June 30, 2021 • 51 mins
Ben Levenson is the Chairman of The Levenson Foundation and founder of Origins Behavioral HealthCare. Ben chats with Valerie and Carly about harm reduction, or ways to “derisk” drug use for the millions of people who use drugs in the United States, and the gap between “the bench and the trench,” or between scientific findings and addiction treatment. Ben talks about international approaches to drug use and leaves Valerie and Carly with some excellent food for thought about the need to end stigma towards all people who use drugs, not just people in recovery from drug use disorders.
Read more about Ben’s work with the Levenson Foundation here: https://levensonfoundation.org/
Read about the Rome Consensus here: https://romeconsensus.com/
Read about the National Harm Reduction Coalition here: https://harmreduction.org/
Follow Ben on Twitter: @BenLevenson
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Valerie Earnshaw (00:09):
I'm Valerie Earnshaw,
Carly Hill (00:13):
I'm Carly hill,
Valerie Earnshaw (00:14):
and this is Sex, Drugs, and Science.
Carly Hill (00:17):
Today's conversation is with Ben Levenson.
Ben founded Origins BehavioralCare in 2009, a nd Origins
offers comprehensive addiction,recovery services for patients
and their families.
In 2017, Ben founded theLevenson Foundation, which aims
to reduce human suffering andpromote w ellbeing.
Valerie Earnshaw (00:35):
We're grateful to Ben for joining us to
continue thinking about how sexand drugs science is used, and
also not used in the real world.
And also to continue thinkingabout what it is that we just
need more science about or whatwe need to continue researching.
Ben is a tremendous advocate forharm reduction.
And so we really focused ourconversation there.
Harm reduction, includesstrategies and ideas aimed at
(00:57):
reducing negative consequencesassociated with drug use.
So in some of our otherepisodes, we've talked about
Naloxone, which is a medicationthat reverses overdoses from
opioids, medications for opioiduse disorders, things like
methadone and buprenorphine,syringe exchange, and overdose
prevention sites.
So all of these are examples ofharm reduction that we've been
(01:18):
talking about.
So we hope that you enjoy thisconversation with Ben Levenson.
Ben Levenson, welcome to thepodcast.
Carly Hill (01:31):
Thanks for joining us!
Ben Levenson (01:32):
I appreciate getting to spend time with you
guys.
I've been super excited to, uh,to chat with you and, you know,
thinking about the audience thatyou guys have to build.
It's this is a really specialopportunity.
So thanks for having me.
Carly Hill (01:43):
Of course, It's our pleasure.
Valerie Earnshaw (01:44):
Yeah.
You couldn't be more excitedthan us.
We've spent a couple of dayslike digging into your
background, listening to otherpodcasts and things that you've
done.
And so we're 15 out of 10excited to talk to you like.
Ben Levenson (01:56):
My condolences if you've been background checking
me.
Valerie Earnshaw (02:00):
No, no, it's been fun.
So could you start off, Ben, bytelling us just a little bit
about yourself?
Ben Levenson (02:06):
Sure, sure.
I'm going to share a little bitfrom a personal frame and also
professionally.
Substance use disorder and, andkind of chaotic drug use kind of
permeated my familygenerationally on the, on the
maternal side, my mom lost herbrother to an overdose in the
nineties and, uh, she's 30 yearsin recovery now and I lost my
(02:30):
brother the week the towers camedown and I looked in the city
and, and so it was a real doublewhammy.
And, you know, you would thinkthat, oh, after that you would
just total, like I'm not-- butmy drug use actually increased.
And so I had my own, you know,my own journey with kind of
(02:51):
problematic drug use.
And I think most of us who endup here, like in the substance
use disorder or kind of dualdiagnosis space typically have
some personal connection orinvestment, you know, I went to
treatment and I was really avictim of this like acute
episodic intervention on what weall know is a kind of a chronic
(03:12):
process.
Right.
And just wasn't sufficient.
And so, yeah, I mean, I, Idecided to, to build, to iterate
and innovate on treatment and,and that's what brought me into
the field.
It Was kind of like,"Hey, look,we can do this better".
That was 20 years ago.
And here we are.
Thanks for asking about mybackground.
Valerie Earnshaw (03:31):
Yeah.
So you started OriginsBehavioral Healthcare.
I mean, this is a little bitrelated to the first group of
things I went in to talk to youabout, which is, what do
traditional models of care looklike?
And then what, what do placesmaybe like Origins do a little
bit differently?
So one of the things that youjust said was that, you know,
(03:52):
treating substance use disorder,treating problematic substance
use, like in an acute short-termway, as opposed to a chronic
illness, that seems to be onepart of it.
Are there other pieces or?
Ben Levenson (04:04):
There's reasonable data that, that suggests, you
know, maybe 80 million Americanswill use an illicit substance
one or more times in 2021, if werely on SAMHSA's data-- and we
tend to act like we do-- theysay there are 20 call it 24
million of those drug users,have substance use disorder and
(04:27):
kind of writ large with thetreatment apparatus, both public
and private combined, onlyinterfaces like formally with,
with 3 million people annually.
You know, the question used tobe,"well, how do we get the
other 21 million to, to, youknow, to seek care?" Like, how
do we motivate that?
Then what's the breakdown on, onwhy they're not, you know,
(04:49):
they're not seeking help.
Is it resource related?
Is it, you know, what are thebarriers?
But the world has changed.
It's not just the 24 million whoare, you know, kind of eligible
for support.
It's actually now the entirecohort because we have a
profoundly contaminated,irreversibly contaminated drug
(05:11):
supply.
And every one of them are usingfrom the same trough.
It used to be the 66 millionthat, what do they need support
for?
I mean, they're, they're lower,no problem drug drug users.
But they do.
They, they need helpunderstanding that the supply is
contaminated.
And it's fundamentally, youknow, care that's centered in
harm reduction sciences that,you know, helps them de-risk
(05:34):
that drug use.
Valerie Earnshaw (05:35):
I'm really glad I asked because that's not
necessarily what I was thinking.
When I asked that question, Iwas thinking, how do we better
serve the 20 million?
That is really interesting tothink like, no, actually we need
to be thinking about the full 80million and in Delaware, which
is where Carly and I are, wethink about this contaminated
(05:57):
supply issue a lot because we've...
we're the state with the secondhighest rates of opioid overdose
deaths.
And those rates really startedto climb in 2017 when fentanyl
gets in the system.
And so it really does seem likeit's, yeah, it's a contaminated
supply issue.
So is that, is that what you'respeaking to in terms of the
(06:18):
contaminated supply or are thereother other pieces to that that
I might be missing?
Ben Levenson (06:23):
So there are other adulterants that we're seeing in
the drug supply.
So it's not just fentanyl orfentanyl analogs there's
Xylazine is, is showing up,which is kind of a, a veterinary
drug.
So yeah, I mean, I think whenyou asked about kinda treatment,
you know, the systems that westill have and the systems that
I designed domestically, um, youknow, were rooted in this ethos,
(06:47):
right?
That says all drug use ispathological, you can be down at
the bar drinking all afternoon,and you're just a swell gal, but
if you use cocaine once it'spathological, right?
The treatment systems that webuilt over the last kind of 40
or 50 years are a reflection ofhow we think about people who
(07:08):
use drugs, drugs, themselves,and how they're used.
And so, I think that the modelsthat are innovative, are going
to be responsive to the kind ofthe entire cohort who have
really varied needs.
And a lot of those needs kind ofviolate our fundamental beliefs
about drug use.
Valerie Earnshaw (07:27):
Let's dig into that.
So what are some of thesefundamental beliefs about drug
use.
A part of it, from what you'resaying?
Sounds like, you know, any druguse is pathological.
Right?
Ben Levenson (07:38):
Yeah.
I mean, some of these beliefsare things like, certainly that,
but also this idea that if aperson uses drugs, there's
really only, kind of, two statesthey're allowed to exist in.
Either you're abstinent andeverything is grand, or you're
using, you're in chaotic use andit's jails, institutions, and
(07:58):
death.
Right.
And that's just not true.
That's not at all supported bythe research.
The bell curve lives through,you know,"in the gray" and
actually very few drug userslive on either of those polls.
Valerie Earnshaw (08:10):
Right.
And so"A" that's like a reallylovely description of it.
That's really great to thinkabout.
And there's two things poppinginto my mind, you know, when I'm
listening to you.
So one is, I don't think that'show it works for any chronic
illness, any chronic illness wewould ever study has like a
continuum of outcomes.
You know, so I'm thinking aboutthis right now because I live
(08:32):
with a chronic illness.
There are times when I'm likereally very sick, clearly having
a flare up.
There are times when I'm likereally clearly well, but right
now I'm like definitely liketeetering.
So that would be terrible if Ihad to wait until everything was
really out of control with mychronic illness until I had to
like go interact with my doctor,you know, like I'm probably the
(08:55):
80 million zone, you know, orthe 60 million zone right now
who, you know, or the equivalentfor like these substance use
stats.
And I'm able to be working witha doctor and like figuring that
out.
And how do we keep me out oflike the kind of like extreme
end of the spectrum.
That's one thing that I'mthinking about.
It just, it maps on to everyother chronic disease, you know,
(09:15):
contexts that we think about.
And then the other is just thatthe way, you know,
scientifically that we likemeasure our outcomes and like,
it, it all does guide us towardsthinking about those buckets.
Like, you know, are you in likethis very disordered use
category or not?
Right.
And so if we don't use, I mean,we call them"continuous
(09:38):
outcomes", you know, when we'relike analyzing our data, like if
we don't look at that full, like1 to 10 scale, if we're only
thinking about 10 versus one tonine, then yeah.
You're going to miss all of thatnuance.
So that's a really interestingobservation for me.
Ben Levenson (09:55):
It's really interesting kind of the
departure, right?
From, from even just, justfundamental medical logic and,
and right?
And scientific method that thiskind of runaway medical
specialty has been allowed todo.
And I mean, and I, and I getwhy, like you go back in time, I
mean, you know, medicine didn'thave efficacious therapies for
(10:19):
alcohol use disorder or a drugsrelated substance use disorder,
but these"woowoo" people believethey had, you know, an answer.
And so I think medicine waslike, yeah, just throw them over
the wall.
"You go, go do your voodoo.
And when they need real medicalcare, bring them back to me".
And so it was orphaned, youknow, addiction treatment and
medicine became orphaned.
(10:41):
And in, in that kind of orphanedstate, they never got, they just
didn't get some of thescientific norms, you know, some
of the logic and decision treesthat we use in medicine.
And candidly, I mean, some ofthe patient kind of rights were
and are trampled pretty heavilytoday.
And, and, and so, yeah, it's,it's, you know, you can look
(11:03):
back in the history of medicine,look at Lobotomy, are there,
there are examples, right?
Where ideological kind ofcentered care in, got on a
runaway train and on a levelthat's what we've done with
treatment.
And, and, and that has to change
Valerie Earnshaw (11:18):
Making connections to the bottom is
really interesting.
The other thing that is, I'mmaking connections with in my
mind is, so with the history of,you know, for example, like
black women in America, or womenliving with mental illness in
America, like there was a longperiod and it probably, you know
, continues today inincarcerated settings where
(11:39):
women were just, you know, givenhysterectomies.
