Professor of Psychobiology, Department of Psychiatry, Harvard Medical School; Member, President’s Commission on Combating Drug Addiction and the Opioid Crisis
Health Commissioner, City of Baltimore
Executive Director, Drug Policy Alliance
Managing Director, Foresite Capital
Speakers discuss the growing opioid epidemic in cities across the United States, the influx of inexpensive heroin and potent synthetics such as fentanyl, and the lessons the United States can learn from other countries in curbing the deadly crisis.
ZBAR: Welcome to today’s Council on Foreign Relations meeting with Bertha Madras, Leana Wen, and Maria McFarland Sanchez-Moreno on, “The Growing U.S. Opioid Crisis: Lessons From Around the World.” I’m Brett Zbar, managing director of Foresite Capital. And I’ll preside over today’s discussion. Thank you so much for joining us.
So, immediately on my left, Professor Bertha Madras is a professor of psychobiology at Harvard Medical School, where she’s been on faculty for 30 years. Her research is published in over 200 manuscripts, articles and book chapters. She’s an expert on brain biology and addiction, in addition to being a prolific inventor. She’s also one of six commissioners on the president’s Commission on Combating Drug Addiction at the Opioid Crisis, which just released its report several weeks ago. She’s also former deputy director for demand reduction in the White House office of National Drug Control Policy.
To Bertha’s left, Maria McFarland Sanchez-Moreno is executive director of the Drug Policy Alliance, a nonprofit organization advancing policies that reduce the harms of both drug use and drug prohibition, and promotes the sovereignty of individuals over their minds and bodies. In her previous role as co-director of the U.S. program for Human Rights Watch, Maria developed extensive international and domestic drug policy expertise. In that role, she also advocated for the treatment of the war on drugs as a human rights issue. And in 2013, Human Rights Watch became the first major international human rights organization to call for decriminalization of the personal use of and possession of drugs, and global drug reform more broadly.
And then all the way on my left, Dr. Leana Wen is commissioner of health for the city of Baltimore. I’m going to skip the part about her graduating summa cum laude with a degree of biochemistry at the age of 18—(laughter)—and go to the fact that she’s an emergency physician by training and an ardent patient and community advocate. In her current role, Dr. Wen leads the Baltimore City Health Department, which is actually the oldest continuously operating health department in the United States, formed in 1793. Now has a $130 million budget and 1,000 employees. Leana has been an innovative leader in combatting the opioid epidemic and in the movement to treat addiction as a public health crisis. And has testified before Congress on the topic on multiple occasions. Thank you, again, for joining us today.
So as many in the audience are likely aware, and as cited in the recent commission report, the leading cause of unintentional death in the United States is now drug overdose, killing on average more than 175 Americans every day. The New York Times estimates that the number of drug overdose deaths jumped nearly 20 percent in 2015 to 2016. And at approximately 60,000 drug overdose deaths per year, this number now exceeds the peak number of deaths we saw attributable to HIV in 1995. And of course, two weeks ago President Trump declared the opioid crisis as a national public health emergency. I’m sure we’ll talk more about that later.
So opioids have been known and used for literally thousands of years. We know, in part, the crisis has been fueled by an increase in illicit synthetic opioids that are manufactured outside of the United States, in particular China, which certainly contributes to a national security issue. But we also know that that’s only part of the problem. So, to start off, let’s talk a little bit about why the United States is in this situation and others aren’t. What’s happened here that’s so unique and has led us to the severity of the situation we see today?
Bertha, you’ve investigated, as you said, 20 different causes of the opioid epidemic. Let’s start with you. We don’t have to hit all 25.
MADRAS: (Laughs.) I’ll try to be brief. It began with dreadful science. It moved on to patient advocacy, then on to the pharmaceutical industry that paid close attention to dreadful science. And after that, the FDA, I would have to say, was flummoxed into approving oxycontin as a long-acting, extended-release drug that is, in fact—was claimed as non-addictive. The FDA packet insert that was approved for its distribution said that if you crushed it or if you dissolve it in water, it could be dangerous. And that was a wonderful clue for how to tamper with the drug.
After that, we began a rampant increase in uptake of prescription opioids, particularly oxycontin, which increased dramatically in terms of number of prescriptions. From there, we had a steady increase in the death rates, due to more and more people being recruited into addiction. And then, when some of the drugs became what are called tamper-proof, or resistant to being injected intravenously, and heroin purity increased, price decreased, fentanyl began to be produced once again in offshore sites, we got this tremendous, dramatic increase starting in 2010. And that increase in death rates has not abated.
