August 5, 2021 • 44 mins
More people died last year from a drug overdose than from gun shootings, motor vehicle accidents, drownings and AIDS combined! Few people bring greater research and insight to this issue than Dan Ciccarone, a physician and professor at the University of California, San Francisco (UCSF), who has studied illicit drug markets, communities and consumers for two decades. We talked about the role of prescription opioids and street heroin, why the fentanyls are so deadly, and why COVID made the problem worse. I asked him why overdoses increasingly involve stimulant drugs like cocaine and methamphetamine, why fatal overdose rates vary so greatly around the country, and why so few other countries are suffering similar problems. And we talked about what needs to be done, including lessons from abroad, to dramatically cut the number of people dying this way.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
M Hi. I'm Ethan Natalman and this is Psychoactive, a
production of I Heart Radio and Protozoa Pictures. Psychoactive is
the show where we talk about all things drugs. But
any views expressed here do not represent those of iHeart Media,
Protozoa Pictures, or their executives and employees. Indeed, as an
(00:23):
inveterate contrarian, I can tell you they may not even
represent my own. And nothing contained in this show should
be used as medical advice or encouragement to use any
type of drug. You know. On this show, we talk
(00:43):
about the wonders of drugs, and we can also talk
about the horrors of drugs, because so much of this
is about the nature of our relationship with drugs, both
as an individual um and as communities and societies. Today,
we're gonna talk about one of the most devastating aspects
of drug use, which is the overdose epidemic, the overdose crisis,
(01:07):
the number of people dying from overdose. A few weeks ago,
the US Center for Disease Control came out with its
latest report, and it said that last year in over
ninety three thousand Americans died of an overdose. That was
an increase of almost thirty percent from the previous year.
(01:29):
This is a national problem where the overdoses went up
in forty eight of the fifty states in the United States.
If you think about how much is being lost if
we compare it to COVID, those nine three thousand deaths
were about a quarter of the three and seventy five
thousand people who died from COVID. But if you look
(01:52):
at the number of years of life lost, because so
many people who die from COVID are oftentimes quite elderly,
where so many people to die of overdose are whole
spectrum of ages from their teens into their fifties or sixties.
When you look at it from that perspective, COVID resulted
in five and a half million years of life lost,
but with overdoses it was three and a half million
(02:14):
years of life lost. I mean that's like six So
it's really a truly devastating problem. Now, in the New
York Times, the headline was a quote from an expert,
and it quotes said, it's huge, it's historic, it's unheard
of and on precedented. In a complete shame. You don't
(02:36):
see that in New York Times very often. That a
quote lands up being the headline of a major article.
The author of that quote is our guest today, and
that's Dan Chickerni, who's talking to me from Truckee, California,
out near Taho. Dan is um one of the world's
leading experts in this issue. He's a New Yorker who's
(02:56):
been in California for many decades now. He's a professor
and a doctor, a professor of Family and Community medicine
at the University of California, San Francisco. He's been studying
drug issues as it relates first to HIV A S
and now as it relates to overdose. He has one
of the biggest and most substantial grants from the federal
government to study this issue about heroin, marcus, invential markets
(03:20):
and all this sort of thing. I've known Dan for
a little bit for about twenty years, but I heard
him give a talk at International harmyshi and Comference a
few years ago, which is the best talk I ever
heard given on this subject. So he really is my
go to guy to talk about this. So Dan, thank
you so much for joining me today. I really appreciate
your taking the time and your expertise that it's a
pleasure to be here, and thank you for the kind introduction.
(03:43):
But your introduction to this crisis was excellent, so thank
you for that. Well, look, let me just start off
with a broad question, which is, what the hell is
going on here? I mean, it just keeps going up
and up. It's a devastating problem. We'll get into nitty gritty,
but what's your kind of bird's eye view of what's
going on in America? It is, well, as I told
(04:04):
the New York Times, this is a historic crisis. This
is a crisis that's unprecedented. Um, if you look back
almost forty years at mortality data due to illicit drugs,
we see a log rhythmic upward trend. That's a trend
that you would have to deliberately try to make that outrageous.
(04:26):
So why is it that we have exponentially increasing drug
overdose trend or log rhythmically increasing drug overdose trend for
the past thirty eight years? And the reason is that, um,
the drugs are getting more powerful, more potent, more available.
Despite our best efforts, they have become more deadly. Well,
(04:46):
you know, the standard history that's typically out there now
right is that these overdose who started growing in substantial
numbers back around the beginning of the century, so twenty
years ago. And I remember even the late nineties. I
was aware of this issue when I was running what
was then the Lindismith Center then Drug Policy Alliance, and
we organized the first international conference I'm Preventing over those
(05:07):
fatalities in January two thousand and We did it in
Seattle because that part of the Northwest was already seeing
kind of the early years of this stuff. But the
standard history that's happened since then is Phase one. The
first decade is about prescription opioids, oxy content, per Due
Farm and all the other manufacturers and distributors sort of
putting this stuff out overly aggressively. You know, you know
(05:30):
it's supposed to be be for serious pain. In the
marketing for chronic pain, it's getting diverted. Black markets cracked
out on that, and then you see the emergence of heroin.
People turning to heroin and heroin markets emerging. And then
I don't know if the crackdown on that was that effective,
but then Fentinel, the very powerful synthetic opioid, enters the market,
(05:50):
and then Phase four in some respects um is COVID,
which sort of kicks things up a whole another level.
So is that from your perspective, the basic frame for
looking at this historically as twenty years or how would
you nuance that to help our listeners understand this. Yeah,
So I coined the term a triple wave of epidemic,
and so there's three ways of mortality due to the
(06:13):
latest opioid related phenomenon. So first wave is opioid pills.
We wouldn't have been concerned about excessive prescribing practices or
excessive supply and the detailing, the manufacturing, the distributing of excessive,
huge numbers of opioid pills if it wasn't for the
(06:33):
fact that we saw a mortality curve increase along with
that supply. And we can talk about what the drivers
of that first wave were, but um, I will stand
by the statement that as we started to curtail that supplies,
we said, oh wow, opioid pill overdoses are going up,
deaths are going up. There's a problem. As we started
(06:54):
to curtail that and as we started apply downward pressure
on that supply, whether it's telling doctors to curb their
prescribing practices, whether it was through lawsuits that curtailed the
manufacturers and distributors that you know, they're still going on now.
As we saw that supply get constrained, we started seeing
heroin being picked up, and we started seeing an overdose
(07:16):
curve due to heroin UM. That would have been an
epidemic in and of itself if it wasn't for the
fact that in hot and synthetic opioids, including fentyyl and
hundreds of fentyel analogs UH started flooding the American streets
and people who were using heroin maybe depending on heroin,
(07:38):
started experiencing a fentyyl adulterated heroin and that increased the
mortality risk tremendously. So that's we've three of the crisis,
and that is still going on now. That started the
East coast, it's now hit the West coast as UM
and the mortality of old drugs overall is being driven
(08:00):
a synthetic opioids, including fentanyl and the analogs. So, Dan,
you look at the latest report and it's to some
extent fentinyl fentinyl fentinyl. What is fentinyl and why is
it playing such a massive role in killing people? So
fentanyl is a synthetic opioid. In order to understand that,
we need to know that opioids come in three forms.
(08:23):
Is natural opioids that come straight out of opium, which
is the extract from the poppy plant, that would include
morphine and coding. Then we have the semisynthetics, where you
change one part of morphine or one part of coding
to produce a medicine like hydrocodum um. And then you
have synthetics, which are fully they have nothing to do
(08:44):
with poppy plant, they have nothing to do with opium,
and they are manufactured in the lab Methodone is an
example of a synthetic opioid, as is fentyl and the
six D plus fentinyl analogs. So fentinyls is potent synthetic opioid.
It is forty times as strong as heroin by weight.
(09:04):
It's a hundred times as strong as morphine by weight.
It comes in a variety of chemical cousins, we call
them analogs, some of which are a couple of times
more potent than heroin, some of which reach almost a
thousand times as strong as heroin. That would be car
fentanyl and and the other n I l fentanyls. And
so when we saw that you jump in Ohio or
(09:26):
people dropping like flies, that was because car fentinel all
of a sudden hit the streets in a way that
people didn't know how to deal with it. Right, car
Fentanyl should not be in the human drugs supply. It
is meant as a large animal think elephant uh and
analgesic uh. So instead of injecting an elephant with a
gallon or two of opioid to help them with their
(09:48):
broken leg, you inject them with a normal size uh syringe,
but with a very potent chemical to help them deal
with pain or surgical procedure something like that. So, I mean, Dan,
when ask why this dramatic jump jump in the last
year and over those fatalities as creating headlines, I mean,
(10:08):
apart from COVID, is this about people just not knowing
the potency of what they're getting, or not knowing that
drugs they're getting, or is about all sorts of things
getting mixed into the supply? I mean, what do we
know about why this dramatic jump? So we have to
understand it is a twenty year historic phenomenon, right, and
talking about deaths, those deaths are higher than UM the
(10:32):
number of deaths at the height of the crisis. UM.
It's surpassed the number of motor vehicle accidents as as
the number one cause of unintentional accidental injury. And we
need to understand that it's a the reason I use
the metaphor of a triple wave, that each wave has
a certain energy behind it. We had the first wave
(10:53):
of opioid pills. It increased on the size of the
population that uses opioids. Some of those folks got cut
off from their supply and moved on to heroin, and
we saw it. Even though it is a fraction of
the original size of the population, that population was huge.
