WEBVTT - “Drug Use for Grown Ups” with Dr. Carl Hart 0:00:15.356 --> 0:00:25.076 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:25.116 --> 0:00:28.916 where we explore the stories behind the stories in the news. 0:00:29.916 --> 0:00:36.316 The world is full of books proposing counterintuitive claims about 0:00:36.436 --> 0:00:39.236 the way things are. You could even say books like 0:00:39.276 --> 0:00:43.116 that are a dime a dozen, But doctor Carl Hart's 0:00:43.156 --> 0:00:47.436 book Drug Used for Grown Ups is exceptional, and I 0:00:47.516 --> 0:00:50.156 might even call it unique. You may have heard about 0:00:50.156 --> 0:00:54.716 it in the press recently. Doctor Hart provocatively argues that drugs, 0:00:54.996 --> 0:01:00.876 including drugs like heroin, are much safer physiologically than we 0:01:00.996 --> 0:01:05.436 ordinarily think, and that the major dangers, including the dangers 0:01:05.556 --> 0:01:10.836 of addiction, come from comorbidities, risks that people have associated 0:01:10.876 --> 0:01:15.716 with mental illness and poverty, and not from the physiological 0:01:15.796 --> 0:01:20.636 substrate of these drugs themselves. He goes further than that, 0:01:21.036 --> 0:01:24.716 suggesting that we need a radical reform in light of 0:01:24.756 --> 0:01:28.876 a new understanding of drugs as having far fewer negative 0:01:28.876 --> 0:01:33.676 effects than we believe and far more positive effects associated 0:01:33.716 --> 0:01:39.036 with the altering of consciousness than we usually consider. Doctor 0:01:39.076 --> 0:01:42.916 Hart is a professor of neuroscience and psychology at Columbia University, 0:01:42.956 --> 0:01:46.156 where he's been chair of his department, and his research 0:01:46.196 --> 0:01:50.716 focuses on the physiological and behavioral effects of psychoactive drugs. 0:01:51.476 --> 0:01:55.516 The book is heavily deeply footnoted, as I learned by 0:01:55.596 --> 0:01:58.676 reading it closely and going into the footnotes. At the 0:01:58.756 --> 0:02:02.996 same time, it's a highly accessible and indeed personalized account 0:02:03.396 --> 0:02:06.716 of a serious and complex set of issues with major 0:02:06.756 --> 0:02:10.916 consequences for how power is distributed in our society, including 0:02:11.156 --> 0:02:16.396 an in particular on the basis of race and racialized hierarchies. 0:02:17.036 --> 0:02:19.156 Drug Use for Grownups is one of the most thought 0:02:19.196 --> 0:02:22.836 provoking books I've read this year, and I had to 0:02:22.876 --> 0:02:28.036 have doctor Hart on the show. Doctor Hart, welcome to 0:02:28.076 --> 0:02:32.396 deep background. Let's dive in by starting with a crucial 0:02:32.436 --> 0:02:35.876 definition that you provide at the beginning of the book 0:02:36.076 --> 0:02:38.956 that really follows us all the way through, and that 0:02:39.076 --> 0:02:42.956 is the definition of the word addiction. And you say 0:02:42.996 --> 0:02:45.116 in the book that you're going to use the definition 0:02:45.156 --> 0:02:48.756 of addiction borrowed from the DSM, the Diagnostic and Statistical 0:02:48.796 --> 0:02:53.356 manual that psychologists use, and that that definition of addiction 0:02:53.596 --> 0:02:58.036 entails not just that you are using a substance regularly, 0:02:58.116 --> 0:03:01.236 but that it is negatively affecting a major life activity 0:03:01.276 --> 0:03:04.276 and that it's causing distress to the user. And under 0:03:04.276 --> 0:03:09.676 that definition if someone drings coffee every morning but negatively 0:03:09.676 --> 0:03:12.076 affect the person. Even though you know, if I don't 0:03:12.076 --> 0:03:15.076 get my coffee, i have headaches or I'm cranky, I'm 0:03:15.116 --> 0:03:18.596 not addicted. Right, that's right. I mean you can imagine 0:03:18.796 --> 0:03:23.556 people who drink coffee, people who drink alcohol or other substances, 0:03:23.676 --> 0:03:26.716 and their life is not impacted. They're able to meet 0:03:26.756 --> 0:03:29.676 all of the obligations. Why would we say that they 0:03:29.716 --> 0:03:32.316 have an addiction problem. Like in this culture, we have 0:03:32.396 --> 0:03:36.676 this popular saying of functional adding. There is no such thing. 