The Lazarus Drug | Hidden Brain More than 70,000 people died of drug overdoses last year — many of them from heroin and other opioids. One of the most widely-used tools to confront this crisis is a drug called naloxone. It can reverse an opioid overdose within seconds, and has been hailed by first responders and public health researchers. But earlier this year, two economists released a study that suggested naloxone might be leading some users to engage in riskier behavior — and causing more deaths than it saves. This week, we talk with researchers, drug users, and families about the mental calculus of opioid use, and why there's still so much we're struggling to understand about addiction. For more information about the research in this episode, visit https://n.pr/2OZfuGQ.
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Life, Death And The Lazarus Drug: Confronting America's Opioid Crisis

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Life, Death And The Lazarus Drug: Confronting America's Opioid Crisis

Life, Death And The Lazarus Drug: Confronting America's Opioid Crisis

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SHANKAR VEDANTAM, HOST:

Heads up, parents - this episode contains strong language and mature themes. If you're listening with young kids, I strongly urge you to save this one for later.

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VEDANTAM: This is HIDDEN BRAIN. I'm Shankar Vedantam. There's an old saying - the best things in life are illegal, immoral or fattening. There's another way to think about this. Many things that give us pleasure - sex, food, adventure - they contain risks. As a smart species, we've come up with ways to minimize those risks - condoms, seat belts, drugs to lower cholesterol. But something interesting happens as we do this. As we move the risk-benefit calculation for each activity away from the risk end of the spectrum to the benefit end of the spectrum, we imagine people will become safer. Seat belts, for example, will keep drivers from getting hurt. Now, that would be true if people kept doing things exactly the way they did before.

But some people make another calculation. If putting seat belts in cars means you are likely to survive a crash, there's now a temptation to go faster. An ocean swimmer might go out a little further when a lifeguard is nearby. Football players who know their heads are protected by helmets might start to hit a little harder.

This phenomenon has a curious name. Economists call it moral hazard. It's a bit of a misnomer because moral hazard has little to do with morality. It's about what happens when you move the risk-benefit calculation to make things safer, and people respond by taking more risks.

JENNIFER DOLEAC: So there was a paper a while back by Sam Peltzman that kind of lays out that the classic case of moral hazard that economists like to point to.

VEDANTAM: This is economist Jennifer Doleac at Texas A&M University.

DOLEAC: And his idea was that when seat belts first became required in cars, I think most people would assume when you have seat belts, that's unambiguously a good thing. It's going to save lives. And he saw that and thought, if you have a seat belt, maybe you drive a little bit more recklessly.

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VEDANTAM: Sam Peltzman found that while drivers were safer because of seat belts, they also drove more recklessly. That put pedestrians at risk. He argued that the safety benefits of seat belts were canceled out when you took this into account. Now, subsequent studies have challenged this finding, but the seat belt example illustrates the dilemma posed by moral hazard. Should you make things safer if people are just going to take more risks? Or should you allow people to face the consequences of their actions by doing away with safety measures?

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VEDANTAM: This dilemma has political dimensions. Liberals tend to say, the more safety measures, the better. Conservatives worry about the negative consequences that interventions might have on personal responsibility. So are safety measures useful? The answer is - it depends. There can be safety measures that cause so much moral hazard that they make things worse, and there can be other interventions where the benefits far outweigh the risks.

Today, we consider this dilemma in the context of a deadly public health crisis.

TIFFANY: I know I was dead for four minutes by the time the ambulance got there, but they revived me with Narcan.

VEDANTAM: The opioid epidemic.

UNIDENTIFIED PERSON #1: He is playing Russian roulette.

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JAMES: If they knew where the dope was...

JASMINE PIERCE: A grain as small as a piece of salt can kill a human, and it is 10,000 times more potent than morphine.

JAMES: ...They would haul ass to get that shit, and they figure, OK, well, I'll just do a little bit, so it won't hurt me.

VEDANTAM: Life, death and trade-offs - this week on HIDDEN BRAIN.

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VEDANTAM: The Centers for Disease Control and Prevention recently released an astonishing statistic. It estimates that, in 2017, about 72,000 people died from drug overdoses.

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VEDANTAM: The vast majority of these deaths were caused by overdoses of heroin and other opioids.

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VEDANTAM: How do you understand the magnitude of 72,000 deaths? I don't know. But I can tell you one story.

JENNIFER SCHMIDT, BYLINE: You want me to shut this front door?