And now we have a historic number of people who
are using heroine. Some estimates make it as high as
(11:15):
three million active heroin users in the United States. We've
never had anywhere close to that number. You usually the
number of the past was half a million or three
quarters of a million heroin users. So the population of
heroin users has gone up multiple fold. That alone would
have been historic crisis in and of itself. A historic
crisis of heroin use and heroin consequences now comes along
(11:39):
a potent opioid meant to replace heroin, meant to come
from an industrial supply as opposed to an agricultural supply
that's forty times as potent as heroin by weight. Right,
and the fens we overfocus sometimes on this idea of potents.
But it also comes in adulterating heroin. It's not being
sold as is. It comes in as a contaminant, comes
(12:02):
in as a poison, comes in as an adulterant of
the heroin supply in the East Coast. Users don't know
what hit them, and they start complaining the heroine is different,
it doesn't feel right, it's too strong. When was the
last time you heard a heroin user say, oh, the
ships too strong. So it came in as a tsunami.
So you have this triple wave of the third wave
(12:23):
of which is a tsunami that's bowling people over because
they're using it unbeknownst to them. They think they're using heroin,
but they're getting something else. And then to add to
that that fentel comes in all these different analogs chemical cousins,
if you will. That undulation and potent, say also asks
adds hugely to the risk because what causes overdose, amount
(12:46):
of opioid over your tolerance, and so you're messing with
people's tolerance by undulating the supply. So it's all those
forces that have led to three maybe even more than
because that's an under account death last year. Add on COVID,
add on the fact that our interventions have not been
powerful enough, potent enough to meet this historic foe, and
(13:10):
then we have a historic crisis. You know, I came
across I mean, let's just dig in a little further.
I came across the report recently, I think, put out
by the Rand Corporation, which has a drug policy analysis unit,
and there in their analysis they found that, you know, paradoxically,
when the pharmaceutical companies, under pressure from the government everybody else,
started to crack down and reformulate oxy content so it
(13:33):
was harder to kind of crush the pill and inject it,
the result was actually an increase in overdose fatalities. Yeah,
that's that's quite unfortunate. And I've actually produced a graphic
just using Google that as Google search terms for oxy
cotton went down, and they went down because they got
re formulated from the original crushable formula, which we called
(13:56):
CS to the op formula, which was non qrushable. You
see Google search is for heroin go up. It's just
beyond ironic. And so what we call this in drug
policy we call this the humble term of the balloon effect. Right,
And we try to squeeze supply on one end of
the balloon, it bubbles out in another part of the balloon.
And the important part of the balloon metaphor that I
(14:17):
like to remind people is not that the fact that
the other end of the balloon has gotten bigger. It's
gotten bigger, usually in an unpredictable direction. Think about when
you squeeze a balloon, you don't know where the rubbers
weakest on the other part of the balloon. It not
only bubbles out overall, but it might bubble out in
a funny direction. And that's exactly what we're seeing here.
(14:38):
We're seeing paradoxical effects of the war on drugs. So, now, Ethan,
you and I could really get into this, because this
starts to really explain why fentonel even came about in
the first place. Right, What is it about interdiction? What
is it about supply reduction that produces a thirty year
exponentially increasing curve in illicit drug mortality. Yeah, I remember
(15:04):
there was a moment with fentonel. I think there was
some lab in Mexico maybe fifteen twenty years ago that
was started supplying fentanyl and started to come into the
US or some overdose associated with it, and then in
a rare case of law enforcement being successful, the US
and Mexican authorities shut it down and the federal went away.
But now federals coming in from China, China directly, China
(15:25):
via Mexico, China via Canada. It's coming in small packages.
I mean, there essentially is no supply side solution to
this at this point. Right. A subtitle of one of
my papers UM a few years ago was the end
of introdiction. I think fentonyl proves that point. There's a
lot of us who have been kind of cynical about
supply side interventions and and whether there worth the money
(15:46):
or whether they're actually effective at all, um, and the
evidence is going against them. Do you think about it.
One of the main goals of introdiction is to stop
the flow of drugs sufficiently so that the price at
the end market user, the retail user, goes up. Well,
let's look at the data. Heroin for the last twenty
(16:07):
or so years has never been cheaper at the retail level.
So what does that say about interdiction Using their metric
of trying to curtail supply so that the price goes
up and purity goes down, they have failed. Because heroin,
if we if we use a standardized measure, which is
price per milligram pure keeps bouncing along at rock bottom
(16:28):
prices for the last decade or so. Now at the
same time, because of interdiction, there's been a honing effect, right,
And the honing effect is that there's exclusive markets of
heroin worldwide. So in North America, we have producers in
Colombia and in Mexico, and both of those bring heroin
(16:48):
only to the United States. That's what I mean by honing.
They're kind of exclusive supplier to wholesale to retail markets.
We used to have four suppliers in the United States.
We used to have Southeast Asia, Southwest Asia, and Colombia
and x Go. Now we only have two suppliers. And
guess what, the Colombian market just dried up. So now
the only way we get heroin in the United States
is from Mexican suppliers, Mexican CTOs, colinal trafficking organizations. So
(17:13):
the end game that the interdiction folks are hoping for
is that, well, now we just have one chest piece
and knock off the board. Left unfortunately made an end
run around that, and what is the end run. The
end run was fentinel adulterated heroin importing from a whole
new player. When you think of illicit drug producers in
the world, right, you just ask the general waties. They'll say, oh, Afghanistan, Pakistan,
(17:33):
there's like Colombia. They might say Mexico. No one's gonna
come up with China. Well, China is a balloon effect.
It's an invention in supply. So what we have now,
we have a whole new supply of powerful opiate. It's
immune to interdiction effects. There's no crops brain, there's no
large shipment that could be busted. It comes in smaller packages.
When I spoke to Congress a couple of years ago,
(17:55):
between my representatives and myself, there's a space between those
two desks, and I said, all the fentanyl that came
in could fit into twelve industrial oil barrels that could
all be seen right in front of us. Now, how
do you stop that flow across the Pacific Ocean from
(18:16):
a friendly training partners like China? The not on our
enemy list can go and invade them and and bring
military advisors there to stop the flow. So that is
what I call the end of interdiction. We've played the endgame,
and what we got was a super powerful and dangerous
drug on the American streets. Yeah, although you know, even
with heroin. I remember, I think was Senator moynihan who
(18:36):
kind of got smart about this at some point. He
pointed out, like all the cocaine being consumed in America
back twenty years ago could be in like a half
dozen or something shipping containers. I mean that there was
essentially no way to stop this. And people are realized
Mexico has been the source of at least a third
of the heroin consumed the United States for like seventy
eighty years. So which you say there is at Fentinel
(18:59):
just kind of pointed out the absurdity of the interdiction.
The supply side control strategy was always apparent, even though
the idiots and the Pentagon and law enforcement kept insisting
on it. Fedital just kind of made it the absurdity
totally clear. I mean, how many FedEx packages can you
stop coming in from, whether it's China directly or China
(19:19):
the in Mexico or what have you. We'll be talking
more after we hear this ad. Let me ask you
(19:41):
this question. And I know there's no really reliable to
answer this question. It's a it's an impossible question, but
I'll throw it at you, okay, which is imagine if
Produe Pharma, with its oxycontent and its competitors, that Johnson
and Johnson's and all the other firms had never started
over supplying opie it's pharmaceutical opioids twenty years ago, in
(20:01):
late nineties, early two thousand's right? Do you think we
still would have had this opioid epidemic? Wouldn't have happened anyway.
There's two ways to look at it. So the opioid crisis,
this trip away, a phenomena of pills, the heroin defense
and al that would not have happened. So supply does
lead to overuse. So I'm as a supply side thinker,
(20:25):
I can with two halves of my brains say on
one half says supply matters, right, supply actually does lead.
It's just pure economics. You bring in a cheaper good
and people are going to use it, right, And in fact,
that's one of the reasons why heroin and methomphetamine are
so cheap right now, is because we have free trade
agreements across the American borders NAFTA and KAFTA that not
(20:48):
only bring down the price of illicit goods, but they
also bring them the price of illicit goods. But it's
contrastraining supply that has been problematic. We have not been
able to do it. But let me get back to
your question, right, and that is if opioid pill supply
stayed at sort of normal levels. Now normal levels are
still high for American compared to other countries, but let's
just push that aside for a second, would we still
(21:10):
have had some kind of drug overuse problematic use cycle.
The answer is probably yes, right, and the reason is
because we have myasthmic drivers in America. So what does
my asthma? My asthma means that there's a syndrome of
issues that caused suffering and that leads to something that
(21:31):
public health is concerned with, you know, whether it's poverty
or social and economic inequities, disparities and access to health
care or in health care utilization. Right, America has these
false zones in which problematic drug use. Now we're not
talking about recreational drug use here, we're talking about problematic
(21:53):
drug use falls into the cracks off. And so what
issues do we have in America that that might be
creating these law scale cracks that might be fomenting problematic
drug use. Um, we could spend another hour on. Let's
just look at one issue in particular, and that is
the disenfranchisement of working class Americans. The whole idea of
you jobs going overseas, the whole idea of loss of
(22:15):
hope between a generation of a parents generation and the
kids generation. Um. And there have been some good economic
work showing that economic disenfranchisement of particularly you know, Midwest,
we think about sort of the this might be a
derogatory term, but for lack of a better term than
the so called rust belt where industry left left some
(22:35):
decaying disenfranchise communities. Well, guess where pills and heroin and
fencinel fell into. And I can say that if you
took the pills in, heroin and fentral away, that some
other miasma condition wouldn't have fallen in to those cracks.