Like the decision to take awaylike the right to have a child
it's like taken away from thembecause they were, it was
decided that they weren't ableto make that decision.
Carly Hill (11:51):
you're too hysterical.
Valerie Earnshaw (11:53):
Your too hysterical! That history sounds
similar to me just in terms oflike, how do we treat people
over time?
How much do we, like value theirlives?
How much do we invest infiguring out ways to keep them
well?
And it seems like an evolutionthat's continuing.
Ben Levenson (12:16):
I mean, you know, addiction is it's, it's
anomalous addiction treatment isit's just anomalous in medicine.
And, you know, it's one of theonly kind of processes what--
and let's say, I mean, it's, we,-- we conducted this campaign as
addiction professionals thatsaid"you will call it a
disease".
Right.
Valerie Earnshaw (12:32):
Yes.
Ben Levenson (12:32):
And if you don't we'll attack you.
Right.
And so we're down this, this,this train.
Okay.
So fine.
Okay.
Let's just say we'll, we'llstipulate, it's a chronic,
progressive deadly disease.
Okay.
So then why on the other hand,do we require like patients to
really put their chief symptomdrug use-- Right-- into perfect,
(12:57):
immediate and sustainedremission in order to initiate
care?
It's completely shocking.
Right.
And so I say that because whenyou were talking, you reminded
me that, we fight forincremental improvements to
patient health and safety everyday in medicine.
And if we can get a half a pointimprovement, right?
(13:20):
Like that's amazing.
But with people who use drugs,you have must either be perfect
and perfect today, or-- right--We'll discharge you from care
and blame you, you know, for ourinadequate capabilities, it's
shocking.
Like fundamentally, when youthink about this and the rest of
(13:41):
the world does this differently,but here we don't value
incremental improvements.
You know, a case example is likea patient who comes in and is
injecting heroin 30 days a monthand says,"I'm overdosing once a
month.
And I have a one-year-old and mywife and I have an-- our first
anniversary is coming up and I'mscared and I'm scared I'm going
to die, but I drink and I usecannabis every day, every other
(14:07):
day.
And I shot 14 people for thiscrappy country when I was in
Afghanistan for you.
And yeah, I overeat my benzos.
Okay.
But I'm not stopping takingbenzos for my PTS today.
My wife and I, we, we, we get,you know, we get a stimulant two
(14:28):
to three times a year, some,some Molly or, or whatever, and
we get the best hotel room wecan afford, with great sex.
And the connection that we buildthose nights are really vital to
my relationship.
I'm not stopping doing that.
Will you help me?" Right.
And the answer right now is"no"
Carly Hill (14:49):
No.
Ben Levenson (14:50):
"We can take your money.
So you can come in andparticipate in our fantasy about
your best life.
Right.
And so you could come in andmasquerade that you're not going
to drink.
We're going to force you off thebenzos.
You can't take Bupe because wedon't think it's real recovery.
And look, when you get out andyou return to active use, by the
way-- you're a total treatmentfailure" and"go, go get finished
(15:13):
and let us know when your ass ison fire again." Right.
It's, it's, it's insane.
And it's not, that's not what wedo in medicine.
Valerie Earnshaw (15:21):
Can we talk for just a minute about-- well,
first off, what an excellentexample, like what an excellent
case study to show what thatcould look like.
Can we talk just for a momentabout this dominant, like
prohibition or abstinencenarrative and where we think
that comes from, does that, dowe think that that comes from AA
and, and how AA is so enmeshedin our treatment, like protocols
(15:44):
and such in the, in the US doyou think that's where it comes
from?
Or do you think it comes fromsomewhere else?
Ben Levenson (15:49):
So there's no question about the inmeshment
between 12 Step kind of beliefsystems and treatment.
And certainly I think that 12Steps do focus on abstinence,
and they do value abstinence asa primary outcome that they're
seeking.
Look, the prohibition, It's notabout the safety of people,
(16:11):
right?
Prohibition isn't about likedrug safety or keeping you safe.
In fact, we Scheduled drugsthat, I mean, that, that really
aren't that dangerous.
So it's not about drugdangerousness.
It's a lot about controllingpeople, particularly communities
that people think arethreatening or whatever.
And so, for example, prohibitionpredates Nixon and the Nixon
(16:36):
administration.
But we know from his senioradvisor who helped kind of
architect this, this modern drugwar they've even said, right.
"We knew we couldn't make itillegal to be African-American
or to be a hippie and a warprotester.
But what we can do is heavilycriminalize cannabis, right?
(16:56):
For the hippies and heroin, forthe African-Americans and
demonize that drug every nighton the evening news, and use
that to penetrate right there,their groups and their
leadership and their homes".
And he says, at the end,"did weknow we were lying about the
(17:17):
drugs?
Of course we did".
Right.
It's not about...
Valerie Earnshaw (17:23):
Right.
So one of the things that thismakes me think about is, you
know, stigma's totally pervasivein this, right?
Like it's super pervasive.
And there are folks who theorizearound why stigma exists.
Like, because if it's here, itmust serve some sort of function
for humans.
Right.
And so the two that ringrelevant to me right now is
(17:44):
that, racism is about keepingpeople down.
It's about oppression, right?
It's about maintaining the powerof white folks in society, over
others.
And then, uh, substance usestigma or drug stigma associate
with drug use is all aboutsocial control.
It's about, they call it keepingpeople in, like keep like
(18:05):
defining what the social normsare and then trying to keep
people inside of them.
And so these examples are likethis perfect intersection of
like, of very deliberately, likehow do we keep people down?
And then how do we likemanipulate, like kind of like
make this line in the sandaround, like who counts as a
(18:26):
good person in our society andwho doesn't?
You know, it's reallyinteresting.
We think a lot about structuralstigma and like policies that
have stigma baked into them.
And it's just, it's such a,like, perfect example of a
moment in time when people likecreated a policy to oppress and
to monitor, like what makespeople a good person versus a
(18:48):
bad person?
Ben Levenson (18:50):
There's no question about it.
And I think the data, you know,it makes it it's in
controvertible.
I mean, the disparate kind ofapplication of drug policy and
drug law, and the way that thateffects communities of color is,
I mean, it's profound.
I mean, you can just look at theincarceration rates for
non-violent drug use.
And, you know, we see that, youknow, it's almost like it's like
(19:11):
one to nine, in terms of ratios,between, you know, white people
and those incarcerated who arepeople of color, but we use
substances at the same rates andat the same levels.
If people want to say,"well,they use more drugs".
No, they don't, they don't usemore drugs.
Right.
You arrest them and white peopleget to go to treatment.
(19:31):
That's what you do.
It is, it's deeply broken and,you know, I mean, I think that
there's a call to like tear itto the ground.
I don't think that's how changeactually occurs.
It sounds great.
Right?
The system needs a completereinvention.
You know, I think the truthabout change, is that it's the
same thing about valuingincremental improvements in our
(19:51):
patients.
I think we are going to need toseek incremental improvements to
drug policy reform, but we're atthis very special moment.
There's no question about that.
And change is happening.
Valerie Earnshaw (20:01):
You know, I go around, I give these talks about
stigma to folks and they'realways like,"how do you change
stigma?
How can we, how can we do this?"Then I'm like, great question.
So, yeah, I'm always, I havethis spiel about how there's
like"many tools in the stigmatoolbox".
And I always like to say that,but you know, the thing I'm
always thinking about is like,as a woman standing up here,
(20:22):
like, we still have sexism, westill have racism.
Social change is slow.
Even right now, I would argue,we are in a period of rapid
social change around like LGBTQstigma and equality and human
rights.
And even that is too slow, youknow?
So yeah.
Ben Levenson (20:41):
Yeah.
I mean, I think for drug users--I mean, fundamentally right--
when we want to stigmatizesomething, we criminalize it.
I don't believe that any druguser will be free of the threat
of stigma until active drugusers are not stigmatized
either.
Right.
And we have this crazy view,like where, when we talk about
(21:02):
stigma and anti-stigma endeavorsin terms of drug users, it's
always about people in recovery.
It's always about,"oh, wait,well, but she's sober.
She's a good person now", as ifabstinence gives rise to being a
good person, you know.
I do think that thecriminalization of drug use,
which is not in and of itself acrime, and it's also something
(21:25):
we've been doing since timeimmemorial; altering our
consciousness.
You know, I don't think thatwe're going to get to where we
want to go without addressing,you know, the criminalization of
not just drugs, but of drugusers too.
Valerie Earnshaw (21:39):
I really appreciate you bringing that up
because I study, and Carly isinvolved in these studies, It's
like, we focus on people who arein treatment, who are on
medications for opioid usedisorders.
That's our population.
So when I'm thinking, when I'mstudying stigma, like that's the
group of folks that I am focusedon, but for me, this is like
really great food for thoughtthat, that I'm not going to
(22:03):
solve stigma for that populationuntil I help to solve stigma for
all people who use drugs.
Like, and that's wrapped up inthat criminalization.
Like, I can't just be like, oh,if you are at the end of the
spectrum substance use disorder,in treatment, I need to be
helped, like working on that.
I need, you know, you reallyneed to think about the whole
thing to be actually helpful,
Ben Levenson (22:22):
But that's part of the fantasy that we live in as
Americans.
Right?
Talk about baked in stigma.
I mean, it's, it's almost bakedin violence, really.
It's, it's, it's like systematicviolence to, you know, to do
what we do to active drug users,which is we starve them out.
We won't engage with you.
We systematically orsystemically believe that people
(22:44):
who use drugs should facemaximum risk, unmitigated harm
and, and deep and lastingconsequences, because we
mistakenly believe that thosethings precipitate recovery.
When you take away my kids, andmy car and insurance, and my
ability to make money, you giveme a felony, you lock me up.
(23:05):
And my kid, I missed years of mykids' life.
The research has never suggestedanything different.
What we know is that thatprecipitates, chaotic drug use.
Which is fine with the system.
Cause they'll just incarcerateyou again.
And so, yeah, I mean, it's thistrillion and a half dollar, it's
one of the most violent policiesthat we've had in I think the
(23:25):
moderate, modern era.
I don't know domestically, ifthere are policies that are more
brutal to our fellow Americansthan that.
Valerie Earnshaw (23:34):
Yeah.
It's traumatizing with a big T.
Carly Hill (23:36):
Yeah.
Valerie Earnshaw (23:37):
Then I know you do a lot of work with folks
internationally and some of themdo this better, and some of them
do it worse.
I do a lot of work in SoutheastAsia.
So like in Indonesia, Malaysia,uh, you know, familiar with what
happens in the Philippines withfolks who use drugs.
It's not great.
Could you fill us in a littlebit on your perspectives of what
(23:57):
other countries do better, ormaybe what other countries do
worse in comparison to the USwith these international
collaborations that you have?
Ben Levenson (24:05):
You know, I was raised in this abstinence
centered ethos.
Most of us have been, right?
And I got to this place where Iwas tired of like this
monolithic case-mix that I wastreating with, like not even
very much diagnostic variationin the case mix.
So we decided to take it, takesome money off the top line of
the hospitals.
(24:26):
And it was like, look, let's gofind a population that's not
like what we're treating.