HOPE TROXELL: Yes, if you don't mind. I appreciate it.

VEDANTAM: It unfolds in a tidy ranch home in Frederick, Md. My producer Jenny Schmidt and I have made the hour-long drive from Washington, D.C. We sit down at the kitchen table and start with introductions.

H. TROXELL: Yes, my name is Hope Troxell.

PETE TROXELL: Hello, my name is Pete Troxell.

VEDANTAM: Hope and Pete Troxell live in a neighborhood on a hill just outside of town.

H. TROXELL: I've been here all my life and - my husband and I both.

P. TROXELL: We've been married 46 years, lived in the same area.

VEDANTAM: Hope exudes a comforting warmth. She's the kind of person you want to hug. Pete is tall and reserved, with long, white hair and a thick, white beard. It's not easy for them to share their story. Hope fidgets. Pete clenches his hands. They begin by telling us about the life they once had, a life that made sense. Their first child was their son Jeremy.

P. TROXELL: He's very easygoing. He doesn't get upset.

H. TROXELL: He's very quiet. He never said a whole lot when he was young.

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VEDANTAM: Four years later, Alicia arrived.

H. TROXELL: My daughter is more of a strong person. She was determined, more so than my son.

VEDANTAM: Alicia was self-possessed, outgoing, a people person. She took risks, like the time when she was just 7 and decided she wanted to compete in a beauty pageant. Hope and Pete drove her to Virginia. Pete wore a tux.

P. TROXELL: 'Course, she didn't win, but she was so upset. But we had to tell her that, you know, life is full of disappointments, but you go to go on, and you got to move on. And she did. And she - I mean, she got over it. She was 7, 8 years old. She got over it and...

H. TROXELL: She came in the top 10. She was in the top 10. She didn't come in the first place, but she was in the top 10 out of the girls.

VEDANTAM: Do you remember what she wore?

P. TROXELL: I remember she had a little gown on, but it was - had the little crown thing and all that. I can't remember what color, but it was a little long gown. And she's just so cute.

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VEDANTAM: That memory of their little daughter in her long gown still makes them both smile. Hope says, as the kids grew older, they stayed close with their parents. Jeremy started working for his dad's trucking business. Hope says she and Alicia were like two peas in a pod.

H. TROXELL: You know, she had to call me every day, or I had to be on the phone with her.

VEDANTAM: After Alicia finished high school, Hope convinced her to apply for a job at Fort Detrick, a nearby Army installation. Hope worked there, too. Alicia started as a cleaning person. Within a couple years, she was working in the mailroom. She was thriving. She met her soon-to-be husband, and she was pregnant - with twins.

H. TROXELL: And then my daughter decided, I'm going to go back to college. I said, how can you go to college when you're pregnant, going to have two little kids and go to college? So she says, I'm going to do it online. She would put them girls to bed, and then she would go online and do her college, and she got her associate's degree in business. So from there, from that, she moved up again and went to administrative assistant. And my daughter was making good money - really good money.

VEDANTAM: They were proud. Pete says Alicia was the first person in his family to graduate from college, and a decade of hard work at Fort Detrick had paid off.

P. TROXELL: And I mean, things were going really good for her.

VEDANTAM: But Alicia also had scoliosis, and as the years went by, it got worse.

P. TROXELL: 'Course, she had back problems. And, 'course, she went to the doctor, and they put her on oxycodone.

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VEDANTAM: It's a story of our time. Alicia started taking oxycodone in 2014. Her twin girls were now about 8 years old. Besides her back, there were other things in Alicia's life that weren't going great. She had split from her husband and was in the midst of a divorce. She'd moved back in with Pete and Hope, and the twins lived there, too, part of the time. The oxycodone didn't just help with the back pain. It made Alicia feel better about everything. Then, one day, Hope realized her own pain pills, the ones she'd been prescribed following a rotator cuff surgery, were running suspiciously low.

H. TROXELL: I would leave my pills set on the counter, and then I could see that maybe one, two pills are being taken, and I'm not taking them. Well, then I really started counting. I actually would start writing them down, when I would take my pills. And my pills should be lasting me longer.

And, of course, I approached my daughter one day and, she said, well, Mom, my friend needed it. He's having back trouble, so my friend needed the pain pill. I said, you don't take my pain pills. You come to me first and ask me.

VEDANTAM: Looking back on it, Hope thinks Alicia was already hooked. There were signs.