0:03:36.756 --> 0:03:40.036 That's a Nazi mourn by definition of addiction, that means 0:03:40.036 --> 0:03:43.156 you're not functional, you're not meeting your obligations. And so 0:03:43.716 --> 0:03:46.956 simply based on what people put in their body or 0:03:46.956 --> 0:03:49.436 what they're using, if you use that as a definition 0:03:49.436 --> 0:03:53.236 of addiction, everybody would be labeled an adding I think 0:03:53.276 --> 0:03:56.316 the thing that I was so fascinated about in your 0:03:56.356 --> 0:03:59.836 clarity about pointing this out about addiction is that you're 0:03:59.836 --> 0:04:03.076 a neuroscientist. So at least in principle, you're supposed to 0:04:03.116 --> 0:04:07.436 be a physiology guy. But that definition is way bigger 0:04:07.436 --> 0:04:11.236 than the physiological definition. Right, No, that's right. So you 0:04:11.276 --> 0:04:14.036 know the goal of neuroscience is to try to explain 0:04:14.236 --> 0:04:16.956 human behavior. And if you're going to explain human behavior, 0:04:16.996 --> 0:04:19.676 you can only look at the brain. You have to 0:04:19.956 --> 0:04:23.596 understand the animal of the human in its social context. 0:04:23.716 --> 0:04:27.556 Without the context, you will make some mistakes about what's 0:04:27.596 --> 0:04:31.196 going on without understanding the context. And so I think 0:04:31.276 --> 0:04:34.716 most of us who understand anything about human behavior know 0:04:34.916 --> 0:04:38.796 that we need to understand the social contact and under 0:04:38.796 --> 0:04:42.596 which the behavior happens, because you can imagine some behavior 0:04:42.956 --> 0:04:49.196 happening in one context maybe inappropriate, whereas it's entirely appropriate 0:04:49.396 --> 0:04:54.396 in another. Let's say somebody physically assaults somebody and that's 0:04:54.436 --> 0:04:57.236 all you know, and it turns out the person who 0:04:57.236 --> 0:05:01.276 physically assaulted the other person was a defensive end for 0:05:01.436 --> 0:05:05.676 the Tampa Bay Buccaneers, and he physically assaulted the quarterback 0:05:05.756 --> 0:05:10.556 for Kansas City. On the field, that's entire appropriate, But 0:05:10.796 --> 0:05:14.676 off of the field that's not appropriate. So context is everything. 0:05:15.916 --> 0:05:18.316 It sure is, And that's a great example. Let's move 0:05:18.356 --> 0:05:21.756 on to another really important topic for you, and that 0:05:21.876 --> 0:05:26.876 is you condemn the language of harm reduction that tends 0:05:26.876 --> 0:05:33.156 to surround our discussions about drugs. Say more about that, 0:05:33.196 --> 0:05:35.996 because on the surface, harm reduction sounds like the most 0:05:36.396 --> 0:05:39.116 who could argue with it, you know, idea in the world, 0:05:39.156 --> 0:05:41.196 and yet in your view that framing of harm reduction 0:05:41.276 --> 0:05:45.076 has had disastrous consequences. Yeah, I just want to be clear. 0:05:45.156 --> 0:05:48.556 You know, in principle, what people do with harm reduction, 0:05:48.636 --> 0:05:51.116 they try to help folks who are in need of help. 0:05:51.196 --> 0:05:53.516 I support that. The thing that I had took issue with, 0:05:53.796 --> 0:05:57.636 it's just the term harm reduction. We do harm reduction 0:05:58.036 --> 0:06:00.396 when we brush our teeth in the morning, we want 0:06:00.396 --> 0:06:03.356 to avoid cavities, we put on our seatbelt, we want 0:06:03.396 --> 0:06:05.836 to avoid any sort of harm that might come if 0:06:05.876 --> 0:06:08.156 we had a car crash. But we don't call that 0:06:08.356 --> 0:06:11.676 harm reduction, and we reserve the term harm reduction only 0:06:11.716 --> 0:06:14.756 for drugs. And when you do that, you pair the 0:06:14.796 --> 0:06:19.076 word harm with drugs over and over in our language, 0:06:19.116 --> 0:06:23.036 shapes how we behave, how we think. So I'm asking 0:06:23.076 --> 0:06:28.156 folks maybe reconsider another term, like we're really trying to 0:06:28.316 --> 0:06:31.876 enhance the health and happiness and safety of folks, and 0:06:31.956 --> 0:06:36.876 so maybe health and happiness, But to focus exclusively on 