And let's not walk in asAmericans with money who know it
all, let's walk in with moneyand a deep curiosity and a
willingness to be taught and tolearn.
And that began this journey forme, this ideological journey,
you know, now is centered inharm reduction, which includes
(24:48):
abstinence, by the way.
I mean, Abstinence is...
it's an extreme form of harmreduction, but yeah, I mean, I
ended up in environments where,like you mentioned in, in, in
Malaysia, but for me, it was inthe middle east.
These were, you know, strict,uh, Sunni, Islamic cultural
containers where homosexualityand drug use are really, really
dangerous for people who, who dothat.
(25:10):
Helping build systems that areresponsive to the cultural
conditions, or at least mindfulof the cultural conditions and
responsive to the patients wassome of the, of my favorite
work.
But that precipitated thisjourney into the Balkans.
And then, and then westwestward, where I started to
learn about how the rest of theworld cares for drug using
(25:30):
populations.
And it broke my brain and myheart too actually.
Um, I'm coming back and I'm liketelling my mom, like these are
high level peers at the, all thebrand name, treatment programs
that we all know.
And I'm like,"Hey, do you knowthat the rest of the world
engages with people who areactively using drugs?
(25:50):
You know, they don't conditioncare on an agreement to live
this moral version of life thatwe think we're going to force
down your throat?" What they doreally well is there are
systems, particularly in WesternEurope, that I admire a lot
because they're centered onperson empowerment.
(26:10):
The same really laws that wehave here and rights that we
have here that we just, we justtrample them.
But I'm talking about thingslike, like agency, and rights of
self-determination, and evenrights to kind of informed
consent, which they honor.
I'll tell you a story.
There's a fantastic program thattogether we have partnered with
(26:30):
them and others on this thingcalled the Rome Consensus.
And it's a humanitarian drugpolicy framework.
You know, that's international,it's this core kind of framework
of drug policy that can beacculturated, you know, locally
to reflect the populations thatit's affecting.
And, and we're really proud ofthat work.
Uh, I think that it, it, itspeaks about how we see the
(26:52):
world right now, and I encouragefolks to go take a look at it.
But in that process, I wasworking on a, uh, volunteering
on a, on a mobile kind ofsyringe service van in rome.
And there was this guy who keptcoming, you know, I see him
every day on the, on the vanright.
Coming to, and he pulls up inhis Mercedes and he gets out,
(27:13):
takes the suit jacket off.
Right.
And he comes over to the van andhe chucks some old syringes.
He prepares an injection, doesone and grabs a plate of
spaghetti that we're making inthe truck, does some
backslapping, you know, with,with other people who were there
from totally different walks.
And, and I, and I, I said tothis guy, I'm like,"what are you
(27:35):
going to do today?" And he said,"well, I'm going to do what I do
every day." He goes,"I'm goingto go back to work.
And then, uh, I'm coaching mydaughter's soccer practice
tonight.
My son has something in thetheater.
My wife, is going to see that.
We'll have dinner and prayer.
And then I will wash, rinse andrepeat." He said, and I go,"you
(28:01):
like your life, don't you?" Andhe goes,"I love my life.
This is exactly the life I wantto live.
It doesn't mean I don't needsupport.
It doesn't mean that I, youknow, I can't be safer or be
healthier.
I want those things just likeeverybody else, but no, I love
my life the way it is rightnow." And being able to meet him
(28:24):
in that space and validate thatand connect-up with that is so
fundamental and so important interms of how we begin to care
for domestic populations who usedrugs also.
Look, everybody uses drugs.
The question is, what drugs doyou use?
Are they ones that white peoplesay you should and pharmacists,
(28:46):
you shouldn't, or are theyapproved or unapproved, right.
Which is not again, rooted inany, anything meaningful, other
than bias and crappy policy.
Valerie Earnshaw (28:55):
All right.
Observation, number one, Ben isa gifted storyteller, and I
wanted to drill down into whythat's so important for just a
moment.
And from my perspective is thatone of our ways that we can
reduce stigma is throughstorytelling.
And so I know that implicitly,you know, that that's what
you're doing when you're doingthis is that you're humanizing
folks.
(29:15):
You're helping people doperspective taking and empathy,
but like just what an amazingthing to do in your day to day
to like, come on these podcasts,or, you know, before you got on
with us, you're talking to aSenator-- Which I'd love to come
back to-- but, you know, just tolike bring these stories and
share them and then be such agifted storyteller at it.
That's great.
But putting that, you know, justputting that observation aside,
(29:38):
I just had to say it out loud.
The thing I'm really noticinghere and in a fundamental
difference, and I know that yousaid this, between like the US
and these other places that arereally getting right is the
fundamental right toself-determine.
To decide what a good, what agood life for me is.
And also to say that that caninclude drug use, can include
(30:01):
substance use.
One of the things I'm wonderingabout connecting to earlier in
our conversation; do you thinkthat like the narrative around
saying that substance usedisorders are like a brain
disease is getting in our way?
Like if we call it a braindisease, do we think that that
makes it harder to believe thatpeople can self-determine that
(30:25):
they can be trusted to decidewhat's best for them?
Ben Levenson (30:29):
Great question.
How that manifests in certainquarters in treatment today.
What it looks like is, you know,we have a patient who comes in
first of all, but there's apredicate that says that if you
have substance use disorder, youcan not make meaningful and
effective choices about yourhealth and your safety.
(30:49):
Right.
Right.
That's not true.
It's not legal, like a personwith SUD, their rights to agency
and informed consent are notreduced at all because they have
substance use disorder.
Lawfully.
It's not-- there, there are someinterventions, legal
interventions that reduceagency, but not generally.
Right.
(31:09):
But we act like that's the casewith everybody.
So we're treating them from thisframe, like they've been
committed, like they have hadtheir agency limited.
And so how that, how does thatshow up in treatment systems?
It's like patient comes in andsays,"man, I, I'm not staying
here longer than, you know,three weeks.
I'm not staying here a month.
I'll be here three weeks".
(31:30):
And they're like,"buddy, youneed to be here six weeks for
that.
We've got to tell you what yourlength of stay is.
You know?
And basically we're going totreatment plan in ways that are
completely opposite of whateveryou say you think is right for
you, right?
Your best thinking got you here.
You're going to let thetreatment team think for you."
(31:50):
Right?
Look, let's use buprenorphine asan example for, uh, Sarah
Wakemans' work out of massgeneral, in the comparative
study that I encourage everybodyto go look at, they looked at
45,000 opioid use disorderedAmericans and they controlled
for everything basically.
They were doing an outcome, acomparison of treatment
(32:11):
pathways, based on clinicaloutcomes.
Okay.
Including morbidity andmortality and other health
centered outcomes.
The treatment to be candid,doesn't even seek treatment,
seeks one outcome it'sabstinence.
And that's it.
They don't really treat tohealth, but in any event, her
work showed that buprenorphinehas a 72% reduction in
(32:34):
likelihood of overdose at monththree and like a 59% at month
12.
Okay.
And it, I mean, no otherintervention that they looked
at, not counseling, not a, uh,not residential treatment, none
of those had any measurableefficacy during the fentanyl
(32:54):
contaminated drug supply crisis,because that risk paints all of
the data.
The old ways we engage, youknow, they're not responsive to
the changed conditions.
And so what could happen intreatment, which is very common,
is a significant section oftreatment, they don't believe
that buprenorphine is sober,right?
Carly Hill (33:17):
yup.
Ben Levenson (33:17):
And here's how that shows up.
So patient walks in with opioiduse disorder.
You know w hat, let me tell youwhat they're not doing.
So thousands of patients indetox units all over the country
this morning w ere met by anurse or someone who came in and
said,"listen, it's the end ofyour buprenorphine taper.
And you knew that was today.
You don't worry.
It's going to be a difficultcouple of days.
(33:39):
We have some Ativan, someclonidine for you, and we're
going to get you through this."Right.
But what are they not sayingwhat they're not saying, they're
not coming in and going,"listen,you are about to proceed o n a
far more lethal pathwayrecovery.
The medicine that we're going totake you off of today, simply
taking you off of this medicine,no matter what else you do
(34:01):
results in a 600% greaterlikelihood of overdose in the
proceeding 12 months.
And we just need you to signhere t hat we've warned you.
Right?
And we've counseled you andyou're still s hooting".
That's not happening.
They're not saying anything tothem.
Right?
It's-- so i magineoncologically, if you're stage
three, you go in to MD Andersonor wherever Mayo or wherever.
(34:26):
Imagine if the prescriber hadpersonal bias against the one
chemo that s ave you a life.
R ight.
And doesn't tell you about that.
Look, that's trampeling agency.
It goes beyond malpractice.
Look, right now, there are attorneys general who believe
(34:49):
that that crap ventures intocriminality.
And I believe it does too.
It's those kinds of scenariosthat people need to think about
and go, oh my gosh, like there'sno standardization.
This is crazy.
It's crazy.
Valerie Earnshaw (35:02):
Well, it's definitely valuing somebody's
idea of abstinence over keepingpeople alive.
Right?
Like, that's really interestingto me, like moral enforcement is
more important than keepingpeople alive.
So one of the things I've beenwondering is thinking about your
work, Ben is like, what's theproblem?
(35:23):
How can scientists help better?
So like, you know, some of thetimes I oversimplify it and I
think like, does science need tocommunicate what they have
better?
Or do we need to do morescience?
So what you just described therewas: the science is there.
Like we know that thesemedications are good, that they
keep people alive, that theyprevent overdoses, but people
(35:44):
aren't using them.
So that seems to be part of theproblem.
I also think that, you know, wecan dig into like what the gaps
are in science, but what areyour thoughts on this
disconnect?
Ben Levenson (35:54):
There's always been this gigantic gap between
the bench and the trench when itcomes to substance use disorder
treatment.
And one of the reasons for thatis we talked a little bit
earlier about kind of therunaway ideological train, that
the orphanage of, of treatment.
One of the ways that I want tokind of talk about this for
science for scientists is: treatment married a therapy. (36:15):
undefined
We married a therapy, that's 12step centered, that we have
profound personal attachment to.
"saved my life.
I got the, I have the elixir.
You just have to do it the way Idid it." And you know, we don't
(36:37):
marry therapies in medicine.
In fact, we stand before theriver of science and as evidence
flows by, we pick up andleverage that evidence and those
tools and those therapies forour patients.
And nobody is butt hurt aboutnot using penicillin anymore for
(36:58):
streptococcus.
It's like, no, there's a better,there's a better-- amoxicillin
is better, right?
Nobody's like, oh, well, youknow, you, you know,"you have
stage three ovarian cancer.
And when I got treated in theeighties, this is what I--",
that's just not how it works.
Right.
So if this is weird attachment,at the expense of patient health
of public health, certainlydisposes it with science.
(37:21):
And it's like, what else do Ineed to know?
I mean, I'm a master, I've gotmy doctorate in recovery.
Like I don't need to learnanything else.
So there is this huge departurebetween treatment and, and the
research.
And it's terrifying.
It's maybe one of the kindadirtiest little secrets in
American healthcare is thatthere is no standardization in
(37:43):
treatment.
The research is not valued.