And so I'm a balanced thinker. I think them both
supply side, but I also think in terms of demand side,
(22:56):
and if interdiction is an endgame, right, if we if
we've run a ground with our forty year war on drugs,
we need to pay attention to the demand side. We
need to pay attention to those false zones, to the
cracks in society. Need to make America more resilient, not
necessarily to drug use in general. We've we focus our
resiliency on that don't use drugs, don't use marijuana. Right,
(23:18):
What if we just focus on resiliency to problematic drug use,
to drug use that's used to solve, to soothe, for
people to self medicate with. Right, Let's bring it back
to a robust medical system. Let's bring it back to
a robust public health system. Let's work on fixing those
cracks in society and making any more just and equitable society.
(23:38):
M we know. I think also if you look at
the recent data of who's dying now, we so much
associate this with the kind of white middle lower middle class,
declining income group in these kind of Midwestern states. At
the same time, it's worth pointing out to other things,
you know, I mean I live on the upper west
side of New York and about a block for me,
on the very expensive apartments that lines the west side
(23:59):
of sand Hill Park, Central Park West, there is a
building there probably average department caused five, ten, fifteen million dollars, right,
very wealthy families. I know of at least four families
in that building who have lost a son to an
opioid overdose. So you can see it can hit the
kind of upper income folks as well in a way.
(24:20):
But at the same time, if you look at the
data that's coming out in the last year, I mean,
overdose has always been a problem among poor black and
Hispanic people in the cities and elsewhere. Remember New Mexico
used to have a big problem, but it's also in
the cities. But when you look at the data last year,
you see the most dramatic increases in over those fatalities
are happening among blacks and Hispanics. Just explain what's going
(24:40):
on there. Yeah, So let's start with the earlier phase
of the crisis, right, So, when it was pills, you know,
wave one of the Triple Waves that showed inequities in
access to medication. So so the fact that it hit
middle class, upper middle class, white more than it hit
brown and black folks in America shows that they had
(25:02):
greater access to pain medication. And that's is well substatiated
in the literature. There's that there's disparities in access to
pain medication as it moves towards and and and the
pain has been so widespread ethan, I mean, this is
this is why I use language like crisis. You know,
I'm not just calling this an epidemic, which you know,
the epidemiologist and me would say, hey, let's just call
(25:24):
it an epidemic, which is a rising curve of something,
in this case, a rising curve of death. But I
call it a crisis because we're out of control and
because we don't fully understand what tools we need to
apply to this. Right, we lack deep understanding and we
lack a strong sense of intervention. But let's talk about
the disparities that are happening now. Right, So, as we
(25:45):
moved towards Heroin, as we moved into the we we've
three the fentinel crisis we are seeing in the inner
city more rapidly increasing rates of death among black and
brown populations. What's going on there? Based on my ethnographic
work where I spend time in the inner cities, I've
been extensively to Baltimore. I've been to Chicago a few times.
(26:05):
I spent a lot of time, of course at my
hometown of San Francisco. I've been to New York a
few times. What's happening there is there was some resistance
to fencyl Right, if you're African American and you lived
in Baltimore, you knew how to get good heroin that
wasn't adulterated with fentanyl for a couple of years, and
then the gauntlet fully got dropped and you couldn't find
(26:27):
anything but defenconyl laced heroin. And so the African American
death rates going up now because they're u accustomed to it.
They didn't like it for a while. They have no
resilience to it. Um Now shift over to San Francisco.
San Francisco has just recently begun seeing fencyyl. It's being
sold as is. And I can't fully explain this ethan,
(26:47):
but our African American opioid related mortality rate is skyrocketing.
It's much worse than it is for whites. I don't
understand it. I don't understand in a in a free
flowing fentyyl market, why African Americans might be choosing the fenyel.
This all needs to be explored. COVID simply got in
the way. We weren't able to do research last year.
But this is what we need to do in San Francisco.
(27:09):
We need to find out why it is that the
opioid death rate among African Americans is so high in
San Francisco. Yeah, so, I mean, Dan we typically think
about the United States is one great, big national market,
but there are clearly substantial regional variations in terms of
overdose and even drugs. I mean, so, is the US
not really a national market? Is what California gets different
than what Louisiana gets, different than what Maine gets, different
(27:31):
from what Ohio gets. So the overdose due to fentonel
and other synthetic opioids went up far more dramatically in
the Midwest, Northeast, down to mid Atlantic, over to Appalachia
regions um far ahead of the rest of the country.
So they were of that area got hit in fourteen
so that's your our first indication that supply is different
(27:54):
than the supply of fentyyl. And this is again fentyel
adulterating heroin was different. And if you say the northeast
quadrant of the United States, then it's spilled over to
the south. And now it's spilling over to the west.
And why is it different, Well, where is it coming from? Well,
defending is coming from China, but it's being put into
the heroines through the Mexican criminal trafficking organizations. Right. Those
(28:18):
criminal trafficking organizations have been multiple, right, And the reason
why they're multiple is because some of the bigger ones
have been successfully toppled and that leads to fragmentation of them.
So now there's a bunch of little carteltos or or
smaller c t o s and they've just divided up America.
You know, Sinala has been sort of the big one. Uh,
(28:39):
it's still kind of fairly large and monolithic. But Sinelo
has been split up by the arrest and next tradition
of its leader was held in Chicago jail right now,
and um, the so lower cartel has become fragmented and
more creative and and splitting up the country and and
again my research has been curtailed. I'm not getting much
from the D A, from O, N, D C, be
(29:00):
from from height I mean, uh, to tell me, you
know why it is that fentinel's hitting the western half
the United States. But my suspicion is that it's less
cartel based. This seems to be more fentel being sold
as is um. I'm not sure that it's cartel based.
It might be entrepreneurial based. It might be local people
buying it directly from China and selling it. I I
(29:22):
really don't know. But there's a lot more mystery. And
so here we are five years into a fenil epidemic,
and there's still mystery. There's still things that need to
be explored. There's still things that we should have and
could have been on top of. But for some reason,
we lack sufficient curiosity, we lack sufficient understanding of drug
flows to really make a public health impact. And this
(29:44):
is one of the things that I'm pushing. Since I
am a supplied side thinker, I've been pushing anyone will
listen to me, D O J HIDA, D A C
d C to say, listen, this is a poisoning crisis.
Fentinel represents an unfeseen and historic foe. In order to
understand it better, we need to understand the supply of it.
(30:04):
So let's start sharing data. We could use it for
public health. It's called an epidemiology. We'd call it surveillance, right.
Don't you want to know where the poison comes from,
what products it's in, what its potency level is, what
its purity level is, And that's what information we lack
here on the West Coast. We're operating blindly in public health.
We're operating blindly in the e r S and we're
(30:25):
only counting the quote dead bodies as they lie, which
is a hundred and fifty years UM old process of
doing public health. We should use technology, We should use
modern surveillance, modern toxicology to understand supply better. By the way,
all those initials that Dan was reeling off O N
d CP refers to the Drugs RS Office Higher refers
to another federal drug enforcement collaboration. I think most people
(30:49):
know what d e A is, um but you left
out one of them, which is not a National student
on drug abuse, And uh, you know I one of
the people I talked to for Psychoactive. Is Nora Vocale
the head of it to National stud on Drug Abuse.
I think the interview with her will run after yours,
But I gave her a hard time about this. I mean, you,
thank god have one of the big grants to do
the ethnic, graphic and statistical and all the sort of
(31:10):
work that's necessary to dig into this. But there should
be a hundred people like you being funded, whereas there's
only five or ten. I believe you know. And I'm
asking the question like, who knows what retail drug sellers
know about what they're selling? How much do retail drug
sellers actually know about whether there's ventil in their drug,
what it's being cut with, or what about the people
one level up from them? What do we know about
(31:31):
where stuff is being mixed and where stuff is being cut?
And these are not impossible questions to answer. One could
be interviewing people who are behind bars for drugs selling
and offering them confidentiality and some money in order to
tell you what's going on. One could have that type
of research, but it's not happening. We'll be talking more
(31:51):
after we hear this ad. Until fentanyl came around, the
large majority of people who quote unquote overdosed. It wasn't
(32:12):
because they just took too much actual content or too
much heroin. You typically have to mix it with alcohol
or benzos or their tranquilizers. Fentanyl changes the game. But
before Fentonel, there was almost no effort on behalf of
either federal or state authorities to educate consumers of these
illicit drugs, don't mix drugs or if you do, know
the consequences. So, I mean there's an element of gross
(32:34):
policy failure and gross public education failure on the part
of the government when it comes to these sorts of things.