H. TROXELL: Like her work, going to work late, saying, Mom, I need to use this extra time from work. I have all this vacation time. I need to use some of this time from work.

P. TROXELL: I would, myself, would take the girls down to school, drop them off - noticed that, more and more, she was like, well, I'm going to be late. Dad, can you do this? And I'm like, you're already late for work.

VEDANTAM: Soon, skipped hours turn into skipped days.

P. TROXELL: I told her one day, I said, you're going to end up losing your job. You got a very good job. Don't mess it up. But she - she did after a while, and they left her - they left her go from Fort Detrick.

VEDANTAM: And then, things just got worse.

H. TROXELL: She just had a real hard time - what do I want to say - functioning. You know, she just couldn't seem to get herself together, to be able to even - with her girls.

VEDANTAM: Eventually, she lost shared custody of the twins.

H. TROXELL: She was able to get her girls if she would do pee test. If she could get a clean urine, she could visit her girls at the Department of Social Services.

VEDANTAM: It was after one of these visits that Hope and Pete believe Alicia finally lost whatever will she had to keep her life together. She'd driven with her parents for a supervised visit. Hope and Pete waited in the car. They watched Alicia walk inside, her arms filled with toys.

H. TROXELL: But when she came out of there, I could see her failing because she came out, and she was really crying. She said, they won't even let me hug them. They won't even let me kiss them. And that took my daughter downhill.

P. TROXELL: And she came out of there with her toys. The girls didn't want the toys, didn't want to get close to her. They left early, and when she came out that day, that - in my heart, and I believe 100 percent - that that was the turnaround point for her to get on heroin.

VEDANTAM: Once Alicia started using heroin, she lost the remnants of her former life. First went the last few rights she had left as a mother.

P. TROXELL: The last time she was in court, the judge wouldn't even allow our daughter to talk to her girls on the phone. And I'm like, people in prison get to talk to their kids on the phone.

VEDANTAM: So the - why did the judge not want...

H. TROXELL: Sometimes they felt when she did talk to the girls on the phone, that she - either she was nodding out or her speech was slurred. It's hard. I know it's hard for families with this situation, with the drugs. But when you have an addict, you have to help this person.

VEDANTAM: But most people simply turned away from Alicia. Isolated and addicted, she burned through her savings. She got evicted from her apartment. She also started a new relationship and got pregnant.

H. TROXELL: She was six months about the time then. And I told her - I said, Alicia, you have to get straightened out, but she just couldn't. She could not help herself. She had gone to rehab, and she was only there five days, and she left. She just couldn't do it.

VEDANTAM: But Pete and Hope kept fighting for their child. They worked with her, pleaded with her. Finally, something shifted in Alicia. She went back into rehab. This time, she made it through the 28-day program covered by Medicaid. When she came out, Pete and Hope opened their doors to her. She was seven months pregnant and very fragile.

H. TROXELL: She was home a week. She was doing great.

VEDANTAM: She shopped for baby clothes. She watched TV at night with her parents. She met a friend for lunch. She and her dad had an honest talk. Pete told her that he loved her. Alicia said she was sorry for all she'd put them through. One night, Hope fixed Alicia her favorite meal - corned beef and cabbage.

P. TROXELL: And she was so happy that night.

H. TROXELL: Matter of fact, after we got done dinner, I went back with her. She had these little boy clothes, and her and I was folding them up and putting them away. And she was going to name the little boy - Camden was his name. And her and I were sitting there. Like my husband said, he'd come back there, and he told her that he loved her and that everything was going to work out. We all were going to work together.

VEDANTAM: Eventually, Hope and Pete went to bed. In the morning, Hope walked to Alicia's room to bring her the medicine she took to stave off withdrawal symptoms.

H. TROXELL: And I went in, and her light was on. I went in and opened the door, and then I saw her. And she was slumped over. I hollered, Alicia, and she did not answer. And I hollered for my husband to come running. And he went around where she was at and tried to pull her back, and she was already stiff. So when I called 911, they told us to try to get her on the floor and use - give her compressions. And I told the woman - I said, ma'am, she's gone. I know she's gone.

VEDANTAM: Camden was also dead. Alicia Troxell was 34 years old. She left behind her twin daughters, her parents, a brother. Hope and Pete wouldn't allow an autopsy because they didn't want to disturb their unborn grandchild. Hope says blood tests showed Alicia had taken a deadly dose of fentanyl. Having just finished rehab, she was especially vulnerable to an overdose because her body had just been detoxed. Alicia's addiction didn't just kill her - it destroyed the family. Hope and Pete no longer have any contact with their granddaughters. It's something that Hope struggles with.