0:06:36.996 --> 0:06:41.996 harms associated with drugs seems shortsighted. Most people are using 0:06:42.076 --> 0:06:44.836 drugs to enhance the pleasure to have a good time 0:06:45.196 --> 0:06:48.796 to alter their consciousness. We're not thinking about harm so much, 0:06:49.076 --> 0:06:52.196 but this term harm reduction forces us in this sort 0:06:52.236 --> 0:06:56.836 of unique dimensional space, as if harms are the only 0:06:56.876 --> 0:07:01.436 things that happen when you take drugs. I think the 0:07:01.476 --> 0:07:03.836 reason that point that you're making was so powerful for 0:07:03.876 --> 0:07:06.676 me and reading the book is that, like a lot 0:07:06.676 --> 0:07:08.716 of what you do in the book, it just challenges 0:07:08.756 --> 0:07:12.356 the reader to say, start somewhere different. You know. I 0:07:12.396 --> 0:07:15.276 get the sense again and again reading your book that 0:07:15.956 --> 0:07:20.876 what you're fighting against is preconceptions that have been kind 0:07:20.916 --> 0:07:22.876 of drilled into our heads, and not by accident. It's 0:07:22.876 --> 0:07:25.196 not just they're out there in the culture. They've been 0:07:25.236 --> 0:07:28.476 created by the television that we've watched, the PSAs that 0:07:28.556 --> 0:07:30.916 we've been seeing. If you're in our generation since we 0:07:30.916 --> 0:07:33.796 were kids, and that the next generation is still getting 0:07:34.436 --> 0:07:36.196 it's a full you know, I guess it's what the 0:07:36.236 --> 0:07:38.996 sociologists would call a full discourse, you know, a full 0:07:39.076 --> 0:07:42.796 set of ideas and language and beliefs that have been 0:07:42.836 --> 0:07:46.116 created in a very self conscious way. Am I getting 0:07:46.116 --> 0:07:50.356 you that you're trying to start us off by saying, hey, everybody, 0:07:50.676 --> 0:07:52.596 take a deep breath and realize that you're in the 0:07:52.636 --> 0:07:56.116 grips of these ideas and just question them. Doesn't mean 0:07:56.156 --> 0:07:57.676 you have to reject them at the end, but start 0:07:57.716 --> 0:08:00.076 by putting a question mark in front of them. That's 0:08:00.116 --> 0:08:03.756 exactly right. In our culture, we've been inundated with these 0:08:03.796 --> 0:08:09.756 messages about drugs that are largely inactress. And we've been 0:08:09.796 --> 0:08:14.156 innovated with these messages because it facilitates some sort of 0:08:14.436 --> 0:08:18.676 argument or some sort of position of the person who's 0:08:18.756 --> 0:08:23.516 producing the messages. And it's really easy to say that 0:08:23.676 --> 0:08:26.996 anybody who uses crack cocaine will become addicted, and we 0:08:27.076 --> 0:08:31.196 all believe it. It's really easy to say one hit 0:08:31.236 --> 0:08:34.436 of heroin and then you're addicted. And I'm asking people 0:08:34.516 --> 0:08:38.876 to just reconsider this with the evidence, and I'm trying 0:08:38.916 --> 0:08:41.996 to present evidence throughout the book that I hope people 0:08:42.036 --> 0:08:48.316 will look at, consider and reconsider their starting point. Those 0:08:48.356 --> 0:08:50.316 stories are so powerful. You know, I'm from Boston and 0:08:50.396 --> 0:08:52.796 grew up as a big Celtics fan, and i remember 0:08:52.956 --> 0:08:56.196 very very vividly as a kid when Len Bias died 0:08:56.196 --> 0:08:58.996 of a cocaine overdose, or at least so it was reported, 0:08:59.596 --> 0:09:03.676 and you know, the takeaway for kids, and I was 0:09:03.716 --> 0:09:07.316 a kid was supposed to be you could die from 0:09:07.476 --> 0:09:11.316 one use of cocaine. There was no serious analysis of 0:09:11.396 --> 0:09:14.476 the history, the context, any of it. And I don't 0:09:14.476 --> 0:09:16.836 actually know the facts of it except that, boy, did 0:09:16.836 --> 0:09:19.396 it make a central impression on me as a kid. 0:09:19.476 --> 0:09:23.356 You know, this was a terrifying, terrifying drug and you 0:09:23.356 --> 0:09:27.516 should avoid it at all costs. Yeah, same here. I 0:09:27.676 --> 0:09:30.836 came of age about that time. Not only did Lin 0:09:30.996 --> 0:09:34.196 Baias die, a week later, Don Rogers died from the 0:09:34.236 --> 0:09:38.076 Cleveland Browns, And so the message was this drug is 0:09:38.196 --> 0:09:42.676 so unpredictable. Even one hit can take out the most 0:09:42.756 --> 0:09:47.916 fit person in our society. That's just the overly simplistic message. 