Scientists would do well tosupport, you know, ways that
motivate the field to valueresearch.
And there's some ways includinginfluencing some of the purchase
models that can do that withvalue-based and risk-shared, uh,
arrangements.
(38:03):
Put their fiscal well- being,align that with patient health
outcomes.
You wanna see an ideologicaldivorce overnight?
This is the only thing they caremore about than their ideology,
it's their money.
So value-based purchasing hasthe ability to revolutionize the
way we care for people who usedrugs.
(38:24):
Because the next morning, whenwe do that, when we attach his
or her margins to patient healthoutcomes, the next morning,
they're walking into the officegoing,"what does the research
say we need to do today to keepthis gal out of the emergency
department in month seven."Right?
And it's like,"well thebuprenorphine switch you got to
(38:45):
do".
--"Oh, great.
Well, we're going to supportbuprenorphine then" right?
There, there's some importantopportunities for research right
now in the space.
Valerie Earnshaw (38:53):
Well, It also just strikes me that, you know,
people with lived experiencehave tremendous expertise for
these folks who say, like I havea PhD in rehab.
Like it strikes me that one ofthe problems is also when we
have research happening thatdoesn't involve people with
(39:13):
lived experience, like, thatprevents the uptake as well.
So inviting folks from thesecommunities to work on these
research projects might also,you know, be helpful.
We think about that a lot in,you know, just in the HIV field
and things like that.
Ben Levenson (39:31):
So in terms of areas of focus, I very much
agree.
I, I think again, we talkedabout kind of the norms of
focusing on populations that nolonger use drugs, but the most
meaningful research and theresearch that I'm using at the
federal level and at all levelsis looking not at that, but
rather at this much broadercohort of Americans who use
(39:53):
drugs, right?
And it's, it's about sittingdown in the reality, right?
The people use drugs.
And I think that what we want todo, and I think what harm
reduction is all, I mean is alot about, is, you know, helping
people live the safest,healthiest version of the life
that they choose for themselvestoday based on the science,
(40:15):
based on an unbiasedpresentation of the data.
Right?
And so data that, and researchthat, that starts to break away
these old ideas, that if you usedrugs on the weekend, you can't,
you know, we're not going toresearch that because the guy's
health is, you know, whatevercatastrophic or something though
, it's exactly what we need tobe researching, because it will
(40:35):
inform, you know, how we carefor people.
As we normalize, as drug usebecomes more normalized in the
United States.
And as you know, the clinicalarchitectures are kind of
reformed in ways to interfacewith, and care for those people.
Valerie Earnshaw (40:51):
To me, it really speaks to, for
scientists, like, how do youthink about your outcomes?
You know, the thing that you'repredicting, which is usually
like, this is good, or this isbad.
And, you know, in this field,it's almost always like
substance use.
Substance use yes.
Substance use no.
So like, what's reallyinteresting about this
conversation is like, usually ifI have an intervention, I want
(41:14):
to show that intervention is, isworking well, I would need to
show that that intervention isleading to less people falling
into the substance UCS category,right?
Like more people who areabstinent.
And this conversation thoughsuggests that like, I may not
need that outcome at all, or Ineed to like, think about like
quality of life, lessdepression, better financial
(41:38):
wellbeing.
Like, I need to really extendwhat I'm thinking about, and
then-- which I'm all for doinglike, as a scientist right?
But then, you know, my challengis, when I go to get that
funded, the National Instituteof Drug Abuse me, they care
about the yes versus no,usually, or at least the peer
reviewers do.
Carly and I are working on thisintervention that's focused on
(42:00):
disclosure, helping peopledisclose that they're in
recovery.
And our main outcomes that we'rereally fired up about are like,
when, if people go through ourlittle intervention, when they
do disclose, do they get abetter response, like, than
people who don't, which we thinkmatters a lot.
Like when you tell somebody, dothey give you a hug or do they
(42:21):
like run away from you or yellat you or something like that?
Carly Hill (42:24):
They kick you out.
Valerie Earnshaw (42:26):
Yeah.
We think that's a big deal, butwe have to like to prove that it
matters.
We need to show that people whouse our tool engage in less
substance use eventually, whichis like really weird,
Ben Levenson (42:39):
Right.
It is weird.
And it's ideology predicated onprohibition and in
criminalization and this binary,you know, kind of perspective on
drug users, when we don't dothat with really anybody else,
it's important for researchersto recognize that the drug-using
population is really saying,look,"nothing about us, without
(43:00):
us".
Right.
That, that, you know, it's themwho get to kind of inform what
good outcomes are.
There was a study that dropped acouple of weeks ago that
actually looked at drug users,mainly people in recovery, which
is, which is not what I'm askingthem to do.
But anyway, and, and asked themlike,"what are, what are good
outcomes for you, right?
(43:20):
Like, what do you think is agood outcome?" And, and it
wasn't like,"that I stay soberforever." It's not what they
said.
You know, they're looking forquality of life.
They're looking for improvementsto, you know, to their domains
of health and, you know, a nd,and family and relationships and
things t hat are important tothem.
But we don't design care forthose outcomes.
Valerie Earnshaw (43:44):
Yeah.
Ben Levenson (43:44):
We design care for abstinence and that's it.
Right?
And so that patient I mentionedearlier, who is injecting heroin
every day and wants to stop.
We can induce him onbuprenorphine, get the needle
out of his arm.
He's no longer at risk forhepatitis C.
He's no longer at risk for HIV.
H e's no longer at risk foroverdose, right.
(44:05):
Medicine.
And we can go to work on,"Hey,let's look at evidence-based
interventions for moderationaround the alcohol, the
continued alcohol use.
We'll prescribe your b enzo.
We'll write it for you." Right.
"And let's get you try to getyou to a therapeutic level with
that".
So medicine looks at this caseand they're like,"Holy crap.
That's amazing.
How did you guys do, how did youget that outcome?" Right.
(44:27):
Treatment looks at that exactsame case and says,"he's a
treatment failure." Right.
And they'll terminatebuprenorphine.
They will knowingly send himback to a fentanyl contaminated
heroin supply because he smokeda joint.
Carly Hill (44:44):
Y ep.
Ben Levenson (44:45):
It's indefensible.
Right.
And it's happening every day inAmerica.
So we have to start thinking andvaluing any positive change.
That's the goal and change thatis, that is patient driven.
That's person driven, right.
L et's be generous and say outof the 3 million that we talked
about being treated earlier,let's be generous and say five,
(45:06):
let's say half a million of themmaintain perfect abstinence.
And so what, what's the benefit.
So we get all of the healthoutcomes associated with half a
million Americans not usingdrugs anymore.
O kay.
It's very small.
What if we could seek and obtaina 15% improvement to health and
(45:29):
safety across 80 or 90 millionAmericans?
That's where the meat is.
And I just want researchers toget that, like, stop obsessing
about abstinence, r ight?
It's about the big gains, right.
That are there to be had whichare improvements to, to health
and safety of drug users.
I d on't, I keep saying that,but it's, that's what it is.
(45:49):
And getting off of this trainthat says,"oh, t hey've g ot t o
be sober." No, they don't.
They don't have to be sober.
Look, drug use is not predictiveof catastrophic health and
abstinence is not predictive ofwhole health.
T hat's just not how it works.
Valerie Earnshaw (46:04):
Yeah.
I mean, just circling back toyour other, you know, your point
you made earlier, like"it's druguse in context".
So it might be it's"drug use"when the civil supply is
corrupted or it's"drug use" whenthere are certain
criminalization policies inplace, or like it's these social
structural things that arehappening that are harmful.
Before we let you go, could-- we talked about your trajectory
(46:28):
in Origins, and I feel likeit's, to me, it's pretty clear
where in this narrative, you,you shift over to the Levenson
foundation, but could you justshare with us with the
listeners, like, what is theLevenson Foundation?
And we'll post links to that andthe R ome Consensus like a n
episode notes cause w e'd lovefor people to read that I found
it to be like, fantastic.
So would you just share a littlebit about that before we let you
(46:50):
go?
Ben Levenson (46:50):
I will.
And I, and I want to share abouta, another coalition that we're
involved with the foundation issupporting the national campaign
for harm reduction funding,which is comprised of some
fantastic advocates and groups,including, you know, the Drug
Users Union who have a voice inthat coalition, which is great.
It's the first time Congress hasever used the words"harm
(47:12):
reduction" in this, you know,$1.9 trillion plan that passed,
$30 million was includedspecifically for harm reduction.
It was the first time that OwenDCP, even, which is the white
house's office on drug policy.
The first time they've even usedthe words harm reduction.
And so there's a lot of energygoing into how do we get it to
the, to the end user, but that'sreally important.
(47:34):
So I want to make sure we get tolead into that.
Also, the Foundation is justreally focused on, you know,
some harm reductionphilanthropy.
And so we're, we're funding harmreduction agencies who may have
fiscal challenges.
And I mean, it's like they'regiving out bleach kits, like,
why are you giving out bleachkits?
Because they don't, they don'thave any money to buy syringes,
(47:55):
right?
Like they're doing everythingthey can.
It's how harm reduction has beentreated.
That community is treated soterribly by us from a civil
society and a governmentalperspective, you know, working
to just help normalize andvalidate and scale harm
reduction for populations thatuse drugs.
That's really the focus.
(48:15):
And we were working abroad alot, but when the contaminated
drug supply became kind ofapparent, we pivoted almost
everything back home, that's thefoundation.
And then I'm focused on, on thefor-profit side on systems of
care that are extremelydisruptive to treatment systems
that are designed recontainerizing treatment
(48:36):
altogether inside of primarymedicine, where we build an
instance of care, that's able tolongitudinally, engage with a
drug using patient and thefamilies and journey with them,
right, as they go through theirchoices and their experiences
with their drug use help seekand celebrate incremental
(48:58):
improvements on pathways thatthey choose for themselves based
on the evidence.
But even more importantly tothat, than that to destinations
that they're choosing forthemselves, including partially
abstinent, fractionally,abstinent, maybe even substance
specific safety, like thepatient I mentioned earlier.
(49:18):
This is a system that would say,alright.
We'll help you.
We'll help you write it yet.
Come on.
You know, we'll write your benzo, like let's, let's let's
journey.
Right.
And so excited about that asthat kind of develops all
sensitive information back toyou guys.
Maybe we can do something onthat.
Carly Hill (49:34):
Please do.
Ben Levenson (49:36):
It'll be fun.
Valerie Earnshaw (49:37):
Ben, thank you so much for coming on the show.
Thanks for what you're doing.
Thank you for giving mepersonally, like so much good
food for thought today.
Like this is, this is exactlywhy I like to do this podcast
because I'm going to be thinkingabout this all week.
This is great.
And you know, this is our firsttime chatting and I'm really
hoping that I can force friendyou, force colleague you, stay
(49:59):
in touch and try to support someof the great work that you're
doing.
Ben Levenson (50:02):
I feel super fortunate to get to visit with,
with both of you and youraudience.
That's growing as we speak.
And I'm just real fond of thework that you're doing here.
It's really important.
So thanks for showing up anddoing that, appreciate it a lot.
