Is The Drug Crisis Getting Worse?

[00:00:00]Drug use was good. It just said that HIV was at that [music] time >> worse.

[00:00:05]>> Fatal. Yeah. Fatal.

[00:00:07]>> Some people were in horrific pain.

[00:00:08]>> You can literally create this in your sink. Production cost is about 1% of the heroin production costs.

[00:00:14]>> Overdose rates have finally started to fall. What happened to the opioid epidemic? Is it just that it burned out because so many of the people who are using died, or is it more complicated [music] than that? For more than two decades, America has watched a drug crisis evolve faster than our attempts to contain it. Then fentanyl arrived.

[00:00:33]Unlike heroin, [music] fentanyl could be manufactured cheaply. It was transported easily, and it it could be mixed into almost everything. It was stronger, more profitable, and much more deadly. Herm reduction offered a compassionate response. We're not going to try to force you into treatment. We're going to make it so that your habit doesn't kill you. We're going to give you clean needles and nlloxxone and support for people who aren't ready or able to stop using. Goal was simple. We just keep people alive and hope that at some later date we can get them off these drugs.

[00:01:04]But fentanyl changed the stakes and in some places harm reduction became less a tool than an ideology. One that treated pressure to enter treatment as cruel and concerns about public disorder is beside the point. That left Americans stuck between two bad choices. a punitive approach that treats people with addiction as like disposable or a permissive one that mistakes compassion for simply letting people do whatever they want, including dying. My guest today argues there's a better path, one that combines compassion with treatment, accountability, and with concern for the broader community.

[00:01:40]Keith Humphre has been with us before.

[00:01:42]He's a good friend and a professor at Stanford University. He's also one of the country's leading experts on addiction and drug policy. And we talk about how the opioid crisis became a fentanyl crisis, where harm reduction lost its way, [music] and what a more compassionate but also more honest approach might look like.

[00:02:02]Keith, welcome to the show.

[00:02:05]>> Thanks, Megan.

[00:02:06]>> I want to talk a bit about the opioid crisis. If you had to rank the top three factors that were that drove us into this huge I think unprecedented drug crisis in a lot of ways, what would they be?

[00:02:18]>> So the biggest one was the emergence of very unrestricted promotion of pharmaceutically produced opioids. I mean we had a 400% per capita increase in a little over a decade from the 90s up to about 2010 or 11. That created an enormous amount of addiction and it gave a chance also for some illegal markets to surge back. Heroin markets had kind of been sinking. Uh and then once you had a lot of addicted people and eventually that the pill sort of mils you know as they closed down a lot of those folks shifted to heroin. So so that that was the first thing the pill thing. The second thing is the emergence of the synthetic opioids. So like fentanyl although fentanyl is an old drug. It's you know 50 years old. Um but um it wasn't a major presence in illegal markets and it is um you could think of it as a from an economic viewpoint the ultimate disruptive innovation. You know here you have a drug that's substantially more addictive than heroin um and substantially cheaper to produce.

[00:03:24]There's no field in Afghanistan you have to protect. There's no 7,000 mi supply line. there's no board officials to pay off. You can literally create this in your sink. Production cost is about 1% of the heroin production cost. So when that comes in, as you see it moving across the country from east to west, everywhere death just goes up enormously, you know, from this drug. It it it drives it. It's amazing what could get rid of heroin. Well, it wasn't law enforcement. It was basically it got out competed by fentanyl, which is parallel to what happened a century ago when heroin out competed morphine when people used to be addicted to morphine. never see that anymore. Um so so that that's that's also been really huge. And then the last thing uh that has driven like recent policy I would say is the combined effects of COVID and uh Black Lives Matter honestly. So we we had this period like 2000 to you know 2022 or 23 understandable outrage about police brutality. Uh understandable outrage about racism in in law enforcement including in drug law enforcement combined with the pandemic which you know just be colloquial made us all a bit crazy including me. You know it was scary it was difficult. We were, you know, we got emotional, we got extreme, which produced a a policy, but this these two things together produced a policy cluster in a lot of cities, especially more left-leaning cities.

[00:04:45]That was basically that public spaces were there for drugrelated commerce, and if you didn't like it, uh, then you were racist and that was too bad. Um, addiction, you know, treatment and recovery were kind of, uh, you know, moralistic, and that's not really the point. Our sole point is to support people in their right to use these drugs. We're just going to do harm reduction and nothing else. And by harm reduction, what was meant was harm reduction to the user, not to communities, not to businesses, uh not to the broader the life of cities. So, it wasn't really public health. It was more of a a libertarian kind of argument, very similar to what vaccine refusal arguments are.