0:09:48.436 --> 0:09:52.276 Nearly every day before COVID, at least at our institution 0:09:52.316 --> 0:09:56.316 at Columnia University, we give cocaine to research subjects and 0:09:56.396 --> 0:09:58.916 never have we seen such a thing like that. But 0:09:59.116 --> 0:10:02.436 you know, it's in a controlled environment, in a medical setting. 0:10:02.476 --> 0:10:06.316 But limbaias experience as the way it was reported in 0:10:06.396 --> 0:10:10.396 the media just seemed to be an extreme aberration. But 0:10:10.676 --> 0:10:14.156 that was the standard that was presented as if it 0:10:14.236 --> 0:10:18.436 was the standard. The real troubling thing about the media's 0:10:18.436 --> 0:10:22.196 approach to drugs is that the approach is done to 0:10:23.036 --> 0:10:29.316 the sensationalized event and almost never done to actually help people, 0:10:29.836 --> 0:10:32.836 help people who may be using a drug, or help 0:10:32.916 --> 0:10:37.236 people who want a deeper understanding about these things. And 0:10:37.396 --> 0:10:41.876 as a result, it shapes what we think, it shapes 0:10:41.916 --> 0:10:46.876 our policies, and it contributes to the restricting of civil 0:10:46.956 --> 0:10:49.716 liberties and a number of sort of things. And that's 0:10:49.756 --> 0:10:52.756 the real concern that I have about the way that 0:10:52.756 --> 0:10:57.156 the media covers drugs. And more importantly, you can be 0:10:57.276 --> 0:11:03.156 completely wrong in your coverage of drugs and it's okay. 0:11:03.356 --> 0:11:06.476 You don't have to be complete, and you can be 0:11:06.556 --> 0:11:10.316 praised as a reporter in the media. And I wonder 0:11:10.316 --> 0:11:12.276 if that maybe has connected all sort of harm reduction, 0:11:12.316 --> 0:11:14.636 because if you said to a reporter or later on, well, gee, 0:11:14.676 --> 0:11:18.156 you overstated the risk, the reporter will say, well, that 0:11:18.276 --> 0:11:20.756 might be true, but we were reducing harm overall. If 0:11:20.796 --> 0:11:23.276 people are more scared of drugs rather than less scared 0:11:23.276 --> 0:11:25.356 of drugs, that's a good thing, because less drugs means 0:11:25.916 --> 0:11:29.156 less harm. Yeah, you know, I think we even take 0:11:29.196 --> 0:11:32.316 that approach in science. It's it's better to air on 0:11:32.356 --> 0:11:35.396 the side of caution, and then that way, fewer people 0:11:35.516 --> 0:11:39.396 will use it's like that would be okay if there 0:11:39.556 --> 0:11:43.236 was not a price to pay. There is a big price, 0:11:43.356 --> 0:11:46.676 but airing on the side of caution when you are incorrect. 0:11:47.156 --> 0:11:49.996 For example, this past summer, we had a lot of 0:11:50.316 --> 0:11:55.036 protests related to Black Lives Matter, the killing of George Floyd. 0:11:55.676 --> 0:11:58.556 The killing of George Floyd is a good example because 0:11:58.836 --> 0:12:02.076 we all saw Derek Schoulbin put his knee on George 0:12:02.076 --> 0:12:05.116 Floyd's next for eight minutes and forty six seconds. We 0:12:05.196 --> 0:12:09.476 all saw it. But George Floyd had some drugs in 0:12:09.516 --> 0:12:15.316 his system, and now the story becomes, oh, the drugs 0:12:15.396 --> 0:12:18.076 did it, even though we saw with our own eyes 0:12:18.196 --> 0:12:22.916 what happened. But people are sensitized to believe anything about 0:12:22.996 --> 0:12:27.876 drugs that's negative, and then we miss some important sort 0:12:27.916 --> 0:12:32.076 of facts like that was a horrible act by this 0:12:32.436 --> 0:12:36.036 police officer or other police officers. When they say something 0:12:36.076 --> 0:12:38.916 like oh, they had PCP in their system. The public 0:12:38.956 --> 0:12:44.156 has been sensitized to believe that PCP causes a superhuman strength, 0:12:44.436 --> 0:12:48.316 causes people to have superhuman strength, which is nonsense. But 0:12:48.916 --> 0:12:52.476 that's the price that we pay in