Valerie Earnshaw (50:18):
Thanks to the Stigma and Health Inequities Lab
at the University of Delawarefor their help at the podcast,
including Sarah Lopez, MollyMarine, James Wallace, and
Ashley Roberts,
Carly Hill (50:27):
Thanks to city girl for the music as always be sure
to check us out on Instagram@sexdrugsscience, and stay up to
date on new episodes by clickingsubscribe.
Valerie Earnshaw (50:37):
Thanks to all of you for listening.
(51:13):
[inaudible].
I'm Valerie Earnshaw,
Carly Hill (00:13):
I'm Carly hill,
Valerie Earnshaw (00:14):
and this is Sex, Drugs, and Science.
Carly Hill (00:17):
Today's conversation is with Ben Levenson.
Ben founded Origins BehavioralCare in 2009, a nd Origins
offers comprehensive addiction,recovery services for patients
and their families.
In 2017, Ben founded theLevenson Foundation, which aims
to reduce human suffering andpromote w ellbeing.
Valerie Earnshaw (00:35):
We're grateful to Ben for joining us to
continue thinking about how sexand drugs science is used, and
also not used in the real world.
And also to continue thinkingabout what it is that we just
need more science about or whatwe need to continue researching.
Ben is a tremendous advocate forharm reduction.
And so we really focused ourconversation there.
Harm reduction, includesstrategies and ideas aimed at
(00:57):
reducing negative consequencesassociated with drug use.
So in some of our otherepisodes, we've talked about
Naloxone, which is a medicationthat reverses overdoses from
opioids, medications for opioiduse disorders, things like
methadone and buprenorphine,syringe exchange, and overdose
prevention sites.
So all of these are examples ofharm reduction that we've been
(01:18):
talking about.
So we hope that you enjoy thisconversation with Ben Levenson.
Ben Levenson, welcome to thepodcast.
Carly Hill (01:31):
Thanks for joining us!
Ben Levenson (01:32):
I appreciate getting to spend time with you
guys.
I've been super excited to, uh,to chat with you and, you know,
thinking about the audience thatyou guys have to build.
It's this is a really specialopportunity.
So thanks for having me.
Carly Hill (01:43):
Of course, It's our pleasure.
Valerie Earnshaw (01:44):
Yeah.
You couldn't be more excitedthan us.
We've spent a couple of dayslike digging into your
background, listening to otherpodcasts and things that you've
done.
And so we're 15 out of 10excited to talk to you like.
Ben Levenson (01:56):
My condolences if you've been background checking
me.
Valerie Earnshaw (02:00):
No, no, it's been fun.
So could you start off, Ben, bytelling us just a little bit
about yourself?
Ben Levenson (02:06):
Sure, sure.
I'm going to share a little bitfrom a personal frame and also
professionally.
Substance use disorder and, andkind of chaotic drug use kind of
permeated my familygenerationally on the, on the
maternal side, my mom lost herbrother to an overdose in the
nineties and, uh, she's 30 yearsin recovery now and I lost my
(02:30):
brother the week the towers camedown and I looked in the city
and, and so it was a real doublewhammy.
And, you know, you would thinkthat, oh, after that you would
just total, like I'm not-- butmy drug use actually increased.
And so I had my own, you know,my own journey with kind of
(02:51):
problematic drug use.
And I think most of us who endup here, like in the substance
use disorder or kind of dualdiagnosis space typically have
some personal connection orinvestment, you know, I went to
treatment and I was really avictim of this like acute
episodic intervention on what weall know is a kind of a chronic
(03:12):
process.
Right.
And just wasn't sufficient.
And so, yeah, I mean, I, Idecided to, to build, to iterate
and innovate on treatment and,and that's what brought me into
the field.
It Was kind of like,"Hey, look,we can do this better".
That was 20 years ago.
And here we are.
Thanks for asking about mybackground.
Valerie Earnshaw (03:31):
Yeah.
So you started OriginsBehavioral Healthcare.
I mean, this is a little bitrelated to the first group of
things I went in to talk to youabout, which is, what do
traditional models of care looklike?
And then what, what do placesmaybe like Origins do a little
bit differently?
So one of the things that youjust said was that, you know,
(03:52):
treating substance use disorder,treating problematic substance
use, like in an acute short-termway, as opposed to a chronic
illness, that seems to be onepart of it.
Are there other pieces or?
Ben Levenson (04:04):
There's reasonable data that, that suggests, you
know, maybe 80 million Americanswill use an illicit substance
one or more times in 2021, if werely on SAMHSA's data-- and we
tend to act like we do-- theysay there are 20 call it 24
million of those drug users,have substance use disorder and
(04:27):
kind of writ large with thetreatment apparatus, both public
and private combined, onlyinterfaces like formally with,
with 3 million people annually.
You know, the question used tobe,"well, how do we get the
other 21 million to, to, youknow, to seek care?" Like, how
do we motivate that?
Then what's the breakdown on, onwhy they're not, you know,
(04:49):
they're not seeking help.
Is it resource related?
Is it, you know, what are thebarriers?
But the world has changed.
It's not just the 24 million whoare, you know, kind of eligible
for support.
It's actually now the entirecohort because we have a
profoundly contaminated,irreversibly contaminated drug
(05:11):
supply.
And every one of them are usingfrom the same trough.
It used to be the 66 millionthat, what do they need support
for?
I mean, they're, they're lower,no problem drug drug users.
But they do.
They, they need helpunderstanding that the supply is
contaminated.
And it's fundamentally, youknow, care that's centered in
harm reduction sciences that,you know, helps them de-risk
(05:34):
that drug use.
Valerie Earnshaw (05:35):
I'm really glad I asked because that's not
necessarily what I was thinking.
When I asked that question, Iwas thinking, how do we better
serve the 20 million?
That is really interesting tothink like, no, actually we need
to be thinking about the full 80million and in Delaware, which
is where Carly and I are, wethink about this contaminated
(05:57):
supply issue a lot because we've...
we're the state with the secondhighest rates of opioid overdose
deaths.
And those rates really startedto climb in 2017 when fentanyl
gets in the system.
And so it really does seem likeit's, yeah, it's a contaminated
supply issue.
So is that, is that what you'respeaking to in terms of the
(06:18):
contaminated supply or are thereother other pieces to that that
I might be missing?
Ben Levenson (06:23):
So there are other adulterants that we're seeing in
the drug supply.
So it's not just fentanyl orfentanyl analogs there's
Xylazine is, is showing up,which is kind of a, a veterinary
drug.
So yeah, I mean, I think whenyou asked about kinda treatment,
you know, the systems that westill have and the systems that
I designed domestically, um, youknow, were rooted in this ethos,
(06:47):
right?
That says all drug use ispathological, you can be down at
the bar drinking all afternoon,and you're just a swell gal, but
if you use cocaine once it'spathological, right?
The treatment systems that webuilt over the last kind of 40
or 50 years are a reflection ofhow we think about people who
(07:08):
use drugs, drugs, themselves,and how they're used.
And so, I think that the modelsthat are innovative, are going
to be responsive to the kind ofthe entire cohort who have
really varied needs.
And a lot of those needs kind ofviolate our fundamental beliefs
about drug use.
Valerie Earnshaw (07:27):
Let's dig into that.
So what are some of thesefundamental beliefs about drug
use.
A part of it, from what you'resaying?
Sounds like, you know, any druguse is pathological.
Right?
Ben Levenson (07:38):
Yeah.
I mean, some of these beliefsare things like, certainly that,
but also this idea that if aperson uses drugs, there's
really only, kind of, two statesthey're allowed to exist in.
Either you're abstinent andeverything is grand, or you're
using, you're in chaotic use andit's jails, institutions, and
(07:58):
death.
Right.
And that's just not true.
That's not at all supported bythe research.
The bell curve lives through,you know,"in the gray" and
actually very few drug userslive on either of those polls.
Valerie Earnshaw (08:10):
Right.
And so"A" that's like a reallylovely description of it.
That's really great to thinkabout.
And there's two things poppinginto my mind, you know, when I'm
listening to you.
So one is, I don't think that'show it works for any chronic
illness, any chronic illness wewould ever study has like a
continuum of outcomes.
You know, so I'm thinking aboutthis right now because I live
(08:32):
with a chronic illness.
There are times when I'm likereally very sick, clearly having
a flare up.
There are times when I'm likereally clearly well, but right
now I'm like definitely liketeetering.
So that would be terrible if Ihad to wait until everything was
really out of control with mychronic illness until I had to
like go interact with my doctor,you know, like I'm probably the
(08:55):
80 million zone, you know, orthe 60 million zone right now
who, you know, or the equivalentfor like these substance use
stats.
And I'm able to be working witha doctor and like figuring that
out.
And how do we keep me out oflike the kind of like extreme
end of the spectrum.
That's one thing that I'mthinking about.
It just, it maps on to everyother chronic disease, you know,
(09:15):
contexts that we think about.
And then the other is just thatthe way, you know,
scientifically that we likemeasure our outcomes and like,
it, it all does guide us towardsthinking about those buckets.
Like, you know, are you in likethis very disordered use
category or not?
Right.
And so if we don't use, I mean,we call them"continuous
(09:38):
outcomes", you know, when we'relike analyzing our data, like if
we don't look at that full, like1 to 10 scale, if we're only
thinking about 10 versus one tonine, then yeah.
You're going to miss all of thatnuance.
So that's a really interestingobservation for me.
Ben Levenson (09:55):
It's really interesting kind of the
departure, right?
From, from even just, justfundamental medical logic and,
and right?
And scientific method that thiskind of runaway medical
specialty has been allowed todo.
And I mean, and I, and I getwhy, like you go back in time, I
mean, you know, medicine didn'thave efficacious therapies for
(10:19):
alcohol use disorder or a drugsrelated substance use disorder,
but these"woowoo" people believethey had, you know, an answer.
And so I think medicine waslike, yeah, just throw them over
the wall.
"You go, go do your voodoo.
And when they need real medicalcare, bring them back to me".
And so it was orphaned, youknow, addiction treatment and
medicine became orphaned.
(10:41):
And in, in that kind of orphanedstate, they never got, they just
didn't get some of thescientific norms, you know, some
of the logic and decision treesthat we use in medicine.
And candidly, I mean, some ofthe patient kind of rights were
and are trampled pretty heavilytoday.
And, and, and so, yeah, it's,it's, you know, you can look
(11:03):
back in the history of medicine,look at Lobotomy, are there,
there are examples, right?
Where ideological kind ofcentered care in, got on a
runaway train and on a levelthat's what we've done with
treatment.
And, and, and that has to change
Valerie Earnshaw (11:18):
Making connections to the bottom is
really interesting.
The other thing that is, I'mmaking connections with in my
mind is, so with the history of,you know, for example, like
black women in America, or womenliving with mental illness in
America, like there was a longperiod and it probably, you know
, continues today inincarcerated settings where
(11:39):
women were just, you know, givenhysterectomies.
Like the decision to take awaylike the right to have a child
it's like taken away from thembecause they were, it was
decided that they weren't ableto make that decision.
Carly Hill (11:51):
you're too hysterical.
Valerie Earnshaw (11:53):
Your too hysterical! That history sounds
similar to me just in terms oflike, how do we treat people
over time?
How much do we, like value theirlives?