[00:05:26]And I think one thing that that highlights is the overprescription of pain pills was a response to the fact that some people were in horrific pain and having difficulty accessing medicine that could control that pain. The harm reduction movement was about the fact that prohibition and enforcement often had bad effects on the people that it happened to. Um, and I think that's important to remember that our our intentions are not necessarily the outcomes.

[00:05:54]>> Yeah. No, no. absolutely always true and and and also that you can have good intentions. It doesn't mean all your allies do. So, you know, I think people the pain medicine docs and a lot of the pain advocates were absolutely sincere in wanting to reduce pain. I think Purdue Farmer was absolutely sincere in wanting to make a lot of money and that's why they just sort of co-opted that into the more pills the better which is you know a pain strategy is can't just be the more pills the better and and again with I think harm reduction which I would say really started about preventing HIV it did not say drug use was good it just said that HIV was at that time >> worse >> fatal yeah fatal right and that basic equation has never been rethought. And and this a very important thing to that worth thinking about. If you go back to say the 80s, a year of heroin use might have had a mortality risk of maybe you know half a percent a percent a year. HIV was 100% fatal. So it was correct to say look if we have to put up with a year of heroin use to to prevent an AIDS case, it's absolutely worth it for cost benefit. So yes, needle exchange, you know, don't don't worry about people can't get into treatment. Let's just keep them away from HIV. Today, HIV, thank God, is treatable. It's not fatal. But a year of drug use is now dramatically more dangerous, maybe as high as a 5% mortality rate per year. And the the thinking has not been updated in a lot of quarters. They're still thinking, we can't just It's like, well, no, no, now the priority is the drugs. It's much worse to have people uh using fentanyl and it is not um uh uh it's actually if you follow the same reasoning, same harm reduction reasoning that you that drove during AIDS, you would say no, now the goal is is not the HIV, it's the it's the drugs. Um but it's sort of continuing on as a kind of you know zombie reasoning I would say from another time. Yeah, I think there's a lesson there and it goes well beyond drug policy that it's very easy for you you develop policies that make sense in a context but but you get then ideologically committed to them in a way that causes you to keep pursuing those policies even after the context has changed dramatically. Um, so we've been talking about the leftright gap in this country and to me that gap has been particularly striking on drug abuse and homelessness because I've seen conservatives who talk as if homeless and addicts are human garbage who doesn't don't matter at all once they're in the way. You can do anything to them to stop the unsightly fact that there's a homeless guy >> acting crazy in your park. But then on you have people on the left who are acting like the homeless are literally the only people on earth and anyone who wants to take a train or sit in a park or walk on the sidewalk without confronting deranged people or stepping on used needles should just shut up and it surely there has to be some middle ground. But what should that look like?

[00:08:54]>> Yeah, that to me is the most interesting thing going on in drug policy right now.

[00:08:58]and and like you know I just got back from Philadelphia and and I I thought that was a wonderful example of trying something that is neither a carceral racist war on drugs nor a a free-for-all where the life for the community doesn't matter in the slightest. So I went through the Kensington neighborhood and those your guests may not know Kensington's the worst open air drug scene in our country and perhaps on earth. I mean really really dystopic and I was amazed how much better it looked.

[00:09:27]I mean relative what I was expecting you know the the mayor has removed the tents removed the human waste and trash and needles from the streets they now have a what's called a wellness court which is a court and so it's uh you know it's protested by some of the advocates saying you know that's war on drugs and all that but the purpose of the court is to get people in services they would not otherwise get so I sat there watching cases you know who's in the court there's no prosecutor there's three social workers. Uh there's a police officer who's standing in saying, you know, so and so did this or that.

[00:10:02]There's a judge who's in recovery who was urging on each person and and saying, you know, you have to go to the center where and I went to that center and like what do you get at the center?

[00:10:11]Wound care, nursing care, they'll help you get on your benefits. Um they have addiction treatment, they have the medications, they have mental health treatment. But it is a push. It's kind of like the Portugal model of, you know, it's not hostile, but it is pressure.