that the police 0:12:52.556 --> 0:12:56.996 can get away with harming people, killing people as long 0:12:57.076 --> 0:13:01.956 as they scapegoat drugs in the process. That's the price 0:13:02.076 --> 0:13:05.636 that we pay as a society for erroring on the 0:13:05.716 --> 0:13:11.596 side of caution. People are susceptible to believe nonsense about drugs, 0:13:11.636 --> 0:13:17.116 even when some abhorrent act has occurred against the person 0:13:17.156 --> 0:13:20.956 who might have drugs in their system. I just want 0:13:20.956 --> 0:13:23.116 to pause for a second to underscore the power of 0:13:23.156 --> 0:13:25.316 the point you're making, because it goes to something really 0:13:25.316 --> 0:13:27.956 subtle about your book that's actually really different from almost 0:13:27.996 --> 0:13:29.716 all the other books that I've read on the topic. 0:13:31.036 --> 0:13:35.716 You are making a very powerful point about the real world, 0:13:36.116 --> 0:13:40.436 hierarchical and race based social impact of not only drug 0:13:40.556 --> 0:13:43.396 enforcement but drug ideology, if I could call it that. 0:13:43.956 --> 0:13:45.796 And you make that point again and again and again, 0:13:45.956 --> 0:13:49.036 and very very successfully and powerfully, so much so that 0:13:49.076 --> 0:13:51.756 when I was describing the book to friends because I've 0:13:51.756 --> 0:13:54.356 been very excited having read it, several people said to 0:13:54.356 --> 0:13:56.236 me who hadn't read the book yet. So, is this 0:13:56.276 --> 0:13:59.356 a version of the familiar argument that we've now been 0:13:59.396 --> 0:14:01.356 hearing off and on for the last five or ten 0:14:01.436 --> 0:14:05.836 years about how the war on drugs has been effectively 0:14:05.916 --> 0:14:09.676 a tool for racial hierarchy in the United States? And 0:14:09.756 --> 0:14:11.996 what I kept on saying people is yes, heart makes 0:14:11.996 --> 0:14:14.396 that argument, but that's not all the book is. The 0:14:14.436 --> 0:14:18.956 book is also adding a separate argument that is analytically 0:14:18.996 --> 0:14:24.516 distinct about the scientific reality underlying the assumptions that go 0:14:24.556 --> 0:14:27.236 into the war on drugs. And what I was saying 0:14:27.316 --> 0:14:29.396 was the book is trying to make both arguments in 0:14:29.436 --> 0:14:32.756 relationship to each other. Yeah, that's one of the things 0:14:32.796 --> 0:14:37.316 that motivated me to write this book. Putting together, for example, 0:14:37.676 --> 0:14:43.036 the people who had been killed by police and they've 0:14:43.076 --> 0:14:47.396 had drugs in their system, and that kind of stops 0:14:47.516 --> 0:14:51.636 any sort of analysis about what actually happened. That's a 0:14:51.716 --> 0:14:56.636 real concern because an injustice may have occurred and we 0:14:57.076 --> 0:15:00.036 say it's okay because they had a drug in their system. 0:15:00.476 --> 0:15:04.996 Can you imagine the millions of Americans who may have 0:15:05.196 --> 0:15:09.236 some metabolite, that is some byproduct of a drug in 0:15:09.276 --> 0:15:14.356 their system and they happen to have some interaction with 0:15:14.396 --> 0:15:18.796 someone and they're killed, and because they had a substance 0:15:18.916 --> 0:15:24.716 in their system, their death is excused or disregarded because 0:15:24.876 --> 0:15:28.276 of the fact that they had a substance in their system. 0:15:28.356 --> 0:15:30.836 That would be a horrible injustice. And that's what I'm 0:15:30.836 --> 0:15:34.596 trying to get Americans to look at so we avoid 0:15:34.876 --> 0:15:39.356 anymore injustices. Let's talk science for a bit, and I 0:15:39.356 --> 0:15:42.196 want to start with one of the most fascinating and 0:15:42.276 --> 0:15:44.796 controversial claims in the book, which has to do with 0:15:45.436 --> 0:15:50.636 calling on us to rethink the opioid crisis or opioid epidemic. 