I actually call it a blind spot, right, and that
is we seem to like the tools that we have,
which is, if somebody winds up in the emergency room,
where somebody winds up in the morgue, we understand what
that body died from, right, We understand the chemistry of
(32:55):
that body. But that is a profound misunderstanding of what
you do in poisoning crises. Right, That's only one way
of looking at it. The other way of looking at
it is what is the person doing? So you bring
up the whole conundrum of poly drug use, of mixing
different drugs. That's poorly understood. As you pointed out, it's
one of the blind spots. But the other blind spot
(33:17):
is what's going on in terms of the wholesale and
retail supply of drugs. We could ascertain that through UH interviews,
We could ascertain that through acquiring some of those drugs,
or for example, any urban setting. Right now, there are thousands,
if not tens of thousands of CIS drug samples that
were obtained through criminal justice proceedings, you know, small busts
(33:39):
that are being held as evidence against that person that
could be analyzed right now. I could go to the
Baltimore Crime Lab and say, can you analyze a hundred
specimens from last week and tell me what's in them?
What mixtures? Is the fencinyl contaminating the method? And fetamine
is that in the cocaine of which different types of
fen anmals were present last week? Right I could have
(34:00):
a great understanding mapped out across all of Baltimore with
a couple hundred drug samples tested last week of the
Baltimore crime Lab. I could do that in San Francisco.
I could do that in New York, actually do the Chicago.
I could understand supply from a poisoning point of view,
from a exposure point of view, right, And so now
we would have a more complete understanding. We would understand exposure,
(34:22):
we would understand use, and we would understand the end
result of use, you know, landing up in the hospital
to e er or the morgue. Right. But we only
have one of those three legs of our three legged stool.
So as you suggest that it's a failure to failure
research policy, it's a failure of public policy. Here's the
other big failure, other big blind spot, ethan, Can you
(34:43):
tell me how many active heroin injectors there are in
the United States right now? Yeah? One million, four d
sixty thousand, eight hundred and twelves. How many are there?
How many are there? We don't know, right, We have
no idea. The answer is unknown. Now, why is it
in a growing epidem where the severe consequences including death,
that we don't understand the size of the at risk population?
(35:06):
Basic epidemiology one oh one? What is the size of
the population at risk? We don't know that. And every
time I meet with the CDC, I mentioned this, and
I say, shame on you because you don't know the
answer to this question. Right, who should know the answer
to the question sentence for these controls and the answer
to that question, and they refuse to do it. You
fund five, six, a dozen researchers from around the country
to do capture recapture studies, we can have the answer, right,
(35:29):
but they refuse to fund those studies. Neither refuses to
fund those studies despite the fact that we're in an epidemic.
And what a crisis means, ethan, what a crisis means
is that we don't understand based on our current tool set.
So what you do then is you start getting creative.
What other tools have we ignored? What other interventions have
(35:49):
we ignored? Right? We need to be creative, We need
to be bold, We need new sources of funding, and
we need new understandings in order to handle this historic
crisis we do. The other thing, of course, we don't
know right now is the latest reports say show on
the one hand, that fentanyl is pervasively connected to the
overdose fatality epidemic, but they also show that stimulants cocaine, methamphetamine,
(36:12):
and other things like that are showing up more and
more and more, and it appears that some of these
overdoses involved just the use of stimulants like cocaine and
meth amphetami without fentanyl. Other cases they're mixing it with fentanyl.
But we don't know why they're mixing it, right, I mean,
you know, one of the theories has been it's like
the old heroin cocaine speedball that was popular back in
the eighties, where people like the mixture of the drugs.
Another is that the sellers don't even know what they're mixing.
(36:35):
It's just you know, a little bit of stuff getting
mixed accidentally or whatever. But what more can you tell
us about why this stimulant thing is showing up more
and more and more, both with and without fentanyl. Yeah,
this is a great question. It's such a great question
that I've spent most of COVID pondering it and written
two papers. My most recent papers discussed the fourth wave
of the opioid epidemic, which is the stimulant use and
(36:56):
polly substance use that includes the mixture of an opioid
and a stimulant. The goofball, which is historically what we
called methan fetamine and heroin mixed together, was historically unusual.
You had to be an expert to do it, you
had to know what you were doing. You had a
feather in the methanphetamine in just the right amounts, and
so you didn't see a lot of it. You had to.
(37:17):
There was only a few very fussy people who knew
how to mix them the right way, and that's because
the methan and fetamy would simply bowl over the heroine
and you've wasted your money on the heroine. Now, fentanyl
is a very powerful opoid, so now they're meeting manoamano
powerful synthetic stimulant like meth and fhetamine, which is coming
in historic levels of potency and purity potent percent pure.
(37:40):
We've never seen methan and fetamine like this before. You
got this powerful opioid and you get this powerful stimulant
that are coming together, and half of us stimulant deaths
are related to that combination. Now, where fentanyl is being
detected along with meth and fetamine in the bloodstream of
people who have died, it needs to be explained. We
have this vague notion in drug policy that uppers and
(38:03):
downers kind of undulate through history, that we have the
sort of upper wave and then the next generation chooses
downers like heroin, and the next generation uses uppers like crack.
This vague notion of of undulation throughout the decades. Here
they're colliding together. So not only is stimulus coming at
the end of a twenty year opioid triple wave, but
(38:25):
it's coming in as a as a combined use, and
that needs to be explored. There's two forces that are
driving the latest numbers. One is the breaching of the
East West divide in terms of fentel. Fentinel has now
moved westward. And the second is the methophetamine epidemic. We've
(38:45):
always had an endemic problem in the United States in
the West coast. For the opposite phenomenous happening, and that
is meth and fetamine is now going all the way
to the northeast United States where it didn't hit before
and they're not used to it. The size of the
at risk population has increased for methan fhetamine on the
East coast and for fentinel on the West coast, and
that's raising the numbers as well. So the question about
(39:06):
what to do, I mean, obviously there's a bigger socioeconomic
factor here and about jobs, an opportunity and people having
a sense of hope. That is probably the most important
contextual answer to this problem of the opioid epidemic. But
then there's the specifics. We know that making the lock
zone more widely available the antidote has you know, saved
tens of thousands of lives, if not, if not hundreds
(39:26):
of thousands of lives. We know that more drug treatment
smart drug treatment. We know that more needle exchange programs
are hopefully allowing safe injection sites. So what are now
called over those prevention centers that those things could be beneficial.
We know that drug testing slips where people get fentel
and have it tested. But when you think, are there
other key things apart from the ones that I've reeled
off that you think are really important to have out there? Yeah, yeah,
(39:48):
that's a great list. You know, that's a historic opportunity.
And people ask me, am, I that's a mr an optimists,
and I'm I'm always an optimist because here we have
a historic crisis. But in crisis, there's opportunity, right, And
what's the opportunity there? The opportunity is to take a
deeper understanding of where we are as Americans, right to
look at those false zones in America, to look at
what we can do to lift cities up, to make
(40:09):
communities healthier. So I agree with what I would call
primary prevention and not just educating don't do drugs right,
but making communities more resilient, making them healthier, making them happier.
The other historic opportunity here is to move away from
what's been an unfortunately unbalanced drug policy where we focus
too much on supply, too much on catching the quote
(40:30):
bad guys end quote, or or stopping the flows of
drugs or locking people Upright, Remember, the war and drugs
has also been a warm black and brown people. It's
been heavy incarceration rates, right, we need to end that
has been an utter failure. It's broken families apart. It
isn't actually led to the disenfranchisement of communities. Um, to
change how we view drug use is the most important
(40:53):
opportunity here. Right, We're not gonna put the genie back
on the bottle. We're not going to stop recreational drug use.
It's a human phenomena that's been going on for thousands
of years. That's an American phenomena. People like to alter
their consciousness. But can we make it less risky, and
the answer is yes. And that's where harm reduction comes in.
That's where regulation and taxation comes in, and we have
(41:14):
to stop making it punitive to use, stop locking people
up for it. That's where diversion programs come in. That's
where creating an opportunity comes in. That's where I would
expand my list that I love harm reduction. We need
more in the locks than we need more needle exchange.
I love the idea of demand reduction, including treatment low
barrier treatment, including upreneurs the methodone. But I also think
(41:36):
we need to change the conversation about drugs and accept
that it's a normal human behavior that we can redirect
from problematic use to less problematic use. And that's our
cultural opportunity. Okay, well listen, Dan, you've been a spectacular guest.
I have learned a lot. I'm sure our listeners have
learned to use amounts. So thank you ever so much
(41:57):
for joining me today, and I welcome any comments from
our Psychoactive listeners, which I'll be happy to share with you.
Thanks so much, then, thanks for inviting me. It's been
a pleasure. Psychoactive is a production of I Heart Radio
(42:19):
and Protozoa Pictures. It's hosted by me Ethan Naedelman. It's
produced by Kacha Kumkova and Ben Cabrick. The executive producers
are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren Aronovski
for Protozoa Pictures, Alex Williams and Matt Frederick for I
Heart Radio, and me Ethan Naedelman. Our music is by
(42:39):
Ari Belusian and Especial thanks to Avivit Brio, Sef Bianca
Grimshaw and Robert Beatty. If you'd like to share your
own stories, comments, or ideas, please leave us a message
at eight three three seven seven nine sixty. That's one
eight three three Psycho zero. You can also email us
(43:04):
as psychoactive at protozoa dot com or find me on
Twitter at Ethan Natalman. And if you couldn't keep track
of all this, find the information in the show notes.
Tune in next time for one of America's leading writers,
Michael Pollen, whose recent book This Is Your Mind on
Plans is breaking new ground. There are insights. I had
(43:26):
an influence of mushrooms years ago. They still have validity
in my life today. You had I think the same experience.
Oh yeah, I know I did. There are insights I
had and you could. You know. You can also call
them banal insights around love and connectedness, but they're real. Um.