H. TROXELL: My daughter's viewing that night before was so amazing. There was over 150 people there. And I wish my granddaughters could have seen that. They could have seen how loved my daughter was and how loved their grandparents were.

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VEDANTAM: Hope's grief feels like a physical presence, thick in the air, hard to move through.

H. TROXELL: We lost a whole family. And I feel like I have lost my granddaughters, which was all I had left of my daughter.

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VEDANTAM: Alicia's story took place 72,000 times in 2017 to thousands of families, rich and poor, black and white and brown. The scale of this tragedy has generated horror and desperation. Legislators, communities and families have tried everything to stop the deaths. And then, a few years ago, something appeared that looked and sounded to many people like a miracle.

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VEDANTAM: Heroine sets off a chain reaction in the body.

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VEDANTAM: Up to a point, it makes users feel euphoric. It takes away stress and pain. But then, if you increase the dose, heroin begins to affect vital functions.

LEO BELETSKY: The person's system slows down to a point where they stop breathing, and then their brain basically shuts down.

VEDANTAM: Leo Beletsky is a drug policy and public health researcher at Northeastern University.

BELETSKY: And that process typically takes a substantial period of time. With traditional opioids, it can be up to two hours or more.

VEDANTAM: Often, heroin sold on the streets is now laced with fentanyl and carfentanil. These synthetic opioids are cheaper and stronger.

BELETSKY: And so overdose can occur in a matter of minutes.

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VEDANTAM: Now, there has long been a way to reverse overdoses - the drug naloxone. Between 1996 and 2014, the CDC estimates that more than 26,000 overdoses were reversed by laypeople administering naloxone. Not medics, not doctors - ordinary people. Naloxone has been given the nickname the Lazarus drug. In the Bible, Jesus restores life to Lazarus. Naloxone doesn't restore the dead, but it comes close.

BELETSKY: What happens is the person slowly starts to - their breathing starts to return to normal. Their skin starts to turn from its kind of white, ashen color - which is what happens during an overdose - and lips start to return from blue to normal color, and they start breathing again.

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VEDANTAM: In late 2015, the Food and Drug Administration approved a new form of naloxone that was much easier to use. It was a nasal spray, and it was a game changer. It was called Narcan, and it came at a critical time. Deaths from drug overdoses were skyrocketing. Across the country, massive education campaigns spread the word about the magic drug.

PIERCE: We'll go ahead and start, but before I start, if you could pass your applications forward.

VEDANTAM: On a Thursday morning, I'm in a packed conference room at a Maryland county health department. About 30 people sit in three rows. They fall silent as a woman steps to the front.

PIERCE: So my name is Jasmine Pierce. I'm the overdose response coordinator for the Anne Arundel County Department of Health. You all are here for the naloxone-Narcan training. This training should be about 30 to...

VEDANTAM: It's a free training event for the community that officials hold a couple of times a month. People are here to learn how to administer Narcan to overdose victims.

PIERCE: At the end of this training, you will receive a naloxone kit. This kit has two doses of intranasal naloxone. We give two now due to the carfentanil and fentanyl overdoses that have occurred within our county.

VEDANTAM: Fentanyl and carfentanil are so powerful that it often takes more than one dose of Narcan to bring a victim back.

PIERCE: If you're not familiar with carfentanil, that is a tranquilizer used to put large animals down, such as elephants. A grain as small as a piece of salt can kill a human, and it is 10,000 times more potent than morphine. I always mention that we do provide gloves inside of the kits, as well, to protect you from any type of contamination because, with both of those drugs, they can actually seep through your skin with skin-to-skin contact, and you can overdose yourself.

VEDANTAM: The people sitting in the three rows listen. Some look shocked. Some take notes.

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VEDANTAM: There's a high school nurse, a minister, an athletic trainer, a mother, a friend and lots of heartbreak. After the training session, their stories come tumbling out.

UNIDENTIFIED PERSON #2: My friend Jeff, his niece died of a heroin overdose.

UNIDENTIFIED PERSON #1: Since a friend of mine's godson died, and then my son died. He was 22, you know, and he just couldn't - didn't want to stop is what it boiled down to. And, you know, he'd already overdosed, like, five times this year. So he knew it was - he's playing Russian roulette.