How much do we invest infiguring out ways to keep them
well?
And it seems like an evolutionthat's continuing.
Ben Levenson (12:16):
I mean, you know, addiction is it's, it's
anomalous addiction treatment isit's just anomalous in medicine.
And, you know, it's one of theonly kind of processes what--
and let's say, I mean, it's, we,-- we conducted this campaign as
addiction professionals thatsaid"you will call it a
disease".
Right.
Valerie Earnshaw (12:32):
Yes.
Ben Levenson (12:32):
And if you don't we'll attack you.
Right.
And so we're down this, this,this train.
Okay.
So fine.
Okay.
Let's just say we'll, we'llstipulate, it's a chronic,
progressive deadly disease.
Okay.
So then why on the other hand,do we require like patients to
really put their chief symptomdrug use-- Right-- into perfect,
(12:57):
immediate and sustainedremission in order to initiate
care?
It's completely shocking.
Right.
And so I say that because whenyou were talking, you reminded
me that, we fight forincremental improvements to
patient health and safety everyday in medicine.
And if we can get a half a pointimprovement, right?
(13:20):
Like that's amazing.
But with people who use drugs,you have must either be perfect
and perfect today, or-- right--We'll discharge you from care
and blame you, you know, for ourinadequate capabilities, it's
shocking.
Like fundamentally, when youthink about this and the rest of
(13:41):
the world does this differently,but here we don't value
incremental improvements.
You know, a case example is likea patient who comes in and is
injecting heroin 30 days a monthand says,"I'm overdosing once a
month.
And I have a one-year-old and mywife and I have an-- our first
anniversary is coming up and I'mscared and I'm scared I'm going
to die, but I drink and I usecannabis every day, every other
(14:07):
day.
And I shot 14 people for thiscrappy country when I was in
Afghanistan for you.
And yeah, I overeat my benzos.
Okay.
But I'm not stopping takingbenzos for my PTS today.
My wife and I, we, we, we get,you know, we get a stimulant two
(14:28):
to three times a year, some,some Molly or, or whatever, and
we get the best hotel room wecan afford, with great sex.
And the connection that we buildthose nights are really vital to
my relationship.
I'm not stopping doing that.
Will you help me?" Right.
And the answer right now is"no"
Carly Hill (14:49):
No.
Ben Levenson (14:50):
"We can take your money.
So you can come in andparticipate in our fantasy about
your best life.
Right.
And so you could come in andmasquerade that you're not going
to drink.
We're going to force you off thebenzos.
You can't take Bupe because wedon't think it's real recovery.
And look, when you get out andyou return to active use, by the
way-- you're a total treatmentfailure" and"go, go get finished
(15:13):
and let us know when your ass ison fire again." Right.
It's, it's, it's insane.
And it's not, that's not what wedo in medicine.
Valerie Earnshaw (15:21):
Can we talk for just a minute about-- well,
first off, what an excellentexample, like what an excellent
case study to show what thatcould look like.
Can we talk just for a momentabout this dominant, like
prohibition or abstinencenarrative and where we think
that comes from, does that, dowe think that that comes from AA
and, and how AA is so enmeshedin our treatment, like protocols
(15:44):
and such in the, in the US doyou think that's where it comes
from?
Or do you think it comes fromsomewhere else?
Ben Levenson (15:49):
So there's no question about the inmeshment
between 12 Step kind of beliefsystems and treatment.
And certainly I think that 12Steps do focus on abstinence,
and they do value abstinence asa primary outcome that they're
seeking.
Look, the prohibition, It's notabout the safety of people,
(16:11):
right?
Prohibition isn't about likedrug safety or keeping you safe.
In fact, we Scheduled drugsthat, I mean, that, that really
aren't that dangerous.
So it's not about drugdangerousness.
It's a lot about controllingpeople, particularly communities
that people think arethreatening or whatever.
And so, for example, prohibitionpredates Nixon and the Nixon
(16:36):
administration.
But we know from his senioradvisor who helped kind of
architect this, this modern drugwar they've even said, right.
"We knew we couldn't make itillegal to be African-American
or to be a hippie and a warprotester.
But what we can do is heavilycriminalize cannabis, right?
(16:56):
For the hippies and heroin, forthe African-Americans and
demonize that drug every nighton the evening news, and use
that to penetrate right there,their groups and their
leadership and their homes".
And he says, at the end,"did weknow we were lying about the
(17:17):
drugs?
Of course we did".
Right.
It's not about...
Valerie Earnshaw (17:23):
Right.
So one of the things that thismakes me think about is, you
know, stigma's totally pervasivein this, right?
Like it's super pervasive.
And there are folks who theorizearound why stigma exists.
Like, because if it's here, itmust serve some sort of function
for humans.
Right.
And so the two that ringrelevant to me right now is
(17:44):
that, racism is about keepingpeople down.
It's about oppression, right?
It's about maintaining the powerof white folks in society, over
others.
And then, uh, substance usestigma or drug stigma associate
with drug use is all aboutsocial control.
It's about, they call it keepingpeople in, like keep like
(18:05):
defining what the social normsare and then trying to keep
people inside of them.
And so these examples are likethis perfect intersection of
like, of very deliberately, likehow do we keep people down?
And then how do we likemanipulate, like kind of like
make this line in the sandaround, like who counts as a
(18:26):
good person in our society andwho doesn't?
You know, it's reallyinteresting.
We think a lot about structuralstigma and like policies that
have stigma baked into them.
And it's just, it's such a,like, perfect example of a
moment in time when people likecreated a policy to oppress and
to monitor, like what makespeople a good person versus a
(18:48):
bad person?
Ben Levenson (18:50):
There's no question about it.
And I think the data, you know,it makes it it's in
controvertible.
I mean, the disparate kind ofapplication of drug policy and
drug law, and the way that thateffects communities of color is,
I mean, it's profound.
I mean, you can just look at theincarceration rates for
non-violent drug use.
And, you know, we see that, youknow, it's almost like it's like
(19:11):
one to nine, in terms of ratios,between, you know, white people
and those incarcerated who arepeople of color, but we use
substances at the same rates andat the same levels.
If people want to say,"well,they use more drugs".
No, they don't, they don't usemore drugs.
Right.
You arrest them and white peopleget to go to treatment.
(19:31):
That's what you do.
It is, it's deeply broken and,you know, I mean, I think that
there's a call to like tear itto the ground.
I don't think that's how changeactually occurs.
It sounds great.
Right?
The system needs a completereinvention.
You know, I think the truthabout change, is that it's the
same thing about valuingincremental improvements in our
(19:51):
patients.
I think we are going to need toseek incremental improvements to
drug policy reform, but we're atthis very special moment.
There's no question about that.
And change is happening.
Valerie Earnshaw (20:01):
You know, I go around, I give these talks about
stigma to folks and they'realways like,"how do you change
stigma?
How can we, how can we do this?"Then I'm like, great question.
So, yeah, I'm always, I havethis spiel about how there's
like"many tools in the stigmatoolbox".
And I always like to say that,but you know, the thing I'm
always thinking about is like,as a woman standing up here,
(20:22):
like, we still have sexism, westill have racism.
Social change is slow.
Even right now, I would argue,we are in a period of rapid
social change around like LGBTQstigma and equality and human
rights.
And even that is too slow, youknow?
So yeah.
Ben Levenson (20:41):
Yeah.
I mean, I think for drug users--I mean, fundamentally right--
when we want to stigmatizesomething, we criminalize it.
I don't believe that any druguser will be free of the threat
of stigma until active drugusers are not stigmatized
either.
Right.
And we have this crazy view,like where, when we talk about
(21:02):
stigma and anti-stigma endeavorsin terms of drug users, it's
always about people in recovery.
It's always about,"oh, wait,well, but she's sober.
She's a good person now", as ifabstinence gives rise to being a
good person, you know.
I do think that thecriminalization of drug use,
which is not in and of itself acrime, and it's also something
(21:25):
we've been doing since timeimmemorial; altering our
consciousness.
You know, I don't think thatwe're going to get to where we
want to go without addressing,you know, the criminalization of
not just drugs, but of drugusers too.
Valerie Earnshaw (21:39):
I really appreciate you bringing that up
because I study, and Carly isinvolved in these studies, It's
like, we focus on people who arein treatment, who are on
medications for opioid usedisorders.
That's our population.
So when I'm thinking, when I'mstudying stigma, like that's the
group of folks that I am focusedon, but for me, this is like
really great food for thoughtthat, that I'm not going to
(22:03):
solve stigma for that populationuntil I help to solve stigma for
all people who use drugs.
Like, and that's wrapped up inthat criminalization.
Like, I can't just be like, oh,if you are at the end of the
spectrum substance use disorder,in treatment, I need to be
helped, like working on that.
I need, you know, you reallyneed to think about the whole
thing to be actually helpful,
Ben Levenson (22:22):
But that's part of the fantasy that we live in as
Americans.
Right?
Talk about baked in stigma.
I mean, it's, it's almost bakedin violence, really.
It's, it's, it's like systematicviolence to, you know, to do
what we do to active drug users,which is we starve them out.
We won't engage with you.
We systematically orsystemically believe that people
(22:44):
who use drugs should facemaximum risk, unmitigated harm
and, and deep and lastingconsequences, because we
mistakenly believe that thosethings precipitate recovery.
When you take away my kids, andmy car and insurance, and my
ability to make money, you giveme a felony, you lock me up.
(23:05):
And my kid, I missed years of mykids' life.
The research has never suggestedanything different.
What we know is that thatprecipitates, chaotic drug use.
Which is fine with the system.
Cause they'll just incarcerateyou again.
And so, yeah, I mean, it's thistrillion and a half dollar, it's
one of the most violent policiesthat we've had in I think the
(23:25):
moderate, modern era.
I don't know domestically, ifthere are policies that are more
brutal to our fellow Americansthan that.
Valerie Earnshaw (23:34):
Yeah.
It's traumatizing with a big T.
Carly Hill (23:36):
Yeah.
Valerie Earnshaw (23:37):
Then I know you do a lot of work with folks
internationally and some of themdo this better, and some of them
do it worse.
I do a lot of work in SoutheastAsia.
So like in Indonesia, Malaysia,uh, you know, familiar with what
happens in the Philippines withfolks who use drugs.
It's not great.
Could you fill us in a littlebit on your perspectives of what
(23:57):
other countries do better, ormaybe what other countries do
worse in comparison to the USwith these international
collaborations that you have?
Ben Levenson (24:05):
You know, I was raised in this abstinence
centered ethos.
Most of us have been, right?
And I got to this place where Iwas tired of like this
monolithic case-mix that I wastreating with, like not even
very much diagnostic variationin the case mix.
So we decided to take it, takesome money off the top line of
the hospitals.
(24:26):
And it was like, look, let's gofind a population that's not
like what we're treating.
And let's not walk in asAmericans with money who know it
all, let's walk in with moneyand a deep curiosity and a
willingness to be taught and tolearn.
And that began this journey forme, this ideological journey,
you know, now is centered inharm reduction, which includes
(24:48):
abstinence, by the way.
I mean, Abstinence is...
it's an extreme form of harmreduction, but yeah, I mean, I
ended up in environments where,like you mentioned in, in, in
Malaysia, but for me, it was inthe middle east.