But also, think of the people using psychedelics to quit
(43:46):
smoking and they come to the profound conclusion that smoking
is stupid and it's killing them. They knew that at
one level. But there is a sturdiness to the insight
on psychedelics. It's it's what James called the no edic quality,
right that this is not just an opinion, this is
a revealed truth. Subscribe to Cycoactive now see it, don't
miss it. M
M Hi. I'm Ethan Natalman and this is Psychoactive, a
production of I Heart Radio and Protozoa Pictures. Psychoactive is
the show where we talk about all things drugs. But
any views expressed here do not represent those of iHeart Media,
Protozoa Pictures, or their executives and employees. Indeed, as an
(00:23):
inveterate contrarian, I can tell you they may not even
represent my own. And nothing contained in this show should
be used as medical advice or encouragement to use any
type of drug. You know. On this show, we talk
(00:43):
about the wonders of drugs, and we can also talk
about the horrors of drugs, because so much of this
is about the nature of our relationship with drugs, both
as an individual um and as communities and societies. Today,
we're gonna talk about one of the most devastating aspects
of drug use, which is the overdose epidemic, the overdose crisis,
(01:07):
the number of people dying from overdose. A few weeks ago,
the US Center for Disease Control came out with its
latest report, and it said that last year in over
ninety three thousand Americans died of an overdose. That was
an increase of almost thirty percent from the previous year.
(01:29):
This is a national problem where the overdoses went up
in forty eight of the fifty states in the United States.
If you think about how much is being lost if
we compare it to COVID, those nine three thousand deaths
were about a quarter of the three and seventy five
thousand people who died from COVID. But if you look
(01:52):
at the number of years of life lost, because so
many people who die from COVID are oftentimes quite elderly,
where so many people to die of overdose are whole
spectrum of ages from their teens into their fifties or sixties.
When you look at it from that perspective, COVID resulted
in five and a half million years of life lost,
but with overdoses it was three and a half million
(02:14):
years of life lost. I mean that's like six So
it's really a truly devastating problem. Now, in the New
York Times, the headline was a quote from an expert,
and it quotes said, it's huge, it's historic, it's unheard
of and on precedented. In a complete shame. You don't
(02:36):
see that in New York Times very often. That a
quote lands up being the headline of a major article.
The author of that quote is our guest today, and
that's Dan Chickerni, who's talking to me from Truckee, California,
out near Taho. Dan is um one of the world's
leading experts in this issue. He's a New Yorker who's
(02:56):
been in California for many decades now. He's a professor
and a doctor, a professor of Family and Community medicine
at the University of California, San Francisco. He's been studying
drug issues as it relates first to HIV A S
and now as it relates to overdose. He has one
of the biggest and most substantial grants from the federal
government to study this issue about heroin, marcus, invential markets
(03:20):
and all this sort of thing. I've known Dan for
a little bit for about twenty years, but I heard
him give a talk at International harmyshi and Comference a
few years ago, which is the best talk I ever
heard given on this subject. So he really is my
go to guy to talk about this. So Dan, thank
you so much for joining me today. I really appreciate
your taking the time and your expertise that it's a
pleasure to be here, and thank you for the kind introduction.
(03:43):
But your introduction to this crisis was excellent, so thank
you for that. Well, look, let me just start off
with a broad question, which is, what the hell is
going on here? I mean, it just keeps going up
and up. It's a devastating problem. We'll get into nitty gritty,
but what's your kind of bird's eye view of what's
going on in America? It is, well, as I told
(04:04):
the New York Times, this is a historic crisis. This
is a crisis that's unprecedented. Um, if you look back
almost forty years at mortality data due to illicit drugs,
we see a log rhythmic upward trend. That's a trend
that you would have to deliberately try to make that outrageous.
(04:26):
So why is it that we have exponentially increasing drug
overdose trend or log rhythmically increasing drug overdose trend for
the past thirty eight years? And the reason is that, um,
the drugs are getting more powerful, more potent, more available.
Despite our best efforts, they have become more deadly. Well,
(04:46):
you know, the standard history that's typically out there now
right is that these overdose who started growing in substantial
numbers back around the beginning of the century, so twenty
years ago. And I remember even the late nineties. I
was aware of this issue when I was running what
was then the Lindismith Center then Drug Policy Alliance, and
we organized the first international conference I'm Preventing over those
(05:07):
fatalities in January two thousand and We did it in
Seattle because that part of the Northwest was already seeing
kind of the early years of this stuff. But the
standard history that's happened since then is Phase one. The
first decade is about prescription opioids, oxy content, per Due
Farm and all the other manufacturers and distributors sort of
putting this stuff out overly aggressively. You know, you know
(05:30):
it's supposed to be be for serious pain. In the
marketing for chronic pain, it's getting diverted. Black markets cracked
out on that, and then you see the emergence of heroin.
People turning to heroin and heroin markets emerging. And then
I don't know if the crackdown on that was that effective,
but then Fentinel, the very powerful synthetic opioid, enters the market,
(05:50):
and then Phase four in some respects um is COVID,
which sort of kicks things up a whole another level.
So is that from your perspective, the basic frame for
looking at this historically as twenty years or how would
you nuance that to help our listeners understand this. Yeah,
So I coined the term a triple wave of epidemic,
and so there's three ways of mortality due to the
(06:13):
latest opioid related phenomenon. So first wave is opioid pills.
We wouldn't have been concerned about excessive prescribing practices or
excessive supply and the detailing, the manufacturing, the distributing of excessive,
huge numbers of opioid pills if it wasn't for the
(06:33):
fact that we saw a mortality curve increase along with
that supply. And we can talk about what the drivers
of that first wave were, but um, I will stand
by the statement that as we started to curtail that supplies,
we said, oh wow, opioid pill overdoses are going up,
deaths are going up. There's a problem. As we started
(06:54):
to curtail that and as we started apply downward pressure
on that supply, whether it's telling doctors to curb their
prescribing practices, whether it was through lawsuits that curtailed the
manufacturers and distributors that you know, they're still going on now.
As we saw that supply get constrained, we started seeing
heroin being picked up, and we started seeing an overdose
(07:16):
curve due to heroin UM. That would have been an
epidemic in and of itself if it wasn't for the
fact that in hot and synthetic opioids, including fentyyl and
hundreds of fentyel analogs UH started flooding the American streets
and people who were using heroin maybe depending on heroin,
(07:38):
started experiencing a fentyyl adulterated heroin and that increased the
mortality risk tremendously. So that's we've three of the crisis,
and that is still going on now. That started the
East coast, it's now hit the West coast as UM
and the mortality of old drugs overall is being driven
(08:00):
a synthetic opioids, including fentanyl and the analogs. So, Dan,
you look at the latest report and it's to some
extent fentinyl fentinyl fentinyl. What is fentinyl and why is
it playing such a massive role in killing people? So
fentanyl is a synthetic opioid. In order to understand that,
we need to know that opioids come in three forms.
(08:23):
Is natural opioids that come straight out of opium, which
is the extract from the poppy plant, that would include
morphine and coding. Then we have the semisynthetics, where you
change one part of morphine or one part of coding
to produce a medicine like hydrocodum um. And then you
have synthetics, which are fully they have nothing to do
(08:44):
with poppy plant, they have nothing to do with opium,
and they are manufactured in the lab Methodone is an
example of a synthetic opioid, as is fentyl and the
six D plus fentinyl analogs. So fentinyls is potent synthetic opioid.
It is forty times as strong as heroin by weight.
(09:04):
It's a hundred times as strong as morphine by weight.
It comes in a variety of chemical cousins, we call
them analogs, some of which are a couple of times
more potent than heroin, some of which reach almost a
thousand times as strong as heroin. That would be car
fentanyl and and the other n I l fentanyls. And
so when we saw that you jump in Ohio or
(09:26):
people dropping like flies, that was because car fentinel all
of a sudden hit the streets in a way that
people didn't know how to deal with it. Right, car
Fentanyl should not be in the human drugs supply. It
is meant as a large animal think elephant uh and
analgesic uh. So instead of injecting an elephant with a
gallon or two of opioid to help them with their
(09:48):
broken leg, you inject them with a normal size uh syringe,
but with a very potent chemical to help them deal
with pain or surgical procedure something like that. So, I mean, Dan,
when ask why this dramatic jump jump in the last
year and over those fatalities as creating headlines, I mean,
(10:08):
apart from COVID, is this about people just not knowing
the potency of what they're getting, or not knowing that
drugs they're getting, or is about all sorts of things
getting mixed into the supply? I mean, what do we
know about why this dramatic jump? So we have to
understand it is a twenty year historic phenomenon, right, and
talking about deaths, those deaths are higher than UM the
(10:32):
number of deaths at the height of the crisis. UM.
It's surpassed the number of motor vehicle accidents as as
the number one cause of unintentional accidental injury. And we
need to understand that it's a the reason I use
the metaphor of a triple wave, that each wave has
a certain energy behind it. We had the first wave
(10:53):
of opioid pills. It increased on the size of the
population that uses opioids. Some of those folks got cut
off from their supply and moved on to heroin, and
we saw it. Even though it is a fraction of
the original size of the population, that population was huge.