[00:10:27]And it's between those two things and they're not putting people in jail, but they are using the court as a horror therapeutic jurist prudence. That's an example. Another thing I saw in Philadelphia really impressed me was called Recovery Village. It was a city-owned, it was like I think a senior living community and somehow they managed in less than three months to take their settlement money from the opioid lawsuit and rehab this whole thing uh into a beautiful place for people to live. almost every single one of them was homeless, almost every single one of them addicted. But this just really um like I say like just example how nice this was. The food there when I sat and had breakfast with people was as good as the food at my hotel, you know, lots of resources, lots of, you know, services, uh, you know, healthcare, all that sort of stuff, but not a free-for-all, not this sort of housing first. You can, and now you have a right, you know, to cook meth in your room. If you bring drugs in or you use drugs, you can't stay there anymore. Um and that is you know there's a lot being given there but there's there's a stick and there's a belief in community which is different than the more individualistic understanding of if I bring if you and I are living there you know in that same community I bring fentanyl in it's not just about me because you could relapse because I have brought fentanyl in and you could die right and so there's that recognition of um you know we're in this together and it's not we don't have individual unlimited individual ual autonomy in a community. Um, and so that so that Philadelphia really impressed me for try trying to find that pathway and stand up to the you know the the activists who you know were quite quite hostile to these uh moves. Yeah, I was in uh Utah uh a couple years ago and Utah of course famous for pioneering uh the housing first approach which for listeners viewers who don't know this is the idea that instead of trying to impose conditions like sobriety uh on someone as a condition of getting housing instead you push them into housing and then try to sort the other stuff out later. And I'd been really enamored of this. Um I still, you know, I'm not unenamored of it exactly, but I didn't realize some of the complications. And one of the things that I heard from talking to homeless people who were working through a program in order to get into a a permanent uh tiny homes community that was being built by a social service provider is that one of the reasons they didn't want to be in the shelters was that the the amount of drugs around them made it harder for them to get clean. for those who didn't have a drug problem but did have a mental health problem. Um it meant there was a lot of violence around. There was people behaving erratically and we were people didn't I think often think that through on housing first that like this isn't just about the individual.

[00:13:21]>> It's about all people around him who are also often struggling themselves.

[00:13:26]>> Yeah. Absolutely right. And Utah's I've been working with them as well. Oh, I mean another example, a place that is trying to find some some piece of ground between those two things. Howling first absolutely has a place. You know, someone has schizophrenia and they think aliens are following them and they they don't have any shoes on a cold day.

[00:13:43]They're not going to come into weekly appointments with a psychiatrist. You have to get them housed. They're going to die out there. But, you know, if you're just addicted, you know, if if that's the right term, housing where it's contingent, you know, that there is a recovery culture and it's contingent that you will you can't stay there if you keep using, they have dramatically better outcomes. What people like me are looking for is not um to eliminate that.

[00:14:08]It's just to have something between, you know, a absolute libertarian understanding and uh uh an oppressive, you know, understanding. But the sort of the thing that is therapeutic, a certain amount of social norms, certain amount of support helps a particular subset of this population.

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[00:16:51]So, one reason that it it has seemed to me from outside, you can correct me, but one of the reasons it has seemed to be hard harder to get to a middle ground is that academia itself has seemed so polarized. Am I being fair or am I missing subtleties?

[00:17:08]>> Unfortunately, absolutely true. um and particularly with harm reduction and there are some superb harm reduction researches and and I I hope I've done decent research on like modeling the impact of nlloxxone for example and um uh but but there is also a lot of you know people who would self label activist scholars who do not really see a distinction between those two things.

[00:17:33]So, you know, the as far as as they they would see it, the answer's already known. And yeah, I've got to do the science to have it come out, you know, but it'll just prove what I already know to be true. And if anybody publishes anything that doesn't 100% back that up, we will just, you know, attack them, attack them at their journal, attack them at their institution, attack them online, um almost with like a religious fervor. that that has made it um uh pretty tough to um know what science to trust, you know, first, which is a problem in itself, but second, uh for a while that strategy worked. I mean, you know, the you know, I call them the white kids with good teeth. um you know and they are often they're usually college educated people who don't live in the neighborhood but are a part of an activist group or maybe they work at a nonprofit you know and then they come out but they but they don't actually live there but they believe these things that the people in the community don't believe and you you said something that really stayed with me is we got to a situation where activists were treated like union bosses like you know you had to listen to them because they were voted for They represent a lot of people and in these cases they don't represent anybody. They don't know anybody in the community. The people in community don't particularly like them or believe what they think, but they're good at getting a microphone because they're white kids with good teeth and they're articulate and they have friends in the media who think the way they do.

