we were talking about she used methadone what about buprenorphine I mean the way I understand your preneur Fein is you don't have to go to a clinic to get it you don't have to go somewhere every day to get it why didn't she just use buprenorphine yeah so well her doctor told you to get on methadone but in her area there was no buprenorphine there's no physicians willing to prescribe buprenorphine and that's how that works is if you want to get that drug or that treatment you need to go to a primary care physician is one way to do it and they can prescribe it to you actually um you know we just got a question related to this yes it is exciting and it's Fitz because like you said in the in heathers area there were no physicians who were who were not qualified not qualified who were allowed to prescribe buprenorphine so the question is this how can more physicians be brought in to treat opioid addicts especially in rural areas why don't we first explain a little bit Brian about what physicians have to do to get the permission to to do this so most public health experts agree that buprenorphine is one of the gold standard treatments for opioid addiction and and the problem is that there's not enough physicians who are willing to to prescribe it and part of the because you have to get a waiver from the federal government and it requires an eight-hour training session and and besides that there's also this kind of we talked about stigma there's also a stigma of having to treat a drug-using population that may come with a lot more you know baggage if you will like a lot more behavioral issues and things and so there's a fear that it might disrupt a practice and a lot of these primary care physicians already have practices where they treat patients and there's a there's not a huge incentive for them to do it and so I guess what the question is is like how do we encourage more rural people rural our physicians in rural areas to be willing to do this waiver and willing to kind of treat this population and there's a few different things that are in play in California like the Department of Health Care Services recently gave a got a grant a federal grant that it distributed to a little bit more than a dozen communities to support physicians and prescribing these and kind of giving support from from clinics or other physicians who have already done it so they will have training and help so trained physicians need more training is there anything being done to address the stigma that you mentioned that you know of yeah I think there are I think there's some efforts to work with like emergency room physicians and and there's a lot of outreach you know I know that some of these methadone clinics they some of the ideas as they could set up maybe a satellite clinic and some of these small places so it's not like a full full clinic but like just a small room where people can go because there's not like they don't see as many people coming in as a more urban area like San Francisco or you know even Bakersfield right and the satellite clinic it would be by telemedicine or no it would be just a smaller clinics physician or it could be in conjunction with a primary care physician I see okay okay and and just a reminder that was a great question if you guys anybody watching has questions please go ahead and and post them on to our Facebook page in the meantime Brian you let's move on to one of your other stories you wrote a different story but out of the same area out of baker's ish out of Bakersfield that involves an addiction medicine doctor who prescribed buprenorphine actually and who ended up shooting and killing a former patient in his office his name was dr. song I believe tell us about dr. song yeah and I mean this kind of goes into the the last thing we're talking about and the limited amount of physicians who are willing to prescribe buprenorphine dr. song was not one of them dr. Edwin Zhong he had an addiction clinic and Bakersfield and he was willing to to treat anyone who came to him and based on my reporting and everyone I hurt talked to you like he took only cash and it was like 50 bucks to 80 bucks and if you paid him that he would write you a prescription for people know everything that you could then take to the to the pharmacy and have it filled however you would have a filled either through you know like medi-cal or out-of-pocket and what happened was he end up getting overwhelmed with patients like he had lines out the door according to to neighbors and other patients where it was just like a non-stop kind of what is it like conveyor assembly line conveyor belt of just like people coming in and getting this drug and he at some point started carrying a gun he got a carry concealed permit and brought a gun to the office and one of the one of his former patients David Cole laying he was he was a vet he'd spent two tours three tours in Afghanistan and Iraq and came back and got addicted to heroin and some other opioids and just had a really hard time and he for some reason that we still don't know went to see dr. song and attacked him and during that attack the doctor pulled out his gun and shot him three times three or four times three times he got shot and died three times and and what did the police determine about that case well the police determine I have a self-defense because he was attacked and acted in self-defense according to the police I mean that's a very extreme case right but but the way you're describing it with patients out the door and this assembly line it sounds like there's just a much bigger need this service and there are doctors is that is that what you the moral of the story essentially yeah I mean I think that's that is that there is this lack but there's this there's a great need