0:15:51.636 --> 0:15:54.996 And I think you're making a bunch of different arguments here, 0:15:54.996 --> 0:15:56.676 and I want to tease them all out so that 0:15:56.716 --> 0:15:59.436 the listeners can really get a sense of them. So 0:15:59.556 --> 0:16:03.476 the first one I think is that what we hear 0:16:03.796 --> 0:16:09.556 about the increasing number of opioid deaths or opioid related deaths, 0:16:09.596 --> 0:16:14.316 that some of that apparent increase may be a product 0:16:14.676 --> 0:16:19.796 of reporting, that there's better reporting, or more reporting, or 0:16:19.836 --> 0:16:24.836 maybe overreporting compared to what there was previously. That's just 0:16:24.876 --> 0:16:26.516 the first of several claims. And the first thing I 0:16:26.556 --> 0:16:30.596 want to ask you is what's the social scientific basis 0:16:30.636 --> 0:16:33.876 for thinking that that might be the case. Yeah, if 0:16:33.876 --> 0:16:38.356 we think about this, we think about who does death investigations. 0:16:38.356 --> 0:16:42.036 In the United States, most death investigations are carried out 0:16:42.116 --> 0:16:49.036 by corners. Corners and medical examiners both death investigations, but 0:16:49.196 --> 0:16:52.836 corners do most. And we think about what are the 0:16:52.996 --> 0:16:56.436 skill sets of corners. In order to be a corner, 0:16:56.556 --> 0:16:59.556 all you need is a high school diploma in most 0:16:59.596 --> 0:17:03.556 cases and a few hours of a death investigation course. 0:17:03.876 --> 0:17:08.756 So the skill levels of corners are not that high 0:17:09.116 --> 0:17:12.956 compared to a medical examiner, who is a physician who 0:17:13.076 --> 0:17:18.356 generally has training in forensic pathology. And so now we 0:17:18.396 --> 0:17:21.876 have these death investigations that are being happening all around 0:17:21.956 --> 0:17:25.716 the country, and they're not uniform, that is, they're not 0:17:25.796 --> 0:17:29.716 carried out in the same way. In some cases, we 0:17:29.836 --> 0:17:35.116 don't even have biological confirmation of what drugs the person 0:17:35.236 --> 0:17:39.876 actually had in their system number one. In other cases, 0:17:40.076 --> 0:17:43.556 the person may have had multiple drugs. This is the 0:17:43.596 --> 0:17:47.356 case for most overdose They have multiple drugs in their system, 0:17:47.436 --> 0:17:51.196 including medications that they were prescribed. And also with a 0:17:51.316 --> 0:17:56.556 number of deaths, people commit suicide intentionally. When you add 0:17:56.676 --> 0:18:00.196 all of this to this sort of this mix, it's 0:18:00.276 --> 0:18:03.956 really hard to tease a part what was the culprit 0:18:04.116 --> 0:18:07.796 the cause of the person's death, because when multiple drugs 0:18:07.796 --> 0:18:13.236 are involved, rarely does anyone bother to look at what 0:18:13.396 --> 0:18:17.596 drug actually caused the death or did the combination cause 0:18:18.036 --> 0:18:21.556 the death. And so when we say like these drug 0:18:21.676 --> 0:18:26.196 related overdoses. We tend to focus on the opioids because 0:18:26.916 --> 0:18:30.476 those are the drugs of the moment, but it doesn't 0:18:30.516 --> 0:18:34.716 mean that the opioid actually caused the death. Added to 0:18:34.796 --> 0:18:39.276 that the fact that many people when they do street drugs, 0:18:39.516 --> 0:18:42.756 may get tainted drugs, and so the drugs may be 0:18:42.916 --> 0:18:45.996 tainted with other things that are more dangerous than the 0:18:46.076 --> 0:18:48.916 drug that they were seeking. For example, if someone was 0:18:48.956 --> 0:18:54.156 seeking heroin and they got analog, that analog can be 0:18:54.196 --> 0:18:57.996 a lot more potent than heroin, therefore more unlikely to 0:18:58.036 --> 0:19:03.556 cause overdose in an unsuspecting user. And so all of 0:19:03.556 --> 0:19:09.596 this adds complexity to this overdose mix that is rarely 0:19:09.956 --> 0:19:14.116 tease the part when we document the cause of death. 0:19:15.836 --> 0:19:27.316 We'll be back in a moment. I take the point 0:19:27.396 --> 0:19:30.676 that our statistics are kind of problematic for all of 0:19:30.676 --> 0:19:32.516 those reasons. And by the way, I had no idea 0:19:32.636 --> 0:19:35.756 that most deathIn nittates are investigated by partners who don't 0:19:35.796 --> 0:19:37.356 have medical training. I guess I'm a product of the 0:19:37.356 --> 0:19:40.556 television age, and I always imagine a medical examiner involved. 