[00:19:00]>> So, does that do you feel like that's changing now partly because of the bad results? And if not, how do we fix it? I guess. No, I I I I know it's changing in part just due to the extinction burst uh that we're seeing from that quarter. So in in in be uh when you do behavioral management or anything like for a person but or or like a pet or whatever like you know if you have a you know every time the dog the cat jumps on the table you know you start to impose a consequence then the cat jumps on the table like three or four times in a row just like are you serious? Is is this rule for real or was that just some you know passing fancy you had there human?

[00:19:37]Um, and then it stops the extinction burst. So you I see this extinction burst from the people who were running things that way, like you know, just absolute fury coming out and just looking very uh to now impotent and realizing they've lost the argument. And you know, when when Mayor Mayor Parker told me that, you know, when she said she was going to have the wellness court activist put up signs saying, you know, if you're addicted, the mayor wants to kill you. I mean, that's a really corrosive kinds of stuff. And it didn't work. And I watched in San Francisco, we we um uh had a thing where we say, "We're going to try to help people get in recovery." Was pushed by my friend Matt Dorsio, supervisors and endorsed by Mayor Lurri. And the hearing at that, you know, I watched a lot of people come up uh you know, sort of using the old incantations and finding the spells didn't work anymore, but just standing up there. This is colonialist, racist, transphobic. you know, harassment, yelling, yelling, yelling, yelling, and you all are murderers. And then it's like, thank you for your comments. Next, and it just it didn't work. And that that to me is what people do when that's the extinction burst when they realize they've lost the argument. I sincerely hope they will they themselves will come back because I do think they care. They will come back to a more balanced approach to to these issues. But right now, I think they're in the the rage and denial phase as as the rest of people try to sort out well what is the what is the practical way to do this.

[00:21:07]>> So speaking of extinction bursts, uh one of the pieces of good news recently has been that overdose rates have finally started to fall. What happened to the opioid epidemic? Is it just that it burned out because so many of the people who are using died or is it more complicated than that? Yeah, it's it's that makes a difference, but that wouldn't explain what happened. So, we've had this going on for 25 years. Uh and then in the middle of 2023, it just this precipitous decline, you know, uh you know, where which is now up to 50%, you know, the death rate. So many many people have tried to explain that by things that have been happening all along. You know, well, that must be, you know, the our great policing, that must be, you know, the the the treatment, it must be the lock zone. and all those things would have been affecting the overdose rate all the time. But to explain something sudden like that, it's always about supply. So on the negative side, it was the emergence of fentanyl.

[00:22:05]Why did death suddenly rocket up? It's it was a supply change. in this case um you know at least the work we've done and done us with u uh colleagues at University of Chicago University of Maryland and uh Carnegie Melon um what what we showed is um that in the middle of 2023 you start seeing the strength of fentanyl as measured in seizures dropping you know quite quite swiftly and deaths dropping along with them and if you go to Reddit and you just groups of people talk about fennel this huge surge people talking about shortage, the drugs aren't as strong, I'm going into withdrawal, all that, which seem to suggest some kind of supply shock. Um, the other thing about it's interesting, fentanyl is made from precursor chemicals and the the change in the strength of the drug happened in the US and Canada, which has an opioid epidemic around the same time and they also had these same benefits. So what that suggests is it's something in the precursor chain pretty high up and the big the the most likely candidate is is Chinese intervention. Um very hard to know China's not super transparent but if it had been a Mexican phenomenon uh you would have seen change in the US but not in Canada because Canada doesn't get their fentanyl from Mexico. So that was our best guess of why this happened. Now will it last? Um there's a there's mixed experience in drugs about these kinds of things. Sometimes markets really do die off. Australia had a heroin drought brought on by enforcement. 10 years later you they had lower deaths rates.

[00:23:40]It seemed to like drive a lot of people out of the behavior for a long term.

[00:23:44]>> So does that differ between classes of drugs? because I remember I grew up in the 80s in New York City when you know the crack wars were raging but also cocaine use was high and eventually most people aged out of it. Um but is that different? Is it different for different drugs that some of stickier than others?