So in terms of the number of people that I would put—I would point the bony finger at, it would be science—poor science, patient advocacy, physician naivety, poor physician education, poor medical education on pain management, poor medical education on addictions, and as well as many other pressures on physicians by regulatory bodies to declare pain as a fifth vital sign, as well as to manage pain aggressively. In fact, reimbursement was pegged to patient satisfaction with pain management, which put a weight of pressure on the physician to continue to prescribe opioids. I can go onto the other 17, but I’ll stop there.
ZBAR: Leana, as a practicing emergency room physician, did you ever experience that either explicit or implicit pressure to make sure patients left the ER with their pain completely under control?
WEN: Sure. You know, I feel guilty now in thinking about my medical practice, because in my medical training I don’t recall ever being taught about the addictive potential of opioids. Doctors go into medicine, I think, for the right reason, which is that we want to take away people’s pain. And when we’re told, in combination with big pharma and whoever it is who are teaching us, that this is the tool that you have to take away people’s pain, we use that tool that we have available. So I feel complicit in this.
But I also will say that patients too are complicit in this too, that when people fall and bruise their knee, there is this expectation of being pain free versus saying, actually, it’s OK that I have pain a little bit. But I’ll add one more thing to what I thought was a great description of how we got to where we are, which is when we look at the overprescribing of opioids that’s happening—and the CDC estimates that every year there are about 230 million prescriptions for opioids written—that’s enough for one for every adult American to have their own bottle of opioids. Are Americans really in that much pain?
It’s not just physical pain that we’re treating. It’s also something else. And when we look at the areas that are the hardest hit by the opioid epidemic as of late, it’s also the areas that are the hardest hit by unemployment, unstable housing, where people have unstable futures and where if tomorrow is no better than today maybe opioids are the way to go.
ZBAR: Maria, we talked about some root causes. Are there additional factors you think have exacerbated where we are?
SANCHEZ-MORENO: Absolutely. I think one of the key issues that we need to talk about is how the U.S. approach to drugs and drug use, which is fundamentally about criminalization of drug use and sales, has compounded the problem. So when people are afraid that they will be arrested for using drugs, they use those drugs underground. They don’t seek treatment. Moreover, the U.S. has not prioritized providing access to treatment to people who need it.
People do not have adequate education about safe practices if they choose to use drugs. U.S. education around drugs has—you know, with its roots in “just say no”—but has historically emphasized abstinence and has not emphasized things like if you do—while we don’t advise it. We strongly urge you not to use them. If you do use opioids, you should never mix them with alcohol or other depressants, because that dramatically escalates the risk of overdose. And cases of death from mixing opioids with these other substances, are a huge factor in the overdose crisis right now.
Another piece of it is that the U.S. hasn’t invested in programs that other countries have. Many European countries and even Canada have invested in harm reduction programs, which recognize that there is a sector of society that will use drugs no matter how much you discourage them. And if people are going to use drugs, you want them to do that in a way that minimizes harm. So you have harm reduction services which, in many cases in the U.S., you have places that provide sterile syringes so people aren’t sharing needles and spreading HIV and hep C.
But in other countries you also have places where you can have supervised consumption sites. There are more than 100 around the world in 10 countries, 66 cities, where people can consume opioids that they obtained separately under the supervision of trained professionals who can ensure they don’t overdose, who can ensure they don’t contract infectious diseases, and who can refer them to treatment and other services, and ideally move them on the way to recovery. There are other options like—well, other practices like providing naloxone much more freely. And that is something that has recently been adopted more by the U.S. But naloxone is an overdose reversal medication that is tremendously effective and that other countries have been providing through community programs and over-the-counter for years.
And then there’s drug checking, which means that if people do have access to opioids, if they’re going to take opioids, they can check to see if it’s adulterated, to check to see if there’s fentanyl in their heroin supply, because if fentanyl is in their heroin supply it will kill them. Right now, people who use drugs overwhelmingly don’t have the ability to check to see if there’s fentanyl in their heroin supply. And fentanyl has been another enormous driver of the overdose crisis. So if we’re going to address this properly we have to look at best practices in other countries. And we have to move away from this ideological fixation on the criminal justice system as the way to approach it and on just saying no as the main view.
ZBAR: So—yeah, so it’s been now—this is amazing when I realized this—it’s been more than 45 years since we first declared the war on drugs, President Nixon in 1971. Clearly, it’s a war that’s not going so well for us. So you’re talking about, you know, what we can learn from outside the borders that’s working. If you, Maria, had to think about what country from your point of view seems to be bringing together the best combination of those practices, is there one that seems to be getting it?