UNIDENTIFIED PERSON #3: And then my sister - she had overdosed in October. She came back. They were able to bring her back with the Narcan. And then last month, she died of an overdose at work on break.

VEDANTAM: The trainer, Jasmine Pierce, has her own story. It's the one story everyone here wants to be able to tell - the story with a happy ending.

PIERCE: I was going to 7-Eleven one morning before work, and I noticed there was a man in his car. He looked like he was sleeping, but I started to get a little worried because when I came back out, he looked blue to me. So I knocked on his window. He didn't respond, so thankfully his door was open. I opened his door. I checked his pulse, and I noticed that he was unconscious, and I didn't even think. I just went ahead and sprayed the Narcan, and within 30 seconds, he came back.

VEDANTAM: This is the power of the Lazarus drugs. Across the country, legislators have rushed to pass laws increasing access to naloxone. Some have urged every family in America to keep the drug close at hand. Public health officials have assured people that if they administer naloxone to someone who is not high on opioids, it won't do anything. With most drugs, you have to worry about misuse and unintended consequences. That wasn't true of naloxone.

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VEDANTAM: But then in early 2018, a study came out that suggested naloxone might indeed have an unintended consequence - one so cruel that it called into question all the good the drug was doing. This finding set off an uproar, with many experts rejecting its conclusions. The controversy reflects the mind-boggling complexities of the opioid epidemic and the labyrinth that confronts anyone who finds themselves in this world.

DOLEAC: The growing interest and public push to broaden access to naloxone was - has been really interesting to me for a while.

VEDANTAM: This, again, is Texas A&M economics professor Jennifer Doleac. Jennifer and a colleague, economist Anita Mukherjee from the University of Wisconsin, knew that naloxone was effective but...

DOLEAC: There are always trade-offs. That's something we think about all the time as economists. What are the trade-offs involved?

VEDANTAM: The biggest trade-off Jennifer and Anita were interested in was moral hazard.

DOLEAC: So when it's less risky to consume opioids because naloxone provides a safety net, we might see opioid abuse increase.

VEDANTAM: In other words, could having the safety net of naloxone prompt drug users to take more risks, like injecting bigger doses of heroin or stronger drugs like fentanyl? Answering such a question scientifically is very, very difficult.

DOLEAC: The ideal experiment would be to randomly assign naloxone access to some states but not others. Obviously, that's not happening here, but it's helpful to think about that ideal experiment because it gives you a treatment and control group.

VEDANTAM: Since the ideal data were not available, Jennifer and Anita came up with an indirect way to measure whether naloxone use was affecting opioid use. Some states were passing laws making it easier to get naloxone. The researchers decided to use these new laws as a proxy for people actually using naloxone and then compared states that had broadened access with those that had not. They would then test if there was any difference between these two groups in terms of opioid overdoses and mortality. It was an imperfect experiment, but this was the data they had.

DOLEAC: Well, even then, you know, it's not random, and so we need to be really careful about making sure we're controlling for everything else that might be going on in those states that we think might have an impact, control for pre-existing trends, control for just pre-existing differences across states in levels of opioid use and other policies they might have implemented to address the crisis.

VEDANTAM: With all those controls in place, they thought they may be able to answer the question, what effect was naloxone having on the heroin epidemic? On net, was it saving lives?

DOLEAC: It seems reasonable that a drug that saves lives, you know, would on average have beneficial effects when you look at mortality rates. I think when we first got into this taper (ph), we really expected to see a big drop in opioid-related mortality as a result of these laws.

VEDANTAM: But that is not what they found.

DOLEAC: In fact, what we found was that on net we're not seeing any decline in mortality, and in some places, we actually see an increase in mortality.

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VEDANTAM: It was a stunning result. To be fair, Jennifer and Anita found that some states did see a decline in mortality when they broadened access to naloxone. But on average nationwide, mortality did not decline. And in places like the Midwest...

DOLEAC: We're finding that the naloxone access laws caused a 14 percent increase in opioid-related mortality relative to what would have happened without the law and also a big increase in fentanyl-related mortality - again, relative to the counterfactual - what would have happened without the law?

VEDANTAM: Jennifer and Anita have a theory about what is going on.

DOLEAC: Our interpretation is that, you know, the risk of death associated with a kind of unit use of heroin or prescription pills has fallen now due to naloxone, but the number of uses and the potency of uses has gone up so much that it actually - it doesn't just reduce the mortality benefits, but it completely counteracts them, in the Midwest in particular. And so what seems to be happening is that opioid use is going up so much as a result of broader access to naloxone that we're actually seeing an increase in mortality rather than a decrease.