for it as we can see and illustrated by that by the doctors long story was that there's a lot of people who are and opioids that want this medication and they want it they want it for cheap and they want to easily acceptable and you know maybe those and those always don't those don't always go together and and so yeah there is a need based on that based on just a lot of hearing users who want access to these medications before we go on we do have another question Brian I'm gonna need you what is su D stand for its substance use disorder okay so the question is this the majority of people in jails have some sort of substance use disorder why is it the one place where effective medications are prohibited so I presume they're talking about is it methadone and buprenorphine are prohibited in jails or yeah I think that's what they're talking about I'm not super familiar about it but I do I mean you know there's a lot of things about jails and prisons and incarceration and there's not a lot of you wonder why there's not even more rehabilitative services and this is one of them and it wouldn't make sense to to treat a drug-using population that end up in jail and help support them and stabilize and then continue to help and support them once they get out of jail and I think some of the reasons while that's not being done there could be a lot I think somewhere it's it cost a lot of money to do that and there's a potential for abuse that the jails might be of afraid of within the jails you mean using buprenorphine for the for the as a drug as opposed to a treatment correct like it could be like you know sold and traded I see I see so attention if a potential for abuse then mm-hmm okay okay and actually you mentioned this a little bit earlier I wanted to follow up on it medi-cal can you tell us a little bit about so medi-cal is California's version of the federal medic cade program for low-income Californians what kind of coverage and access to medical patients have to these treatments well they do have a lot of access now and it's kind of changing in it and it depends on what county you live in in California but throughout the state if you have Medicare you can go to a primary care physician and you could start a treatment plan o Cupid or Fein some in some counties methadone clinics which are regulated by federal and state laws and have a lot more regulation around them and some counties are now being able to accept medi-cal for buprenorphine treatment which includes counseling and a bunch of other kind of services our supportive services and you can get that at a methadone clinic correct I see so it sounds like and wasn't there something about naloxone is that available as well do a my a my no long as a trainer does no no locks own do you know about coverage for that for medical patients I don't I vaguely write pologize I don't have the answer off my own yeah maybe someone maybe someone listening can type in actually that's great that'd be great and you mentioned something about how Medicare patients if their primary care physician they can get buprenorphine from from them i my last column from last month was about was offering tips and resources to people who have addictions opioid addictions or their or their loved ones and I'm I'm gonna ask one of our producers to post my column and if you're anybody's interested you just go to the column there are several links you can search by zip code for the doctors in your area who prescribe buprenorphine you can also search for addiction medicine specialists who can help guide you and so hopefully that would be helpful to some people it looks like we have another question keep them coming oh this is a good question I'm not sure that I have the answer okay I think okay okay the question is this how can we approach pharmacists and request them to prescribe edge and educate prescribe to and educate opioid patients so it sounds like the question is not just about doctors and the stigma with doctors but with pharmacists as well yeah I mean I'm not entirely sure what the question is asking if if pharmacists should spend more time educating people who get opiate prescription pain pills or if that's about treatment or what but during my reporting for the doctors long story I talked with a lot of pharmacists and and it appeared that a lot of purposes have a criteria of what they look for in drug seeking patients and if they see enough of them coming from certain doctors they can flag those doctors as being sketchy provider or sketchy for prescribers or just refuse them all together so I don't think that answers the question but interesting thing about pharmacist ya know I wish I knew more it sounds like I'm wondering though to if you know a little naloxone for instance is available in California and most states without a prescription I wonder if pharmacists have a choice for instance in whether to carry it that I don't know the answer to actually so if anybody knows let us know another question for you Brian what surprised Brian most while he was reporting about substance abuse treatment in California well let me think what surprised me I mean I've been reporting and been a part of the recovery world and been a drug user myself so not a lot of that kind of stuff surprises me I think what was most harmful was the or really touched me the most was doing this story about dr. song in the in the former patient who was killed which was cold laying and I was it was just a really sad story about him coming back from three tours you know and like he just and it was just like all that stuff you hear where they just struggled to find help and they struggle to like ask for help really you know and and they have those things like where you're like where they say like oh you'd say like he