SANCHEZ-MORENO: I mean, I think there are a number of Western European countries that are—that have put in place good practices. Switzerland is one that had a heroin epidemic in the early ’90s. And people probably remember Needle Park in Zurich. And they turned that around by adopting these practices that I’m talking about, as well as heroin-assisted treatment, which is a way to provide through medical—
ZBAR: Just to be clear, that’s free heroin for—right?
SANCHEZ-MORENO: That is heroin provided under medical supervision in the presence of doctors in certain regulated amounts to stabilize patients who have not been responsive to any other treatment before. And at least it keeps them from getting worse and possibly dying. And it allows an opening to eventually taper down and maybe put them on the path to recovery. So they do that. They do drug checking. They do supervised consumption sites. They provide naloxone widely. Many other countries have some combination of these practices. And then there’s Portugal, which has decriminalized personal use of drugs and also adopted a number of public-health centered policies.
ZBAR: Yeah. So, Bertha, Harvard has a reputation for sometimes being evidence-based. What would you say is—from what’s going on, some of the practices outside of the U.S. What’s your sense of what’s working and, importantly, what’s not working.
MADRAS: Well, first, I’d like to just comment two issues. One is that the opioid epidemic in this country—make no mistake about it—did not start as—is an illicit drug issue that had all the confounds and factors raised by my erstwhile colleague Maria. It started as an iatrogenic epidemic of addiction, period. It had all the regulations in place in terms of controlled substance, prescription-only, regulated in terms of dose, regulated in terms of purity—
ZBAR: And to just say, iatrogenic means caused by physicians.
MADRAS: Caused by physicians. It was not triggered by the factors and the politicization of this—you know, our concept of war on drugs. This was started in doctors’ offices. Fifty percent—and when I served in government 70 percent—of people who use prescription drugs not according to intended mechanisms. They use them because they got them free from friends and family, out of medicine cabinets. And there were no illegal constraints on that whatsoever. And what we have seen in the past 15 years is that no matter how many drugs are legal—these were legal drugs, legally prescribed. If you have enough of a push and a movement to advertise for patients that they ought to have them, untrammeled prescriptions, under a tightly regulated environment, thing can still get out of control. I think that’s very important to stress.
In terms of other countries, what they’re doing, there are some countries that have very rigorous standards on drugs—such as Singapore, which has a very low level of drug use. They’re a tightly regulated society, but they are economically one of the most successful societies in the world. That’s number one. Portugal, I think, is a Rorschach test in terms of who agrees or disagrees with different policies. It has seen more people with addictions. It has seen more opioid overdoses in the most recent years. It has decriminalized all drugs, and it has these committees that you can come in and, you know, be told that you have a certain level, you either go to this treatment—level of treatment or not. But it’s a Rorschach test because they could have done all of this with intense prevention and treatment strategies. The Opioid Commission, in fact, leans very heavily on prevention and treatment.
ZBAR: I think, Maria and Leana, you both wanted to add to this.
WEN: I mean, so I come from Baltimore. And I want to rely to you some things that have been said quite frequently in community meetings around my city, because I think it directly addressed Dr. Madras’ points. In recent years there has been this focus on calling addiction a disease, which is what science shows us to be true. That addiction is a disease and that treating it like a crime is unscientific and inhumane and, frankly, ineffective—that the war on drugs doesn’t work. But people in my city have stood up at community forums and said: Why is addiction a disease now? Because we have had the heroin epidemic in my city for decades. We had the crack epidemic in my city for decades. Prescription drugs, no doubt, play a big role. And I, as a physician, am complicit in this. But we cannot ignore the roots of where we came from in inner cities.
Now, when it is that poor minorities in inner cities had this addiction, somehow it was not called a disease, that it was considered to a choice, a moral failing. And therefore, if you ended up in jail or dead, it was a choice that you made. And I think it does need to be said that we owe an apology to generations of black and brown people who have faced this injustice, and that this inequity is part of our history that we also have to address. Not saying that we should ignore the prescription issues and big pharma and regulatory issues that also got us here. But I think we have to be honest about where we came from, and that needs to be part of our solution as well. We are addressing this in Baltimore. And I think we have a lot of innovative practices that I’m—that I think we’ll get to talking about. But I couldn’t help but add this perspective, representing where we come from in our city.
SANCHEZ-MORENO: Can I—just very quickly on Singapore and Portugal. All the studies that I’ve seen on Portugal, and the data, indicate that actually rates of problematic drug use in Portugal have decreased since they decriminalized, and that overdoses have decreased, and that people are more referred to treatment, and they’re less likely to get infectious diseases, and that overall it’s been a success of multiple levels. As for Singapore, I don’t see how we would ever want to compare ourselves to a country that supports the death penalty for low-level drug offenses and caning and whipping for people who use drugs. Not to mention, this is a country where the drug—that doesn’t even track numbers of drug use effectively. So we don’t actually know what’s going on in Singapore.