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VEDANTAM: Shortly after Jennifer and Anita disseminated a working paper about their results, the pushback came fast and hard from public health experts.

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VEDANTAM: Critics pointed to studies that had reached very different conclusions. At the University of Colorado Denver, for example, Daniel Rees and his colleagues found that a state's expanded access to naloxone, there was about a 10 percent decline in mortality. And at the federal Substance Abuse and Mental Health Services Administration, Chandler McClellan and his colleagues found an even bigger decline in mortality between the early 2000s and 2014.

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VEDANTAM: Public health researcher Leo Beletsky says Jennifer and Anita's paper was based on flawed assumptions and flawed methodology.

BELETSKY: It's basically what computer scientists call garbage in, garbage out.

VEDANTAM: For one thing, Leo says, the paper argued that state laws expanding naloxone access signaled an increased availability of naloxone in those states. But Leo says this is wrong. Laws making drugs more available and a drug actually being available are two different things.

BELETSKY: So let's say, you know, the state of New York - does the state of New York have a naloxone law or doesn't it have the law is not necessarily a proxy for whether or not naloxone is available on the streets of New York state.

VEDANTAM: Leo has worked on getting such laws passed.

BELETSKY: And say with certainty that in many cases the presence of the law was actually a consequence of naloxone being available in some areas. So, you know, in York City, naloxone distribution started back in the late 1990s, for example. The first naloxone law in New York state was passed in 2013.

VEDANTAM: Now, it's worth noting that this critique of Jennifer and Anita's paper also applies in part to the papers we mentioned that found that naloxone reduced mortality. Leo says Jennifer and Anita's paper not only misconstrues what's happening on the ground but jeopardizes hard-won advances.

BELETSKY: We have worked for a long time to get these naloxone laws passed, and in many cases, there were - there was a lot of resistance based on the moral hazard argument in the legislatures to get these naloxone laws passed.

VEDANTAM: It was only the skyrocketing death toll that caused lawmakers to act. Leo worries that the "Moral Hazard" paper will cause legislatures to pull back.

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VEDANTAM: Jennifer and Anita stand by their results.

DOLEAC: It's not lost on us at all that these are lives that we're talking about and that the increase in mortality that we're seeing - you know, these are actual people who have lost their lives due to addiction. And it's depressing just how - with so many smart people thinking about this, it feels like we're no closer to solving the problem.

VEDANTAM: The truth is we don't fully understand how addiction works. We're still figuring out how to help people quit. We have trouble identifying even what's happening in the course of an epidemic because addiction is stigmatized, and people can't talk honestly about their behavior. The data are incredibly messy regardless of whether you're wearing the hat of an economist like Jennifer Doleac or a public health scholar like Leo Beletsky. At the same time that states were expanding access to naloxone, for example, there was an influx of powerful synthetic opioids into the country. Heroin is increasingly laced with them. It's possible the recent rise in opioid deaths was driven by the surge in synthetic drugs that have flooded the streets.

(SOUNDBITE OF MUSIC)

VEDANTAM: It isn't just families and researchers and policymakers who are grappling with these life-and-death issues. Drug users engage in these debates as well using a mental calculus of their own.

TIFFANY: People that have mentioned they got that Bad Batch app now on your phone and people pin where bad batches of dope are. And there's people that download that just to go find the bad batches and do it.

VEDANTAM: No way.

TIFFANY: Yeah.

JAMES: Yes, yes, it's on there.

UNIDENTIFIED PERSON #4: No way.

TIFFANY: Yeah.

VEDANTAM: Coming up - the dangerous logic that seeks to balance the risk of death with euphoria.

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VEDANTAM: This is HIDDEN BRAIN. I'm Shankar Vedantam. On the day that I attended the Narcan training at the Anne Arundel County Department of Health, I met two people who'd come to the on-site clinic for their daily dose of methadone. It's a drug that helps reduce withdrawal symptoms from heroin. One person was using it to stay off heroin, the other to keep from using too much. We sat down at a picnic bench to chat. We'll only be using their first names.

JAMES: My name is James [name bleeped].

VEDANTAM: And let me get you to tell me your name, please.

TIFFANY: Tiffany [name bleeped].