was you know soldier you know he doesn't he doesn't want to admit his problems and you're like you just have heard that for so long and you're like I can't believe that's still like there's not enough outreach or help that kind of reach these people and give them the encouragement to share because it just was really sad and that's what really like touched me and that he just couldn't find the help you know and he had a really hard time at the VA in the Central Valley area according to his family actually this is a this is a good place to to ask you what other stories on opioid related coverage are you are you looking into or would you like to look into that you think need attention yeah I mean just like off the I mean I was thinking about it but now it just seems to be coming off the top of my head I'm really I'm interested in the state and how it like its medical program they are doing a lot of stuff that's unfolding right now in California and how they address drug treatment in general including opioid treatment and it's really transforming the whole system and so I really want to kind of dig into that more and it's not only is it oh you mean it's filtering kind of beyond medical into the private insurance world is that the idea no it's just it's just changing how treatment is administered because a lot of times people went to resident for rehabs and that's changing and they have all the different different views about the best treatment now and I don't know and so I think that's a good way to look into I'd also think it's interesting to continue to look into the companies that make these open early treatments and why they do save a lot of lives and help a lot of people they are pharmaceutical companies that are driven by profit and there's a big incentive for them to continue to make new formulations of the type of drug so they can continue to get patent and from get though which is a higher they get charged a lot more and so I would like to dig into that a little more and I think that's an interesting point cuz I know naloxone for instance when I was doing Mike my reporting and you probably know more about it naloxone is available in three different Media media I guess you could say you can you can get it as a regular ol syringe in a vial and inject it into something which is kind of scary actually but you know you'd do it if you need to right but if your family member or something and then you can get it as a nasal spray and then the third option is this kind of auto injector EpiPen like device and I think the price of those is increasingly expensive right and so with that EpiPen device being the most expensive so is that the kind of thing you're talking about in with like buprenorphine they have like it was a tablet then it was a tablet mixed with naloxone to prevent like kind of an abuse deterrent and then it was you know a film strip and then that's then they have an injection and then there was like another kind of I think they call a depo injection where they inject something in you that then releases the beautiful nor fiend over a time period so there's just more and more those it's I mean it's a big industry and it there's a lot of money to be made too as well as ways to and also I mean it's trying to help in treat people's game right right I think that's fascinating that's fascinating you had mentioned something to me of oh we have more questions okay here's a question can you please comment on a recent study about the moral the quote moral hazard end quote of naloxone which said that precisely because it can save lives it encourages people to feel less inhibited about using opioids which leads to more overdoses thus offsetting and lakhs owns beneficial impact that's really interesting so the idea is is people know they won't die they're more likely to keep using I think what do you think it's a tricky question um I mean as through my own experience as a heroin user like I could totally see how having that would increase you know you'd be more willing to take chances right and you know that makes sense but that's not an excuse to limit to access to something like this because it's it saves people's lives and like whether whether people are taking riskier chances or not does it shouldn't matter you know like this is a thing that readers read reverses an opioid overdose you know what saves lives and I think that it's important to give that to the people interesting did you hear anybody have you have anybody you've interviewed talked about in the locks own and and using it yeah I mean everyone you everyone I've talked to that has been an opioid user has some story usually some really sad horrible story of someone overdosing and dying and sometimes there's people who have convinced her no I don't save people's lives ok ok I do that there was a Patrick a gentleman named Patrick actually emailed us some questions ahead of time and one of them goes to the question about why more doctors are not prescribing buprenorphine and he wants to know he asks about the limits apparently there's limits on physicians who have been approved you know they've gone through the training and they got their approval to write buprenorphine but there's these limits can you explain those yes so there is some more hurdles and barriers to get access to buprenorphine and and besides the waiver there is patient limits and they those have been changed recently to make to allow for more patient but I think that when you get the waiver you apply to treat a hundred patients and then after a year you can get a jump to about 275 patients and I also think that that also allows for not just primary care physicians but also nurse practitioners can prescribe it so the kind of provider is maybe broad but the number of people is not