0:19:40.716 --> 0:19:42.756 So that's a totally fascinating fact that I had no 0:19:42.836 --> 0:19:46.556 idea of. But let's imagine that we were able to 0:19:46.556 --> 0:19:49.956 tease a part the data. Don't you think there would 0:19:49.956 --> 0:19:53.756 be a rise in the number of deaths where opioids 0:19:53.756 --> 0:19:55.876 were at least involved, even if the cause of the 0:19:55.876 --> 0:19:59.516 death was the interaction between opioids and something else, or 0:20:00.196 --> 0:20:04.796 tainted drugs, or a fentonyl based drug that was way 0:20:04.836 --> 0:20:07.676 more powerful than the person who ended up using the 0:20:07.716 --> 0:20:10.196 drug ever knew. I mean, you're not suggesting, are you 0:20:10.316 --> 0:20:14.036 that the idea that there's a lot more opioids out 0:20:14.036 --> 0:20:15.876 there and that there are a lot more deaths than 0:20:15.916 --> 0:20:18.516 their word is not true, but rather that their connection 0:20:18.596 --> 0:20:21.076 between those things, between the number of opoids and the 0:20:21.156 --> 0:20:24.436 number of deaths hasn't been sufficiently substantiated. Yeah, I think 0:20:24.476 --> 0:20:28.236 that we have to think about what changed, what changed 0:20:28.276 --> 0:20:31.076 in this period where we see this increase. One of 0:20:31.116 --> 0:20:34.876 the things that changed is that we now have more 0:20:35.196 --> 0:20:40.756 phintonyl analogs or opioid synthetic opioids that are more potent 0:20:40.796 --> 0:20:44.236 than heroin and these other sort of opioids of the 0:20:44.276 --> 0:20:47.716 path that changed, and so it will be nice to 0:20:47.716 --> 0:20:50.956 tease the part to see whether or not those are 0:20:51.036 --> 0:20:55.356 the culprits of any increase that we see, and in 0:20:55.516 --> 0:20:58.316 that way, If that's the case, we can approach this 0:20:58.476 --> 0:21:01.956 problem by simply doing as some of the other countries 0:21:01.956 --> 0:21:06.676 have done, implementing drug checking facilities where people can test 0:21:06.756 --> 0:21:10.756 their substance to see if they contain adulterants that might 0:21:10.796 --> 0:21:14.516 be potentially dangerous. And so, I don't really know what's 0:21:14.556 --> 0:21:16.956 going on, but I know one of the things that 0:21:16.996 --> 0:21:20.836 we can do is be more careful in discerning what 0:21:20.996 --> 0:21:25.916 is happening so we can better protect our public. Part 0:21:25.916 --> 0:21:27.796 of the reason that this part of your book is 0:21:27.836 --> 0:21:31.556 so counterintuitive is that we have this narrative, which is 0:21:31.596 --> 0:21:34.116 a new narrative associated with the opioids. It's different than 0:21:34.156 --> 0:21:38.596 the narratives about cocaine or crack cocaine of the eighties, 0:21:38.636 --> 0:21:42.356 and it's a narrative that big pharma, acting quote unquote 0:21:42.396 --> 0:21:46.196 within the bounds of the law, pushed physicians to prescribe 0:21:46.356 --> 0:21:51.316 lots of opioids that were themselves. Those opioids themselves were, 0:21:51.636 --> 0:21:54.236 as it were regulated, they were legal drugs in the 0:21:54.276 --> 0:21:56.236 sense that they were legal if they were prescribed. You 0:21:56.276 --> 0:21:58.276 had physicians being under a lot of pressure and a 0:21:58.316 --> 0:22:01.516 lot of incentive to prescribe them. And then the way 0:22:01.556 --> 0:22:06.916 this narrative runs, people got addicted after having genuine, real 0:22:06.956 --> 0:22:11.756 pain that was medically diagnosed, treated by opioids that were 0:22:11.796 --> 0:22:16.836 medically prescribed, and then couldn't get off of those opioids, 0:22:16.956 --> 0:22:20.996 and then that led them to illegal forms or other 0:22:21.036 --> 0:22:24.956 forms of the drug that may have caused the actual death. 