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VEDANTAM: Tiffany is 24 with dark hair and glasses. James is 59, graying and weathered. They should have little in common, and yet their stories are painfully similar. James started using heroin when he was just 13, a poor kid, he says, from East Baltimore.

JAMES: Well, when we grew up, my father left us with my mother. He had six children. And my father left us with nothing. And he had...

VEDANTAM: To help his mom, James says he started hustling on the streets and carrying guns for drug dealers. Then he started carrying their dope and using it. It made him feel better about his life.

JAMES: I didn't want to go to school - I home-schooled (ph) - because all my clothes were all holey - this, that and the other. My mother had to go to churches, the veteran store, for just, like, a nickel pair of pants, a nickel pair of - a shirt, 10 cent pair of shoes. And, you know, you get tired of that. And then...

VEDANTAM: Tiffany started her drug habit at exactly the same age as James.

TIFFANY: I started doing - I started doing the Percocets when I was 13. So from 13...

VEDANTAM: And like James, she says she was pretty unhappy as a kid. Percocet filled the missing parts of her life.

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VEDANTAM: When the pills got harder to obtain, she moved on to heroin.

TIFFANY: And it was just easier to get and around more. It was cheaper and, I mean, you really got higher off of it in a less amount, so...

VEDANTAM: It's a logic that's common to opioid use. Some users would prefer heroin to Percocet because it's cheaper and stronger. And then they might prefer synthetic opioids to heroin for the very same reason. What public health officials warn about drugs like fentanyl, some users go looking for them.

JAMES: If they knew where the good dope was, and people were falling out and dying from this shit - right? - they would run right to get - so they wouldn't - before they sold out. They would haul ass to get that shit, and they figured, OK, well, I'll just do a little bit so it won't hurt me.

TIFFANY: Yeah, there's plenty of people that do it. And there's even people that have mentioned they got that Bad Batch app now on your phone, and people pin where bad batches of dope are. And there's people that download that just to go find the bad batches and do it.

VEDANTAM: No way.

TIFFANY: Yeah.

VEDANTAM: Tiffany is referring to a text messaging service that uses data from public health officials. She says that figuring out where the best dope is available at the cheapest price is part of the daily calculation of heroin use. For her part, she spent about $50 a day on her heroin habit.

TIFFANY: I know $50 - that's not really a lot compared to some people I know.

VEDANTAM: Really?

TIFFANY: Yeah, I know some people that would be going through...

JAMES: I was doing hundreds. I had a dealer habit.

TIFFANY: One hundred fifty dollars - $250 a day

JAMES: I had a dealer habit.

VEDANTAM: A dealer habit. Since he was selling the stuff himself, James had easy access to both money and dope. Sometimes he'd take a little bit for himself before passing the rest on to his customers.

JAMES: I'd just take the head out of each one.

TIFFANY: Oh, you'd skimp it.

JAMES: Yeah, but then I was capping it up, as well.

VEDANTAM: There were a lot of moments like this when James and Tiffany riffed off each other, building on their shared language of heroin. Another thing they share - they've both overdosed multiple times. The first time for Tiffany was when she was 17.

TIFFANY: I just did it and fell out. I don't remember. I know - I know I was dead for four minutes by the time the ambulance got there. But they revived me with Narcan.

JAMES: I've seen it happen so many times.

TIFFANY: I've overdosed nine times.

JAMES: Me - 12.

VEDANTAM: Tiffany has overdosed nine times; James - 12. They owe their lives to Narcan. James says he now always keeps a life-saving drug close at hand.

JAMES: I got five or six nasal spray Narcans up in my room. So if somebody falls out around me, ain't no ambulance. I just take the Narcan - it's like a nose - like, you know what I mean? You just put - you hold your fingers on it. It looks like a long stem, and it goes like that, and it's got another thing pointing - comes down here that you push in, like that. So you catch them when they're breathing in and then out. Then once they're breathing back in, that's when you shoot it up their nose. Not even 10, 15 seconds later, they're arrived, they're back. And so whoever made that Narcan is some - has some serious ways of saving people's lives, I'm telling you.

VEDANTAM: But Narcan also does something unpleasant to users who are high. It brings them crashing down really fast.

JAMES: When you - when you put that Narcan in you, it eats everything in your - any narcotic, anything you got in your system, it eats it all out. I mean, it's like Scrubbing Bubbles and just goes right through you so fast.

VEDANTAM: And that is not a good feeling. To go from a heroin high to an internal scrub feels awful. That's why many people who are revived with Narcan immediately try to get high again.