And now we have a historic number of people who
are using heroine. Some estimates make it as high as
(11:15):
three million active heroin users in the United States. We've
never had anywhere close to that number. You usually the
number of the past was half a million or three
quarters of a million heroin users. So the population of
heroin users has gone up multiple fold. That alone would
have been historic crisis in and of itself. A historic
crisis of heroin use and heroin consequences now comes along
(11:39):
a potent opioid meant to replace heroin, meant to come
from an industrial supply as opposed to an agricultural supply
that's forty times as potent as heroin by weight. Right,
and the fens we overfocus sometimes on this idea of potents.
But it also comes in adulterating heroin. It's not being
sold as is. It comes in as a contaminant, comes
(12:02):
in as a poison, comes in as an adulterant of
the heroin supply in the East Coast. Users don't know
what hit them, and they start complaining the heroine is different,
it doesn't feel right, it's too strong. When was the
last time you heard a heroin user say, oh, the
ships too strong. So it came in as a tsunami.
So you have this triple wave of the third wave
(12:23):
of which is a tsunami that's bowling people over because
they're using it unbeknownst to them. They think they're using heroin,
but they're getting something else. And then to add to
that that fentel comes in all these different analogs chemical cousins,
if you will. That undulation and potent, say also asks
adds hugely to the risk because what causes overdose, amount
(12:46):
of opioid over your tolerance, and so you're messing with
people's tolerance by undulating the supply. So it's all those
forces that have led to three maybe even more than
because that's an under account death last year. Add on COVID,
add on the fact that our interventions have not been
powerful enough, potent enough to meet this historic foe, and
(13:10):
then we have a historic crisis. You know, I came
across I mean, let's just dig in a little further.
I came across the report recently, I think, put out
by the Rand Corporation, which has a drug policy analysis unit,
and there in their analysis they found that, you know, paradoxically,
when the pharmaceutical companies, under pressure from the government everybody else,
started to crack down and reformulate oxy content so it
(13:33):
was harder to kind of crush the pill and inject it,
the result was actually an increase in overdose fatalities. Yeah,
that's that's quite unfortunate. And I've actually produced a graphic
just using Google that as Google search terms for oxy
cotton went down, and they went down because they got
re formulated from the original crushable formula, which we called
(13:56):
CS to the op formula, which was non qrushable. You
see Google search is for heroin go up. It's just
beyond ironic. And so what we call this in drug
policy we call this the humble term of the balloon effect. Right,
And we try to squeeze supply on one end of
the balloon, it bubbles out in another part of the balloon.
And the important part of the balloon metaphor that I
(14:17):
like to remind people is not that the fact that
the other end of the balloon has gotten bigger. It's
gotten bigger, usually in an unpredictable direction. Think about when
you squeeze a balloon, you don't know where the rubbers
weakest on the other part of the balloon. It not
only bubbles out overall, but it might bubble out in
a funny direction. And that's exactly what we're seeing here.
(14:38):
We're seeing paradoxical effects of the war on drugs. So, now, Ethan,
you and I could really get into this, because this
starts to really explain why fentonel even came about in
the first place. Right, What is it about interdiction? What
is it about supply reduction that produces a thirty year
exponentially increasing curve in illicit drug mortality. Yeah, I remember
(15:04):
there was a moment with fentonel. I think there was
some lab in Mexico maybe fifteen twenty years ago that
was started supplying fentanyl and started to come into the
US or some overdose associated with it, and then in
a rare case of law enforcement being successful, the US
and Mexican authorities shut it down and the federal went away.
But now federals coming in from China, China directly, China
(15:25):
via Mexico, China via Canada. It's coming in small packages.
I mean, there essentially is no supply side solution to
this at this point. Right. A subtitle of one of
my papers UM a few years ago was the end
of introdiction. I think fentonyl proves that point. There's a
lot of us who have been kind of cynical about
supply side interventions and and whether there worth the money
(15:46):
or whether they're actually effective at all, um, and the
evidence is going against them. Do you think about it.
One of the main goals of introdiction is to stop
the flow of drugs sufficiently so that the price at
the end market user, the retail user, goes up. Well,
let's look at the data. Heroin for the last twenty
(16:07):
or so years has never been cheaper at the retail level.
So what does that say about interdiction Using their metric
of trying to curtail supply so that the price goes
up and purity goes down, they have failed. Because heroin,
if we if we use a standardized measure, which is
price per milligram pure keeps bouncing along at rock bottom
(16:28):
prices for the last decade or so. Now at the
same time, because of interdiction, there's been a honing effect, right,
And the honing effect is that there's exclusive markets of
heroin worldwide. So in North America, we have producers in
Colombia and in Mexico, and both of those bring heroin
(16:48):
only to the United States. That's what I mean by honing.
They're kind of exclusive supplier to wholesale to retail markets.
We used to have four suppliers in the United States.
We used to have Southeast Asia, Southwest Asia, and Colombia
and x Go. Now we only have two suppliers. And
guess what, the Colombian market just dried up. So now
the only way we get heroin in the United States
is from Mexican suppliers, Mexican CTOs, colinal trafficking organizations. So
(17:13):
the end game that the interdiction folks are hoping for
is that, well, now we just have one chest piece
and knock off the board. Left unfortunately made an end
run around that, and what is the end run. The
end run was fentinel adulterated heroin importing from a whole
new player. When you think of illicit drug producers in
the world, right, you just ask the general waties. They'll say, oh, Afghanistan, Pakistan,
(17:33):
there's like Colombia. They might say Mexico. No one's gonna
come up with China. Well, China is a balloon effect.
It's an invention in supply. So what we have now,
we have a whole new supply of powerful opiate. It's
immune to interdiction effects. There's no crops brain, there's no
large shipment that could be busted. It comes in smaller packages.
When I spoke to Congress a couple of years ago,
(17:55):
between my representatives and myself, there's a space between those
two desks, and I said, all the fentanyl that came
in could fit into twelve industrial oil barrels that could
all be seen right in front of us. Now, how
do you stop that flow across the Pacific Ocean from
(18:16):
a friendly training partners like China? The not on our
enemy list can go and invade them and and bring
military advisors there to stop the flow. So that is
what I call the end of interdiction. We've played the endgame,
and what we got was a super powerful and dangerous
drug on the American streets. Yeah, although you know, even
with heroin. I remember, I think was Senator moynihan who
(18:36):
kind of got smart about this at some point. He
pointed out, like all the cocaine being consumed in America
back twenty years ago could be in like a half
dozen or something shipping containers. I mean that there was
essentially no way to stop this. And people are realized
Mexico has been the source of at least a third
of the heroin consumed the United States for like seventy
eighty years. So which you say there is at Fentinel
(18:59):
just kind of pointed out the absurdity of the interdiction.
The supply side control strategy was always apparent, even though
the idiots and the Pentagon and law enforcement kept insisting
on it. Fedital just kind of made it the absurdity
totally clear. I mean, how many FedEx packages can you
stop coming in from, whether it's China directly or China
(19:19):
the in Mexico or what have you. We'll be talking
more after we hear this ad. Let me ask you
(19:41):
this question. And I know there's no really reliable to
answer this question. It's a it's an impossible question, but
I'll throw it at you, okay, which is imagine if
Produe Pharma, with its oxycontent and its competitors, that Johnson
and Johnson's and all the other firms had never started
over supplying opie it's pharmaceutical opioids twenty years ago, in
(20:01):
late nineties, early two thousand's right? Do you think we
still would have had this opioid epidemic? Wouldn't have happened anyway.
There's two ways to look at it. So the opioid crisis,
this trip away, a phenomena of pills, the heroin defense
and al that would not have happened. So supply does
lead to overuse. So I'm as a supply side thinker,
(20:25):
I can with two halves of my brains say on
one half says supply matters, right, supply actually does lead.
It's just pure economics. You bring in a cheaper good
and people are going to use it, right, And in fact,
that's one of the reasons why heroin and methomphetamine are
so cheap right now, is because we have free trade
agreements across the American borders NAFTA and KAFTA that not
(20:48):
only bring down the price of illicit goods, but they
also bring them the price of illicit goods. But it's
contrastraining supply that has been problematic. We have not been
able to do it. But let me get back to
your question, right, and that is if opioid pill supply
stayed at sort of normal levels. Now normal levels are
still high for American compared to other countries, but let's
just push that aside for a second, would we still
(21:10):
have had some kind of drug overuse problematic use cycle.
The answer is probably yes, right, and the reason is
because we have myasthmic drivers in America. So what does
my asthma? My asthma means that there's a syndrome of
issues that caused suffering and that leads to something that
(21:31):
public health is concerned with, you know, whether it's poverty
or social and economic inequities, disparities and access to health
care or in health care utilization. Right, America has these
false zones in which problematic drug use. Now we're not
talking about recreational drug use here, we're talking about problematic
(21:53):
drug use falls into the cracks off. And so what
issues do we have in America that that might be
creating these law scale cracks that might be fomenting problematic
drug use. Um, we could spend another hour on. Let's
just look at one issue in particular, and that is
the disenfranchisement of working class Americans. The whole idea of
you jobs going overseas, the whole idea of loss of
(22:15):
hope between a generation of a parents generation and the
kids generation. Um. And there have been some good economic
work showing that economic disenfranchisement of particularly you know, Midwest,
we think about sort of the this might be a
derogatory term, but for lack of a better term than
the so called rust belt where industry left left some
(22:35):
decaying disenfranchise communities. Well, guess where pills and heroin and
fencinel fell into. And I can say that if you
took the pills in, heroin and fentral away, that some
other miasma condition wouldn't have fallen in to those cracks.