is limited it is limited but 275 is still a lot of people for one physician like you why do they do that what's the reasoning behind it I don't know I think that the I think the idea behind all the limiting is that they're controlled substances by the federal government and they they want to continually I don't want to control them and they don't they don't want them to be abused and they I mean like it's the war you know there's still a war on drugs it's like the war on you know I don't want to get too into it right you don't want to talk about the war you know the you raised you talked about rehab a little bit earlier and this is something that came up in my little amount of reporting on opioid addiction when talking to addiction medicine specialists but I'm just going to pose it to you okay um does rehab alone without the use of methadone or buprenorphine or Dell trucks own does that work can people who work I mean you didn't do we have per se but you didn't use medications I mean does rehab alone work well I mean a lot of people say that it doesn't work I guess it depends on what you hope to expect to get out of rehab like you can think that like anyone besides opioid users who goes to a treatment place for us a small amount of time and to think that like being there is somehow going to stop possibly 10 20 years of drinking using or whatever is now it's kind of not realistic yeah I think that I think that there is a change though and Residential's that there's been more of a move to incorporate medication assisted treatment whether they bring that on themselves and/or whether they work with other kind of doctors and the patients who come there and there's also move to actual limit the amount of residential time that people do in general so that they can have more access to outside kind of treatment that would allow for a more robust kind of medication treatment so I don't really know how to answer that but I mean a lot of people say it doesn't work I mean yeah it's interesting how adamant that the the doctors that I spoke to were about that that nor did they they they said rehab alone didn't work but they also said medication alone and for the most part shouldn't be the the the treatment of choices should be combined with 12-step programs and other support therapy things like that yeah um yeah I mean like what's what's crazy about this is that it's just a really like interesting world of drug use and treatment that like there are some things that show that that helped but we don't really know a lot there's a lot of research and still like a lot of money that's thrown at this and we're so like you know how do we reach a drug-using population and get them to get treatment you know I still a big challenge and and sending someone to rehab you know it's like they say it's like a lifetime thing almost to continue to to stay off these type of drugs and that's why there's a lot of like method and we didn't really talk about the lengths of time that people are on them like in this story with Heather like she I think over three years she weaned herself off or to a really low dose and that just means she tapered the dosa she went up to a peak and then went lower and lower and lower until she was basically on very little to zero methadone and that was over three years some people stay on it forever it's called methadone maintenance or indefinite until they're ready maybe to wean off but I know in San Francisco there's like slots for methadone and people just stay in there until they die Oh interesting interesting so that's right and you're touching on something that I heard as well as that people could be on these medications for years if not their entire lives and that we as a society should be looking at and as individuals with loved ones should be looking at substance abuse disorder as a chronic condition like you would look at diabetes or high blood pressure and that you shouldn't expect like some overnight or short you know miracle yeah and that's kind of like some of the advocacy around treating this that's trying to be explained to a lot of physicians that it can be treated like a chronic condition and that after the initial kind of period of getting them off of the street or illicit drugs onto a stable stabilizing on the medication that they can just come in regularly with a doctor as they would with any kind of other chronic condition right and that it's really it's not really much more than that right and it also you know we look I mean we look at it as a disease instead of like the you know the classic of the moral feeling all right the which is a common kind dialogue that people talk about right right it looks like we got a confirmation on great so somebody thank you I don't know who you are you confirmed that naloxone is covered under most insurance plans and covered by medi-cal and Medicare so thank you thank you for that you know folks did you want to add something no we're gonna be wrapping up pretty soon unless you have some last minute question you want to slide under the into the Facebook comments but is there anything you want to add here at the end or no I mean yeah no I really appreciate you you have a unique perspective you know you have the personal experience and thank you for sharing that which may not be the easiest thing in the world to do but you also have the perspective of the journalists who spoken to so many experts and real people so thank you thank you for doing that oh I think we have oh no oh okay no more questions you guys I really appreciate everybody who has joined us today and this is California health lines first Facebook live if you have ideas for future topics please do let us know and we will see you next time

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