These were, you know, strict,uh, Sunni, Islamic cultural
containers where homosexualityand drug use are really, really
dangerous for people who, who dothat.
(25:10):
Helping build systems that areresponsive to the cultural
conditions, or at least mindfulof the cultural conditions and
responsive to the patients wassome of the, of my favorite
work.
But that precipitated thisjourney into the Balkans.
And then, and then westwestward, where I started to
learn about how the rest of theworld cares for drug using
(25:30):
populations.
And it broke my brain and myheart too actually.
Um, I'm coming back and I'm liketelling my mom, like these are
high level peers at the, all thebrand name, treatment programs
that we all know.
And I'm like,"Hey, do you knowthat the rest of the world
engages with people who areactively using drugs?
(25:50):
You know, they don't conditioncare on an agreement to live
this moral version of life thatwe think we're going to force
down your throat?" What they doreally well is there are
systems, particularly in WesternEurope, that I admire a lot
because they're centered onperson empowerment.
(26:10):
The same really laws that wehave here and rights that we
have here that we just, we justtrample them.
But I'm talking about thingslike, like agency, and rights of
self-determination, and evenrights to kind of informed
consent, which they honor.
I'll tell you a story.
There's a fantastic program thattogether we have partnered with
(26:30):
them and others on this thingcalled the Rome Consensus.
And it's a humanitarian drugpolicy framework.
You know, that's international,it's this core kind of framework
of drug policy that can beacculturated, you know, locally
to reflect the populations thatit's affecting.
And, and we're really proud ofthat work.
Uh, I think that it, it, itspeaks about how we see the
(26:52):
world right now, and I encouragefolks to go take a look at it.
But in that process, I wasworking on a, uh, volunteering
on a, on a mobile kind ofsyringe service van in rome.
And there was this guy who keptcoming, you know, I see him
every day on the, on the vanright.
Coming to, and he pulls up inhis Mercedes and he gets out,
(27:13):
takes the suit jacket off.
Right.
And he comes over to the van andhe chucks some old syringes.
He prepares an injection, doesone and grabs a plate of
spaghetti that we're making inthe truck, does some
backslapping, you know, with,with other people who were there
from totally different walks.
And, and I, and I, I said tothis guy, I'm like,"what are you
(27:35):
going to do today?" And he said,"well, I'm going to do what I do
every day." He goes,"I'm goingto go back to work.
And then, uh, I'm coaching mydaughter's soccer practice
tonight.
My son has something in thetheater.
My wife, is going to see that.
We'll have dinner and prayer.
And then I will wash, rinse andrepeat." He said, and I go,"you
(28:01):
like your life, don't you?" Andhe goes,"I love my life.
This is exactly the life I wantto live.
It doesn't mean I don't needsupport.
It doesn't mean that I, youknow, I can't be safer or be
healthier.
I want those things just likeeverybody else, but no, I love
my life the way it is rightnow." And being able to meet him
(28:24):
in that space and validate thatand connect-up with that is so
fundamental and so important interms of how we begin to care
for domestic populations who usedrugs also.
Look, everybody uses drugs.
The question is, what drugs doyou use?
Are they ones that white peoplesay you should and pharmacists,
(28:46):
you shouldn't, or are theyapproved or unapproved, right.
Which is not again, rooted inany, anything meaningful, other
than bias and crappy policy.
Valerie Earnshaw (28:55):
All right.
Observation, number one, Ben isa gifted storyteller, and I
wanted to drill down into whythat's so important for just a
moment.
And from my perspective is thatone of our ways that we can
reduce stigma is throughstorytelling.
And so I know that implicitly,you know, that that's what
you're doing when you're doingthis is that you're humanizing
folks.
(29:15):
You're helping people doperspective taking and empathy,
but like just what an amazingthing to do in your day to day
to like, come on these podcasts,or, you know, before you got on
with us, you're talking to aSenator-- Which I'd love to come
back to-- but, you know, just tolike bring these stories and
share them and then be such agifted storyteller at it.
That's great.
But putting that, you know, justputting that observation aside,
(29:38):
I just had to say it out loud.
The thing I'm really noticinghere and in a fundamental
difference, and I know that yousaid this, between like the US
and these other places that arereally getting right is the
fundamental right toself-determine.
To decide what a good, what agood life for me is.
And also to say that that caninclude drug use, can include
(30:01):
substance use.
One of the things I'm wonderingabout connecting to earlier in
our conversation; do you thinkthat like the narrative around
saying that substance usedisorders are like a brain
disease is getting in our way?
Like if we call it a braindisease, do we think that that
makes it harder to believe thatpeople can self-determine that
(30:25):
they can be trusted to decidewhat's best for them?
Ben Levenson (30:29):
Great question.
How that manifests in certainquarters in treatment today.
What it looks like is, you know,we have a patient who comes in
first of all, but there's apredicate that says that if you
have substance use disorder, youcan not make meaningful and
effective choices about yourhealth and your safety.
(30:49):
Right.
Right.
That's not true.
It's not legal, like a personwith SUD, their rights to agency
and informed consent are notreduced at all because they have
substance use disorder.
Lawfully.
It's not-- there, there are someinterventions, legal
interventions that reduceagency, but not generally.
Right.
(31:09):
But we act like that's the casewith everybody.
So we're treating them from thisframe, like they've been
committed, like they have hadtheir agency limited.
And so how that, how does thatshow up in treatment systems?
It's like patient comes in andsays,"man, I, I'm not staying
here longer than, you know,three weeks.
I'm not staying here a month.
I'll be here three weeks".
(31:30):
And they're like,"buddy, youneed to be here six weeks for
that.
We've got to tell you what yourlength of stay is.
You know?
And basically we're going totreatment plan in ways that are
completely opposite of whateveryou say you think is right for
you, right?
Your best thinking got you here.
You're going to let thetreatment team think for you."
(31:50):
Right?
Look, let's use buprenorphine asan example for, uh, Sarah
Wakemans' work out of massgeneral, in the comparative
study that I encourage everybodyto go look at, they looked at
45,000 opioid use disorderedAmericans and they controlled
for everything basically.
They were doing an outcome, acomparison of treatment
(32:11):
pathways, based on clinicaloutcomes.
Okay.
Including morbidity andmortality and other health
centered outcomes.
The treatment to be candid,doesn't even seek treatment,
seeks one outcome it'sabstinence.
And that's it.
They don't really treat tohealth, but in any event, her
work showed that buprenorphinehas a 72% reduction in
(32:34):
likelihood of overdose at monththree and like a 59% at month
12.
Okay.
And it, I mean, no otherintervention that they looked
at, not counseling, not a, uh,not residential treatment, none
of those had any measurableefficacy during the fentanyl
(32:54):
contaminated drug supply crisis,because that risk paints all of
the data.
The old ways we engage, youknow, they're not responsive to
the changed conditions.
And so what could happen intreatment, which is very common,
is a significant section oftreatment, they don't believe
that buprenorphine is sober,right?
Carly Hill (33:17):
yup.
Ben Levenson (33:17):
And here's how that shows up.
So patient walks in with opioiduse disorder.
You know w hat, let me tell youwhat they're not doing.
So thousands of patients indetox units all over the country
this morning w ere met by anurse or someone who came in and
said,"listen, it's the end ofyour buprenorphine taper.
And you knew that was today.
You don't worry.
It's going to be a difficultcouple of days.
(33:39):
We have some Ativan, someclonidine for you, and we're
going to get you through this."Right.
But what are they not sayingwhat they're not saying, they're
not coming in and going,"listen,you are about to proceed o n a
far more lethal pathwayrecovery.
The medicine that we're going totake you off of today, simply
taking you off of this medicine,no matter what else you do
(34:01):
results in a 600% greaterlikelihood of overdose in the
proceeding 12 months.
And we just need you to signhere t hat we've warned you.
Right?
And we've counseled you andyou're still s hooting".
That's not happening.
They're not saying anything tothem.
Right?
It's-- so i magineoncologically, if you're stage
three, you go in to MD Andersonor wherever Mayo or wherever.
(34:26):
Imagine if the prescriber hadpersonal bias against the one
chemo that s ave you a life.
R ight.
And doesn't tell you about that.
Look, that's trampeling agency.
It goes beyond malpractice.
Look, right now, there are attorneys general who believe
(34:49):
that that crap ventures intocriminality.
And I believe it does too.
It's those kinds of scenariosthat people need to think about
and go, oh my gosh, like there'sno standardization.
This is crazy.
It's crazy.
Valerie Earnshaw (35:02):
Well, it's definitely valuing somebody's
idea of abstinence over keepingpeople alive.
Right?
Like, that's really interestingto me, like moral enforcement is
more important than keepingpeople alive.
So one of the things I've beenwondering is thinking about your
work, Ben is like, what's theproblem?
(35:23):
How can scientists help better?
So like, you know, some of thetimes I oversimplify it and I
think like, does science need tocommunicate what they have
better?
Or do we need to do morescience?
So what you just described therewas: the science is there.
Like we know that thesemedications are good, that they
keep people alive, that theyprevent overdoses, but people
(35:44):
aren't using them.
So that seems to be part of theproblem.
I also think that, you know, wecan dig into like what the gaps
are in science, but what areyour thoughts on this
disconnect?
Ben Levenson (35:54):
There's always been this gigantic gap between
the bench and the trench when itcomes to substance use disorder
treatment.
And one of the reasons for thatis we talked a little bit
earlier about kind of therunaway ideological train, that
the orphanage of, of treatment.
One of the ways that I want tokind of talk about this for
science for scientists is: treatment married a therapy. (36:15):
undefined
We married a therapy, that's 12step centered, that we have
profound personal attachment to.
"saved my life.
I got the, I have the elixir.
You just have to do it the way Idid it." And you know, we don't
(36:37):
marry therapies in medicine.
In fact, we stand before theriver of science and as evidence
flows by, we pick up andleverage that evidence and those
tools and those therapies forour patients.
And nobody is butt hurt aboutnot using penicillin anymore for
(36:58):
streptococcus.
It's like, no, there's a better,there's a better-- amoxicillin
is better, right?
Nobody's like, oh, well, youknow, you, you know,"you have
stage three ovarian cancer.
And when I got treated in theeighties, this is what I--",
that's just not how it works.
Right.
So if this is weird attachment,at the expense of patient health
of public health, certainlydisposes it with science.
(37:21):
And it's like, what else do Ineed to know?
I mean, I'm a master, I've gotmy doctorate in recovery.
Like I don't need to learnanything else.
So there is this huge departurebetween treatment and, and the
research.
And it's terrifying.
It's maybe one of the kindadirtiest little secrets in
American healthcare is thatthere is no standardization in
(37:43):
treatment.
The research is not valued.
Scientists would do well tosupport, you know, ways that
motivate the field to valueresearch.
And there's some ways includinginfluencing some of the purchase
models that can do that withvalue-based and risk-shared, uh,
arrangements.
(38:03):
Put their fiscal well- being,align that with patient health
outcomes.
You wanna see an ideologicaldivorce overnight?
This is the only thing they caremore about than their ideology,
it's their money.