And so I'm a balanced thinker. I think them both
supply side, but I also think in terms of demand side,
(22:56):
and if interdiction is an endgame, right, if we if
we've run a ground with our forty year war on drugs,
we need to pay attention to the demand side. We
need to pay attention to those false zones, to the
cracks in society. Need to make America more resilient, not
necessarily to drug use in general. We've we focus our
resiliency on that don't use drugs, don't use marijuana. Right,
(23:18):
What if we just focus on resiliency to problematic drug use,
to drug use that's used to solve, to soothe, for
people to self medicate with. Right, Let's bring it back
to a robust medical system. Let's bring it back to
a robust public health system. Let's work on fixing those
cracks in society and making any more just and equitable society.
(23:38):
M we know. I think also if you look at
the recent data of who's dying now, we so much
associate this with the kind of white middle lower middle class,
declining income group in these kind of Midwestern states. At
the same time, it's worth pointing out to other things,
you know, I mean I live on the upper west
side of New York and about a block for me,
on the very expensive apartments that lines the west side
(23:59):
of sand Hill Park, Central Park West, there is a
building there probably average department caused five, ten, fifteen million dollars, right,
very wealthy families. I know of at least four families
in that building who have lost a son to an
opioid overdose. So you can see it can hit the
kind of upper income folks as well in a way.
(24:20):
But at the same time, if you look at the
data that's coming out in the last year, I mean,
overdose has always been a problem among poor black and
Hispanic people in the cities and elsewhere. Remember New Mexico
used to have a big problem, but it's also in
the cities. But when you look at the data last year,
you see the most dramatic increases in over those fatalities
are happening among blacks and Hispanics. Just explain what's going
(24:40):
on there. Yeah, So let's start with the earlier phase
of the crisis, right, So, when it was pills, you know,
wave one of the Triple Waves that showed inequities in
access to medication. So so the fact that it hit
middle class, upper middle class, white more than it hit
brown and black folks in America shows that they had
(25:02):
greater access to pain medication. And that's is well substatiated
in the literature. There's that there's disparities in access to
pain medication as it moves towards and and and the
pain has been so widespread ethan, I mean, this is
this is why I use language like crisis. You know,
I'm not just calling this an epidemic, which you know,
the epidemiologist and me would say, hey, let's just call
(25:24):
it an epidemic, which is a rising curve of something,
in this case, a rising curve of death. But I
call it a crisis because we're out of control and
because we don't fully understand what tools we need to
apply to this. Right, we lack deep understanding and we
lack a strong sense of intervention. But let's talk about
the disparities that are happening now. Right, So, as we
(25:45):
moved towards Heroin, as we moved into the we we've
three the fentinel crisis we are seeing in the inner
city more rapidly increasing rates of death among black and
brown populations. What's going on there? Based on my ethnographic
work where I spend time in the inner cities, I've
been extensively to Baltimore. I've been to Chicago a few times.
(26:05):
I spent a lot of time, of course at my
hometown of San Francisco. I've been to New York a
few times. What's happening there is there was some resistance
to fencyl Right, if you're African American and you lived
in Baltimore, you knew how to get good heroin that
wasn't adulterated with fentanyl for a couple of years, and
then the gauntlet fully got dropped and you couldn't find
(26:27):
anything but defenconyl laced heroin. And so the African American
death rates going up now because they're u accustomed to it.
They didn't like it for a while. They have no
resilience to it. Um Now shift over to San Francisco.
San Francisco has just recently begun seeing fencyyl. It's being
sold as is. And I can't fully explain this ethan,
(26:47):
but our African American opioid related mortality rate is skyrocketing.
It's much worse than it is for whites. I don't
understand it. I don't understand in a in a free
flowing fentyyl market, why African Americans might be choosing the fenyel.
This all needs to be explored. COVID simply got in
the way. We weren't able to do research last year.
But this is what we need to do in San Francisco.
(27:09):
We need to find out why it is that the
opioid death rate among African Americans is so high in
San Francisco. Yeah, so, I mean, Dan we typically think
about the United States is one great, big national market,
but there are clearly substantial regional variations in terms of
overdose and even drugs. I mean, so, is the US
not really a national market? Is what California gets different
than what Louisiana gets, different than what Maine gets, different
(27:31):
from what Ohio gets. So the overdose due to fentonel
and other synthetic opioids went up far more dramatically in
the Midwest, Northeast, down to mid Atlantic, over to Appalachia
regions um far ahead of the rest of the country.
So they were of that area got hit in fourteen
so that's your our first indication that supply is different
(27:54):
than the supply of fentyyl. And this is again fentyel
adulterating heroin was different. And if you say the northeast
quadrant of the United States, then it's spilled over to
the south. And now it's spilling over to the west.
And why is it different, Well, where is it coming from? Well,
defending is coming from China, but it's being put into
the heroines through the Mexican criminal trafficking organizations. Right. Those
(28:18):
criminal trafficking organizations have been multiple, right, And the reason
why they're multiple is because some of the bigger ones
have been successfully toppled and that leads to fragmentation of them.
So now there's a bunch of little carteltos or or
smaller c t o s and they've just divided up America.
You know, Sinala has been sort of the big one. Uh,
(28:39):
it's still kind of fairly large and monolithic. But Sinelo
has been split up by the arrest and next tradition
of its leader was held in Chicago jail right now,
and um, the so lower cartel has become fragmented and
more creative and and splitting up the country and and
again my research has been curtailed. I'm not getting much
from the D A, from O, N, D C, be
(29:00):
from from height I mean, uh, to tell me, you
know why it is that fentinel's hitting the western half
the United States. But my suspicion is that it's less
cartel based. This seems to be more fentel being sold
as is um. I'm not sure that it's cartel based.
It might be entrepreneurial based. It might be local people
buying it directly from China and selling it. I I
(29:22):
really don't know. But there's a lot more mystery. And
so here we are five years into a fenil epidemic,
and there's still mystery. There's still things that need to
be explored. There's still things that we should have and
could have been on top of. But for some reason,
we lack sufficient curiosity, we lack sufficient understanding of drug
flows to really make a public health impact. And this
(29:44):
is one of the things that I'm pushing. Since I
am a supplied side thinker, I've been pushing anyone will
listen to me, D O J HIDA, D A C
d C to say, listen, this is a poisoning crisis.
Fentinel represents an unfeseen and historic foe. In order to
understand it better, we need to understand the supply of it.
(30:04):
So let's start sharing data. We could use it for
public health. It's called an epidemiology. We'd call it surveillance, right.
Don't you want to know where the poison comes from,
what products it's in, what its potency level is, what
its purity level is, And that's what information we lack
here on the West Coast. We're operating blindly in public health.
We're operating blindly in the e r S and we're
(30:25):
only counting the quote dead bodies as they lie, which
is a hundred and fifty years UM old process of
doing public health. We should use technology, We should use
modern surveillance, modern toxicology to understand supply better. By the way,
all those initials that Dan was reeling off O N
d CP refers to the Drugs RS Office Higher refers
to another federal drug enforcement collaboration. I think most people
(30:49):
know what d e A is, um but you left
out one of them, which is not a National student
on drug abuse, And uh, you know I one of
the people I talked to for Psychoactive. Is Nora Vocale
the head of it to National stud on Drug Abuse.
I think the interview with her will run after yours,
But I gave her a hard time about this. I mean, you,
thank god have one of the big grants to do
the ethnic, graphic and statistical and all the sort of
(31:10):
work that's necessary to dig into this. But there should
be a hundred people like you being funded, whereas there's
only five or ten. I believe you know. And I'm
asking the question like, who knows what retail drug sellers
know about what they're selling? How much do retail drug
sellers actually know about whether there's ventil in their drug,
what it's being cut with, or what about the people
one level up from them? What do we know about
(31:31):
where stuff is being mixed and where stuff is being cut?
And these are not impossible questions to answer. One could
be interviewing people who are behind bars for drugs selling
and offering them confidentiality and some money in order to
tell you what's going on. One could have that type
of research, but it's not happening. We'll be talking more
(31:51):
after we hear this ad. Until fentanyl came around, the
large majority of people who quote unquote overdosed. It wasn't
(32:12):
because they just took too much actual content or too
much heroin. You typically have to mix it with alcohol
or benzos or their tranquilizers. Fentanyl changes the game. But
before Fentonel, there was almost no effort on behalf of
either federal or state authorities to educate consumers of these
illicit drugs, don't mix drugs or if you do, know
the consequences. So, I mean there's an element of gross
(32:34):
policy failure and gross public education failure on the part
of the government when it comes to these sorts of things.
I actually call it a blind spot, right, and that
is we seem to like the tools that we have,
which is, if somebody winds up in the emergency room,
where somebody winds up in the morgue, we understand what
that body died from, right, We understand the chemistry of
(32:55):
that body. But that is a profound misunderstanding of what
you do in poisoning crises. Right, That's only one way
of looking at it. The other way of looking at
it is what is the person doing? So you bring
up the whole conundrum of poly drug use, of mixing
different drugs. That's poorly understood. As you pointed out, it's
one of the blind spots. But the other blind spot
(33:17):
is what's going on in terms of the wholesale and
retail supply of drugs. We could ascertain that through UH interviews,
We could ascertain that through acquiring some of those drugs,
or for example, any urban setting. Right now, there are thousands,
if not tens of thousands of CIS drug samples that
were obtained through criminal justice proceedings, you know, small busts
(33:39):
that are being held as evidence against that person that
could be analyzed right now. I could go to the
Baltimore Crime Lab and say, can you analyze a hundred
specimens from last week and tell me what's in them?