[00:24:05]>> Yeah, there was no supply shock with cocaine uh in the in the 80s. That didn't explain the dynamics we're seeing with fentanyl did not exist then. It was much more what what you uh said and you know there is a general cycle to drug epidemics. new drug comes uh people start using it you know the and early on negative effects are not typically evident right so cocaine you know 70s was like you know it was the cool drug you know a lot of successful people using it seem without problems time goes on people start dying they start getting addicted the drug gets a more evil name and then initiation drops so new people aren't willing to to deal with it and then you have all the people who you know either were born at the wrong time or couldn't quit and then they're left and then it's just a matter of like how long does that group live or desist and that really differs across uh different kinds of drugs. You know, there's some drugs you can obviously use. You can use nicotine, you know, in smoking cigarettes. Yes, a lot of people die, but you could also do that for, you know, 30, 40 years and and not die of it, right? That's harder to pull off with Kraken. They're probably impossible to pull off with with fentanyl. So um if you know as initiation is dropping in coupling with the supply drop you know we we may have a shot of making this stable um you know that that would be my hope because it's still I mean the death rate is still really appalling. I mean we're still losing as many people as we lost in the Vietnam Wars you know each year. So >> um last question. Uh I I I would ask is there anything you're reasonably optimistic about? But it sounds like you have a lot of reasons of for optimism.

[00:25:42]So what are you most optimistic about?

[00:25:45]>> Well, I'll tell you I'll tell you something in addiction that is exciting to me. So working with a philanthropist uh and uh the VA uh we are uh have launched a study of whether GLP1s uh GGP1 agonist the the drugs that people will know from uh you know being taken for people with metabolic disease and and obesity >> things like oicgovaro >> exactly can help people um control their drinking. So, we're going to do a study with over 600 people in it. Um, and you know, many will be both overweight and and and drinking because the rate risk of being overweight is about 70% higher for people with drinking problems than without. But, you know, I think that could work. I mean, I don't know. I'm a scientist, so I'm I'm not going to, you know, make make my decision in advance of the data, but I'm really excited that that could work. uh because you know there are some medications for alcohol.

[00:26:45]Some of them do help some people but they've never really caught on a lot but people like these GLP drugs because they like the weight effects. Maybe that'll help people. And I just also of all the things GLPs might affect it seemed to me drinking is the most thing like eating.

[00:27:00]So, you know, if the mechanism is a sense of satiety and I'm full, it seemed to me that would probably be more likely to affect something that you consume versus say a powder that you snort. Um, so we'll see. And I'm I'm I'm glad that's that's going and uh I'm really excited to see the answer. So, we actually had Katie Herszog on the show to talk about uh the Sinclair method and this this way of getting extinction of your desire to drink alcohol by drinking alcohol while taking uh an agonist that would basically prevent you from getting the signal that says no, just do more and more and more and more of this. Um, and can you talk about why that hasn't caught on as much as I would think that that would be way easier than AA?

[00:27:47]>> Yeah. So, >> I let me first praise Katie's book, which I read and blurbed. It's a really uh wonderfully written and very honest and funny and smart account. You know, it's an expression of the the author's many virtues.

[00:28:01]>> It's called Drink Your Way Sober. For those who did not catch that episode, although it's still available, so go back and watch slashlist to it. So the drug is nilrexone and it yeah is as as you said it's an antagonist so it would reduce the rewarding effects of of alcohol. So you know you take it a bit before you're going to drink and then you still can drink but you get the extinction over time because like I don't feel like I want the third or fourth or fifth drink. A lot of people then find eventually they just stop drinking period. Some do, some don't.

[00:28:31]Why did that not catch on? um it may have had something to do with the abstinence uh culture, you know, that that persisted in some parts of treatment in medicine. So, a lot of doctors think you just need to stop drinking forever like smoking. Um and uh and I AA is by the way a terrific organization, helps an awful lot of people. Um so I'm not uh I'm not criticizing them say but that that's certainly the AA concept of lifetime not drinking, you know, is is a pre prevalent one. And I think when people think about drinking problems and by the way there are people for whom that is true. They if they really do need to stop um but there are people and Katie you know you know describes being one of them that that approach can really help um for you know certain part of the population but I'm I'm surprised it hasn't taken off more um because no nrexone also blocks the effects of opioids. So um you know it's it's been a interesting um it's been interesting unfold and I you know Katie has reopened this argument you know which has been made before by different people um but it always seems to sort of attract a little attention but doesn't enduringly change uh practice. So, I appreciate you're trying. There's no wrong I mean, just general point is there's not a a wrong way. If you if you've got a drinking problem, you know, however you get to a better place is fantastic, [music] right?

[00:29:59]>> And we don't we don't worry about that in cancer. We don't say, "Oh, you had the radiation. Couldn't you get the surgery? That's too bad." We're just like really happy that you don't have cancer anymore. We need to get that way about alcohol.

[00:30:09]>> Thanks, Keith. This has been amazing.

[00:30:11]And [music] uh thanks for thanks for being on.

[00:30:14]>> Always enjoy our discussions, M. Be well.