So value-based purchasing hasthe ability to revolutionize the
way we care for people who usedrugs.
(38:24):
Because the next morning, whenwe do that, when we attach his
or her margins to patient healthoutcomes, the next morning,
they're walking into the officegoing,"what does the research
say we need to do today to keepthis gal out of the emergency
department in month seven."Right?
And it's like,"well thebuprenorphine switch you got to
(38:45):
do".
--"Oh, great.
Well, we're going to supportbuprenorphine then" right?
There, there's some importantopportunities for research right
now in the space.
Valerie Earnshaw (38:53):
Well, It also just strikes me that, you know,
people with lived experiencehave tremendous expertise for
these folks who say, like I havea PhD in rehab.
Like it strikes me that one ofthe problems is also when we
have research happening thatdoesn't involve people with
(39:13):
lived experience, like, thatprevents the uptake as well.
So inviting folks from thesecommunities to work on these
research projects might also,you know, be helpful.
We think about that a lot in,you know, just in the HIV field
and things like that.
Ben Levenson (39:31):
So in terms of areas of focus, I very much
agree.
I, I think again, we talkedabout kind of the norms of
focusing on populations that nolonger use drugs, but the most
meaningful research and theresearch that I'm using at the
federal level and at all levelsis looking not at that, but
rather at this much broadercohort of Americans who use
(39:53):
drugs, right?
And it's, it's about sittingdown in the reality, right?
The people use drugs.
And I think that what we want todo, and I think what harm
reduction is all, I mean is alot about, is, you know, helping
people live the safest,healthiest version of the life
that they choose for themselvestoday based on the science,
(40:15):
based on an unbiasedpresentation of the data.
Right?
And so data that, and researchthat, that starts to break away
these old ideas, that if you usedrugs on the weekend, you can't,
you know, we're not going toresearch that because the guy's
health is, you know, whatevercatastrophic or something though
, it's exactly what we need tobe researching, because it will
(40:35):
inform, you know, how we carefor people.
As we normalize, as drug usebecomes more normalized in the
United States.
And as you know, the clinicalarchitectures are kind of
reformed in ways to interfacewith, and care for those people.
Valerie Earnshaw (40:51):
To me, it really speaks to, for
scientists, like, how do youthink about your outcomes?
You know, the thing that you'repredicting, which is usually
like, this is good, or this isbad.
And, you know, in this field,it's almost always like
substance use.
Substance use yes.
Substance use no.
So like, what's reallyinteresting about this
conversation is like, usually ifI have an intervention, I want
(41:14):
to show that intervention is, isworking well, I would need to
show that that intervention isleading to less people falling
into the substance UCS category,right?
Like more people who areabstinent.
And this conversation thoughsuggests that like, I may not
need that outcome at all, or Ineed to like, think about like
quality of life, lessdepression, better financial
(41:38):
wellbeing.
Like, I need to really extendwhat I'm thinking about, and
then-- which I'm all for doinglike, as a scientist right?
But then, you know, my challengis, when I go to get that
funded, the National Instituteof Drug Abuse me, they care
about the yes versus no,usually, or at least the peer
reviewers do.
Carly and I are working on thisintervention that's focused on
(42:00):
disclosure, helping peopledisclose that they're in
recovery.
And our main outcomes that we'rereally fired up about are like,
when, if people go through ourlittle intervention, when they
do disclose, do they get abetter response, like, than
people who don't, which we thinkmatters a lot.
Like when you tell somebody, dothey give you a hug or do they
(42:21):
like run away from you or yellat you or something like that?
Carly Hill (42:24):
They kick you out.
Valerie Earnshaw (42:26):
Yeah.
We think that's a big deal, butwe have to like to prove that it
matters.
We need to show that people whouse our tool engage in less
substance use eventually, whichis like really weird,
Ben Levenson (42:39):
Right.
It is weird.
And it's ideology predicated onprohibition and in
criminalization and this binary,you know, kind of perspective on
drug users, when we don't dothat with really anybody else,
it's important for researchersto recognize that the drug-using
population is really saying,look,"nothing about us, without
(43:00):
us".
Right.
That, that, you know, it's themwho get to kind of inform what
good outcomes are.
There was a study that dropped acouple of weeks ago that
actually looked at drug users,mainly people in recovery, which
is, which is not what I'm askingthem to do.
But anyway, and, and asked themlike,"what are, what are good
outcomes for you, right?
(43:20):
Like, what do you think is agood outcome?" And, and it
wasn't like,"that I stay soberforever." It's not what they
said.
You know, they're looking forquality of life.
They're looking for improvementsto, you know, to their domains
of health and, you know, a nd,and family and relationships and
things t hat are important tothem.
But we don't design care forthose outcomes.
Valerie Earnshaw (43:44):
Yeah.
Ben Levenson (43:44):
We design care for abstinence and that's it.
Right?
And so that patient I mentionedearlier, who is injecting heroin
every day and wants to stop.
We can induce him onbuprenorphine, get the needle
out of his arm.
He's no longer at risk forhepatitis C.
He's no longer at risk for HIV.
H e's no longer at risk foroverdose, right.
(44:05):
Medicine.
And we can go to work on,"Hey,let's look at evidence-based
interventions for moderationaround the alcohol, the
continued alcohol use.
We'll prescribe your b enzo.
We'll write it for you." Right.
"And let's get you try to getyou to a therapeutic level with
that".
So medicine looks at this caseand they're like,"Holy crap.
That's amazing.
How did you guys do, how did youget that outcome?" Right.
(44:27):
Treatment looks at that exactsame case and says,"he's a
treatment failure." Right.
And they'll terminatebuprenorphine.
They will knowingly send himback to a fentanyl contaminated
heroin supply because he smokeda joint.
Carly Hill (44:44):
Y ep.
Ben Levenson (44:45):
It's indefensible.
Right.
And it's happening every day inAmerica.
So we have to start thinking andvaluing any positive change.
That's the goal and change thatis, that is patient driven.
That's person driven, right.
L et's be generous and say outof the 3 million that we talked
about being treated earlier,let's be generous and say five,
(45:06):
let's say half a million of themmaintain perfect abstinence.
And so what, what's the benefit.
So we get all of the healthoutcomes associated with half a
million Americans not usingdrugs anymore.
O kay.
It's very small.
What if we could seek and obtaina 15% improvement to health and
(45:29):
safety across 80 or 90 millionAmericans?
That's where the meat is.
And I just want researchers toget that, like, stop obsessing
about abstinence, r ight?
It's about the big gains, right.
That are there to be had whichare improvements to, to health
and safety of drug users.
I d on't, I keep saying that,but it's, that's what it is.
(45:49):
And getting off of this trainthat says,"oh, t hey've g ot t o
be sober." No, they don't.
They don't have to be sober.
Look, drug use is not predictiveof catastrophic health and
abstinence is not predictive ofwhole health.
T hat's just not how it works.
Valerie Earnshaw (46:04):
Yeah.
I mean, just circling back toyour other, you know, your point
you made earlier, like"it's druguse in context".
So it might be it's"drug use"when the civil supply is
corrupted or it's"drug use" whenthere are certain
criminalization policies inplace, or like it's these social
structural things that arehappening that are harmful.
Before we let you go, could-- we talked about your trajectory
(46:28):
in Origins, and I feel likeit's, to me, it's pretty clear
where in this narrative, you,you shift over to the Levenson
foundation, but could you justshare with us with the
listeners, like, what is theLevenson Foundation?
And we'll post links to that andthe R ome Consensus like a n
episode notes cause w e'd lovefor people to read that I found
it to be like, fantastic.
So would you just share a littlebit about that before we let you
(46:50):
go?
Ben Levenson (46:50):
I will.
And I, and I want to share abouta, another coalition that we're
involved with the foundation issupporting the national campaign
for harm reduction funding,which is comprised of some
fantastic advocates and groups,including, you know, the Drug
Users Union who have a voice inthat coalition, which is great.
It's the first time Congress hasever used the words"harm
(47:12):
reduction" in this, you know,$1.9 trillion plan that passed,
$30 million was includedspecifically for harm reduction.
It was the first time that OwenDCP, even, which is the white
house's office on drug policy.
The first time they've even usedthe words harm reduction.
And so there's a lot of energygoing into how do we get it to
the, to the end user, but that'sreally important.
(47:34):
So I want to make sure we get tolead into that.
Also, the Foundation is justreally focused on, you know,
some harm reductionphilanthropy.
And so we're, we're funding harmreduction agencies who may have
fiscal challenges.
And I mean, it's like they'regiving out bleach kits, like,
why are you giving out bleachkits?
Because they don't, they don'thave any money to buy syringes,
(47:55):
right?
Like they're doing everythingthey can.
It's how harm reduction has beentreated.
That community is treated soterribly by us from a civil
society and a governmentalperspective, you know, working
to just help normalize andvalidate and scale harm
reduction for populations thatuse drugs.
That's really the focus.
(48:15):
And we were working abroad alot, but when the contaminated
drug supply became kind ofapparent, we pivoted almost
everything back home, that's thefoundation.
And then I'm focused on, on thefor-profit side on systems of
care that are extremelydisruptive to treatment systems
that are designed recontainerizing treatment
(48:36):
altogether inside of primarymedicine, where we build an
instance of care, that's able tolongitudinally, engage with a
drug using patient and thefamilies and journey with them,
right, as they go through theirchoices and their experiences
with their drug use help seekand celebrate incremental
(48:58):
improvements on pathways thatthey choose for themselves based
on the evidence.
But even more importantly tothat, than that to destinations
that they're choosing forthemselves, including partially
abstinent, fractionally,abstinent, maybe even substance
specific safety, like thepatient I mentioned earlier.
(49:18):
This is a system that would say,alright.
We'll help you.
We'll help you write it yet.
Come on.
You know, we'll write your benzo, like let's, let's let's
journey.
Right.
And so excited about that asthat kind of develops all
sensitive information back toyou guys.
Maybe we can do something onthat.
Carly Hill (49:34):
Please do.
Ben Levenson (49:36):
It'll be fun.
Valerie Earnshaw (49:37):
Ben, thank you so much for coming on the show.
Thanks for what you're doing.
Thank you for giving mepersonally, like so much good
food for thought today.
Like this is, this is exactlywhy I like to do this podcast
because I'm going to be thinkingabout this all week.
This is great.
And you know, this is our firsttime chatting and I'm really
hoping that I can force friendyou, force colleague you, stay
(49:59):
in touch and try to support someof the great work that you're
doing.
Ben Levenson (50:02):
I feel super fortunate to get to visit with,
with both of you and youraudience.
That's growing as we speak.
And I'm just real fond of thework that you're doing here.
It's really important.
So thanks for showing up anddoing that, appreciate it a lot.
Valerie Earnshaw (50:18):
Thanks to the Stigma and Health Inequities Lab
at the University of Delawarefor their help at the podcast,
including Sarah Lopez, MollyMarine, James Wallace, and
Ashley Roberts,
Carly Hill (50:27):
Thanks to city girl for the music as always be sure
to check us out on Instagram@sexdrugsscience, and stay up to
date on new episodes by clickingsubscribe.
Valerie Earnshaw (50:37):
Thanks to all of you for listening.
(51:13):
[inaudible].
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