What mixtures? Is the fencinyl contaminating the method? And fetamine
is that in the cocaine of which different types of
fen anmals were present last week? Right I could have
(34:00):
a great understanding mapped out across all of Baltimore with
a couple hundred drug samples tested last week of the
Baltimore crime Lab. I could do that in San Francisco.
I could do that in New York, actually do the Chicago.
I could understand supply from a poisoning point of view,
from a exposure point of view, right, And so now
we would have a more complete understanding. We would understand exposure,
(34:22):
we would understand use, and we would understand the end
result of use, you know, landing up in the hospital
to e er or the morgue. Right. But we only
have one of those three legs of our three legged stool.
So as you suggest that it's a failure to failure
research policy, it's a failure of public policy. Here's the
other big failure, other big blind spot, ethan, Can you
(34:43):
tell me how many active heroin injectors there are in
the United States right now? Yeah? One million, four d
sixty thousand, eight hundred and twelves. How many are there?
How many are there? We don't know, right, We have
no idea. The answer is unknown. Now, why is it
in a growing epidem where the severe consequences including death,
that we don't understand the size of the at risk population?
(35:06):
Basic epidemiology one oh one? What is the size of
the population at risk? We don't know that. And every
time I meet with the CDC, I mentioned this, and
I say, shame on you because you don't know the
answer to this question. Right, who should know the answer
to the question sentence for these controls and the answer
to that question, and they refuse to do it. You
fund five, six, a dozen researchers from around the country
to do capture recapture studies, we can have the answer, right,
(35:29):
but they refuse to fund those studies. Neither refuses to
fund those studies despite the fact that we're in an epidemic.
And what a crisis means, ethan, what a crisis means
is that we don't understand based on our current tool set.
So what you do then is you start getting creative.
What other tools have we ignored? What other interventions have
(35:49):
we ignored? Right? We need to be creative, We need
to be bold, We need new sources of funding, and
we need new understandings in order to handle this historic
crisis we do. The other thing, of course, we don't
know right now is the latest reports say show on
the one hand, that fentanyl is pervasively connected to the
overdose fatality epidemic, but they also show that stimulants cocaine, methamphetamine,
(36:12):
and other things like that are showing up more and
more and more, and it appears that some of these
overdoses involved just the use of stimulants like cocaine and
meth amphetami without fentanyl. Other cases they're mixing it with fentanyl.
But we don't know why they're mixing it, right, I mean,
you know, one of the theories has been it's like
the old heroin cocaine speedball that was popular back in
the eighties, where people like the mixture of the drugs.
Another is that the sellers don't even know what they're mixing.
(36:35):
It's just you know, a little bit of stuff getting
mixed accidentally or whatever. But what more can you tell
us about why this stimulant thing is showing up more
and more and more, both with and without fentanyl. Yeah,
this is a great question. It's such a great question
that I've spent most of COVID pondering it and written
two papers. My most recent papers discussed the fourth wave
of the opioid epidemic, which is the stimulant use and
(36:56):
polly substance use that includes the mixture of an opioid
and a stimulant. The goofball, which is historically what we
called methan fetamine and heroin mixed together, was historically unusual.
You had to be an expert to do it, you
had to know what you were doing. You had a
feather in the methanphetamine in just the right amounts, and
so you didn't see a lot of it. You had to.
(37:17):
There was only a few very fussy people who knew
how to mix them the right way, and that's because
the methan and fetamy would simply bowl over the heroine
and you've wasted your money on the heroine. Now, fentanyl
is a very powerful opoid, so now they're meeting manoamano
powerful synthetic stimulant like meth and fhetamine, which is coming
in historic levels of potency and purity potent percent pure.
(37:40):
We've never seen methan and fetamine like this before. You
got this powerful opioid and you get this powerful stimulant
that are coming together, and half of us stimulant deaths
are related to that combination. Now, where fentanyl is being
detected along with meth and fetamine in the bloodstream of
people who have died, it needs to be explained. We
have this vague notion in drug policy that uppers and
(38:03):
downers kind of undulate through history, that we have the
sort of upper wave and then the next generation chooses
downers like heroin, and the next generation uses uppers like crack.
This vague notion of of undulation throughout the decades. Here
they're colliding together. So not only is stimulus coming at
the end of a twenty year opioid triple wave, but
(38:25):
it's coming in as a as a combined use, and
that needs to be explored. There's two forces that are
driving the latest numbers. One is the breaching of the
East West divide in terms of fentel. Fentinel has now
moved westward. And the second is the methophetamine epidemic. We've
(38:45):
always had an endemic problem in the United States in
the West coast. For the opposite phenomenous happening, and that
is meth and fetamine is now going all the way
to the northeast United States where it didn't hit before
and they're not used to it. The size of the
at risk population has increased for methan fhetamine on the
East coast and for fentinel on the West coast, and
that's raising the numbers as well. So the question about
(39:06):
what to do, I mean, obviously there's a bigger socioeconomic
factor here and about jobs, an opportunity and people having
a sense of hope. That is probably the most important
contextual answer to this problem of the opioid epidemic. But
then there's the specifics. We know that making the lock
zone more widely available the antidote has you know, saved
tens of thousands of lives, if not, if not hundreds
(39:26):
of thousands of lives. We know that more drug treatment
smart drug treatment. We know that more needle exchange programs
are hopefully allowing safe injection sites. So what are now
called over those prevention centers that those things could be beneficial.
We know that drug testing slips where people get fentel
and have it tested. But when you think, are there
other key things apart from the ones that I've reeled
off that you think are really important to have out there? Yeah, yeah,
(39:48):
that's a great list. You know, that's a historic opportunity.
And people ask me, am, I that's a mr an optimists,
and I'm I'm always an optimist because here we have
a historic crisis. But in crisis, there's opportunity, right, And
what's the opportunity there? The opportunity is to take a
deeper understanding of where we are as Americans, right to
look at those false zones in America, to look at
what we can do to lift cities up, to make
(40:09):
communities healthier. So I agree with what I would call
primary prevention and not just educating don't do drugs right,
but making communities more resilient, making them healthier, making them happier.
The other historic opportunity here is to move away from
what's been an unfortunately unbalanced drug policy where we focus
too much on supply, too much on catching the quote
(40:30):
bad guys end quote, or or stopping the flows of
drugs or locking people Upright, Remember, the war and drugs
has also been a warm black and brown people. It's
been heavy incarceration rates, right, we need to end that
has been an utter failure. It's broken families apart. It
isn't actually led to the disenfranchisement of communities. Um, to
change how we view drug use is the most important
(40:53):
opportunity here. Right, We're not gonna put the genie back
on the bottle. We're not going to stop recreational drug use.
It's a human phenomena that's been going on for thousands
of years. That's an American phenomena. People like to alter
their consciousness. But can we make it less risky, and
the answer is yes. And that's where harm reduction comes in.
That's where regulation and taxation comes in, and we have
(41:14):
to stop making it punitive to use, stop locking people
up for it. That's where diversion programs come in. That's
where creating an opportunity comes in. That's where I would
expand my list that I love harm reduction. We need
more in the locks than we need more needle exchange.
I love the idea of demand reduction, including treatment low
barrier treatment, including upreneurs the methodone. But I also think
(41:36):
we need to change the conversation about drugs and accept
that it's a normal human behavior that we can redirect
from problematic use to less problematic use. And that's our
cultural opportunity. Okay, well listen, Dan, you've been a spectacular guest.
I have learned a lot. I'm sure our listeners have
learned to use amounts. So thank you ever so much
(41:57):
for joining me today, and I welcome any comments from
our Psychoactive listeners, which I'll be happy to share with you.
Thanks so much, then, thanks for inviting me. It's been
a pleasure. Psychoactive is a production of I Heart Radio
(42:19):
and Protozoa Pictures. It's hosted by me Ethan Naedelman. It's
produced by Kacha Kumkova and Ben Cabrick. The executive producers
are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren Aronovski
for Protozoa Pictures, Alex Williams and Matt Frederick for I
Heart Radio, and me Ethan Naedelman. Our music is by
(42:39):
Ari Belusian and Especial thanks to Avivit Brio, Sef Bianca
Grimshaw and Robert Beatty. If you'd like to share your
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at eight three three seven seven nine sixty. That's one
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(43:04):
as psychoactive at protozoa dot com or find me on
Twitter at Ethan Natalman. And if you couldn't keep track
of all this, find the information in the show notes.
Tune in next time for one of America's leading writers,
Michael Pollen, whose recent book This Is Your Mind on
Plans is breaking new ground. There are insights. I had
(43:26):
an influence of mushrooms years ago. They still have validity
in my life today. You had I think the same experience.
Oh yeah, I know I did. There are insights I
had and you could. You know. You can also call
them banal insights around love and connectedness, but they're real. Um.
But also, think of the people using psychedelics to quit
(43:46):
smoking and they come to the profound conclusion that smoking
is stupid and it's killing them. They knew that at
one level. But there is a sturdiness to the insight
on psychedelics. It's it's what James called the no edic quality,
right that this is not just an opinion, this is
a revealed truth. Subscribe to Cycoactive now see it, don't
miss it. M
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