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