Tiffany, when the first time this happened to you, do you recall the - you, obviously, don't recall the emergency people coming to your house, but do you recall what happened right after?

TIFFANY: I remember going into the emergency room. They sat there. And I had to stay there until I was fully coherent.

VEDANTAM: Did you have a sense that you actually came close to dying?

TIFFANY: Yeah. I knew. And as soon as I got out, I did more. It happened every single time I overdosed. I did more as soon as I got out of the hospital, and yeah.

VEDANTAM: It was a revolving door - heroin, overdose, Narcan, heroin, overdose, Narcan. I asked Tiffany and James whether Narcan was causing users to take risks that they would not have taken otherwise. They rejected the idea that Narcan was the reason anyone would choose to get high, but they said the drug might affect how much heroin people use.

JAMES: To where I've noted people say, all right, because I got Narcan - right? - they're just going to amp it up more.

VEDANTAM: Tiffany has a friend who was quite explicit about what Narcan does for his drug habit.

TIFFANY: I know he's mentioned to me quite a few times that, you know, if he falls out, he'll come back. They'll come and give him Narcan and bring him back.

VEDANTAM: So would her friend stop using heroin if he didn't have Narcan?

TIFFANY: No, there ain't no way.

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VEDANTAM: Tiffany sees the moral hazard dilemma of heroin and Narcan.

TIFFANY: I think that it makes people not be as careful about it, but I also think that there ain't no way that they should take it away because then people are going to be dropping left and right. Look at everybody that it saves.

VEDANTAM: And among the everybody that it saves is Tiffany. After multiple overdoses and a blood infection from shooting up the destroyed part of her heart, she finally had enough.

TIFFANY: I was just - I don't know. I was just done with that kind of life. Like, I just really sat down and thought about it one day and how I imagined my life to be and who I was going to be, and that just wasn't how I wanted to live no more.

VEDANTAM: And what did you - when you thought about how you imagined your life was supposed to be and how it had turned out, what went through your head? What did you see, in terms of what your life had become?

TIFFANY: Just everything that addiction does to you. Like, I wasn't even me no more. You do things that aren't you. And knowing of how many times I've died, just none of it even made any sense to me.

VEDANTAM: Tiffany now needs methadone to keep withdrawal at bay. She has a heart that beats only because the damaged portion was replaced with part of a cow's heart. But Tiffany is alive, and at 24, she really does have a whole life ahead of her. She's grateful for the chance and would willingly give it to someone else. That's why, even though she isn't using anymore, she always makes sure she has Narcan close at hand.

TIFFANY: Yeah, I don't want nothing to happen to somebody and me not be able to save them. I couldn't - I couldn't live with being able to see somebody die and knowing that I could've did something.

VEDANTAM: The opioid crisis in America is like a wildfire, racing through towns and cities, consuming individual lives and families and whole communities, with shocking speed. Sometimes, amidst all the smoke and fire, you can barely see what's going on. It's likely, in the coming years, there will be more hard data on the effects of naloxone. For now, the best we can do is to come to terms with the trade-offs, to accept that the interventions we develop to save people might sometimes lead to unintended and unwanted consequences.

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VEDANTAM: At those times, it's worth remembering what we are doing right. The people we pull from the flames - charred, damaged, but not yet destroyed.

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VEDANTAM: This episode of HIDDEN BRAIN was produced by Jenny Schmidt and Parth Shah. It was edited by Tara Boyle and Camila Vargas Restrepo. Our team includes Rhaina Cohen, Thomas Lu and Laura Kwerel. Special thanks this week to Ashley Messenger, Mark Memmott and Neal Carruth. Our unsung hero this week is Elin Jones, the public information director at the Anne Arundel County Department of Health. Elin invited us to sit in on one of the county's Narcan training sessions. She also encouraged community members to speak with us. Elin and her colleagues at the Anne Arundel County Department of Health are the front-line responders to the opioid epidemic. Even as we focus on helping families and those struggling with addiction, we should all be immensely grateful to folks like Elin, who are dealing with a difficult and heartbreaking job of keeping people alive.

For more HIDDEN BRAIN, you can follow us on Facebook and Twitter. If you like this episode, please consider sharing it with a friend and then sitting down to chat with your friend about your reactions to it. Good people will disagree when it comes to questions about moral hazard, but we will all be better off if we can learn from the views of others. I'm Shankar Vedantam, and this is NPR.

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