0:22:25.596 --> 0:22:27.876 And I don't think you talk so much in the 0:22:27.916 --> 0:22:30.916 book about the big Farma part of that story, and 0:22:30.996 --> 0:22:33.156 so I really wanted to ask you, do you buy 0:22:33.156 --> 0:22:34.996 that story? I mean, we're hearing it all the time. 0:22:35.076 --> 0:22:37.396 I suppose big Pharma at one point they wanted to 0:22:37.476 --> 0:22:39.636 deny the story. At this point they've changed strategies, right, 0:22:39.676 --> 0:22:42.236 They've given up and realize their best bet is to 0:22:42.276 --> 0:22:44.876 say we're sorry, that the companies who did the most 0:22:44.876 --> 0:22:48.076 of this will pay large settlements. That the companies who 0:22:48.116 --> 0:22:50.356 advise them were participating it will also take a hit 0:22:50.836 --> 0:22:53.796 and pay large settlements, and they'll do what big companies 0:22:53.796 --> 0:22:55.636 always do to try to move on to the next thing. 0:22:55.796 --> 0:22:57.476 But the reason I think this is significant is that 0:22:57.516 --> 0:22:59.996 it's a different story than the story of a new 0:23:00.076 --> 0:23:03.036 drug came from the streets. This is a story of 0:23:03.436 --> 0:23:06.996 a new set of drugs came from corporate America. And 0:23:07.036 --> 0:23:09.676 I think it makes a lot of people skeptical about 0:23:09.796 --> 0:23:13.036 arguments for legalization because this looks like a story of 0:23:13.076 --> 0:23:15.956 what happens when a big corporation gets involved. The big 0:23:15.996 --> 0:23:18.596 corporation turns into the drug pusher, according to this narrative, 0:23:18.916 --> 0:23:22.356 and is way better at it in terms of quantity 0:23:22.796 --> 0:23:25.956 than any number of street pushers could be, and the 0:23:26.036 --> 0:23:32.236 consequences turn out to be really bad. Well, don't make 0:23:32.276 --> 0:23:36.116 me defend the pharmaceutical industry. I have some contempt for 0:23:36.196 --> 0:23:40.036 the industry, just like most Americans, whether it's opioids or 0:23:40.076 --> 0:23:43.596 some other drug there. But that's part of capitalism. They're 0:23:43.596 --> 0:23:46.796 in it to make money. The point here is that 0:23:47.356 --> 0:23:54.156 the pharmaceutical company downplayed the addictive potential of something like oxycodo. 0:23:54.436 --> 0:23:58.076 They downplayed that's a mistake and they should pay for that. 0:23:58.596 --> 0:24:03.396 Now this narrative, they pushed the drugs onto people, and 0:24:03.436 --> 0:24:07.316 these poor people got addicted as a result. That is 0:24:07.676 --> 0:24:13.156 a little troubling because as a patient, as a person, 0:24:13.956 --> 0:24:17.676 if you see yourself getting in trouble with something, you 0:24:17.876 --> 0:24:21.876 bear some responsibility. And now this isn't to stay that 0:24:22.436 --> 0:24:26.116 people shouldn't listen to their doctor, But if you're having problems, 0:24:26.396 --> 0:24:29.796 if you're concerned that you are going to have some 0:24:29.916 --> 0:24:33.876 withdrawal symptoms or something of that nature, you can not 0:24:34.116 --> 0:24:38.956 take it. That's your responsibility too. I'm just trouble that 0:24:38.996 --> 0:24:44.516 we think that it's okay to just completely absolve adults 0:24:44.676 --> 0:24:49.316 responsibility in their own care. That will potentially lead us 0:24:49.396 --> 0:24:54.276 down a horrible path. Let's dive into that a little bit, 0:24:54.316 --> 0:24:58.516 because it's very provocative in the following way. We live 0:24:58.516 --> 0:25:05.036 in a society where we're really unsure about personal agency 0:25:05.076 --> 0:25:10.036 and responsibility in some zones, and addiction is one of 0:25:10.036 --> 0:25:14.036 those zones, right. I mean, for a long time, the 0:25:14.116 --> 0:25:16.596 society did have the view that someone who's a drug 0:25:16.636 --> 0:25:20.476 addict it's his fault or her fault, and the society 0:25:20.516 --> 0:25:22.556 assigned a lot of blame for that and was happy 0:25:22.596 --> 0:25:26.276 to punish people. In recent years, it seems like there's 0:25:26.276 --> 0:25:28.396 been a bit of a shift, and there's a lot 0:25:28.396 --> 0:25:30.276 of talk about whether the shift is driven by the 0:25:30.836 --> 0:25:33.036 largely white nature of the opioid crisis, and that may 0:25:33.036 --> 0:25:36.036 well be the case, but regardless of the whether the 0:25:36.116 --> 0:25:39.476 underlying cause is race driven, there has been a shift 0:25:39.556 --> 0:25:42.436