But on the race issue, I do want to underscore that because one of the enormous costs of the U.S. having emphasis on criminalization has been with the dramatic scale of arrests and incarceration of, overwhelmingly, people of color for drug use and other drug offenses. Drug use is the single most arrested offense in the United States. People are arrested for drug use more than twice as often as for all violent crimes combined. White people and black people use drugs at the same rate, but black people are three times as likely to be arrested for drug use. So—
ZBAR: And you should—just you should point out that among those deaths that are occurring through the opioid use, 80 percent are non-white—are non-Hispanic white deaths, right?
SANCHEZ-MORENO: Yes. So now with the opioid crisis, we’ve seen it seems in some sectors greater openness to treating drug use as a public health issue and not criminalizing it. And many people in communities of color look at that say, oh, it’s because it has a white face and now you want to treat it nicely and there’s this kinder, gentler approach. That’s a mixed—there’s some reason to doubt whether there really is a kinder, gentler approach in many places because while some—there have been some states passing, for example, good Samaritan laws to help people—to make sure that people aren’t afraid to call 9-1-1 when they witness a drug overdose, and that they won’t get prosecuted for doing so, that’s been undermined recently by a dramatic rise in the number of prosecutions for what’s called drug-induced homicide.
So hundreds of prosecutions in many states of people who were present at the site of an overdose, because they supposedly shared drugs or provided drugs, and were therefore responsible for murder. So that completely wipes out the good Samaritan law effect and raises doubts about the kinder gentler approach. And I’ll just say one more thing, which is that President Trump and Attorney General Jeff Sessions, even though the commission’s report emphasized a lot of public health measures, both of them have been using the opioid crisis as an excuse to push for much harsher sentencing measures, for a border wall which will do nothing around fentanyl, and for increasing the number of people who are prosecuted, particularly immigrants, for offenses that in the past they wouldn’t have been, so.
MADRAS: Well, I think that, as I said, Portugal is a Rorschach test on which side you want to take with regard to permissiveness towards drugs or a more stringent approach to society, because the data I’ve seen completely contradicts yours. And Singapore’s data I actually have seen, and low—there’s very low levels. In fact, there’s very low levels of drug use in our country amongst people of Asian origin, particularly Chinese, Taiwanese, and so on. It’s about 3 percent. It’s about one-quarter of the percentage of use amongst whites and African-Americans and Hispanics. And so there is obviously a very robust cultural difference between certain families and certain cultures that have an aversion to drugs.
The one thing I would like to comment on with regard to the so-called war on drugs, is I really don’t understand what the goals are of the statement that the war on drugs is a failure. It has been, in the 20th century, with regard to opioids, a remarkable success. There was a dramatic decline in Asian opioid use—90 percent—because of international conventions, international control of supplies, international production controls. And in the—globally, these are United Nations Office on Drug and Crime data, in the rest of the world the decline was close to 70 percent because of regulatory oversight. In the 2000s, we saw a definitive decline in cocaine use in our country because supplies went way down. The cost was too high, too prohibitive. And we saw an approximately 20 percent drop in marijuana use from 2002 until about the beginning of 2008 or so, amongst youth, high school students, and—different surveys—12-to-17-year-olds.
It is—what we have to recognize is that drug use is a fluid thing. There are people who will never touch it due to religious reasons or cultural reasons. For example, the Asians—
ZBAR: Let’s go—let’s go to Baltimore today, because I do want to make sure we have a chance to talk about that before we open it up to questions. And just out of curiosity, little moment of audience engagement, how many people—sorry, member engagement—how many members in the room know what naloxone is, just by a show of hands? OK, that’s really good. Maybe, Leana, tell us—just want to make sure everyone is away of what you’ve done in Baltimore as it relates to naloxone and how you’re measuring the impact of that.
WEN: Sure, absolutely. So numbers from Baltimore—and I feel we often hear these numbers of overdose, and it becomes overwhelming. And it is. In my city last year, and our city is 620,000 people, we had 694 overdose deaths last year, two people a day. We talk about homicide, and sure violence crime is a big issue and closely tied in some ways to drug use, but that’s twice the number of people who died from homicide is the number of people who died from overdose. Speaking of fentanyl, the number of people who died from fentanyl in my city has increased by 50 times—not 50 percent, 50 times—in the last three years, because fentanyl is such a strong opioid and is now being mixed in with heroin and other drugs without the person knowing it. And so they’re using it, overdosing, and dying.
I’m an ER doctor. And in my work, the—our first principle, other than first do no harm, is to save the person in front of us who needs help. If someone is dying in front of me now, it’s my job to save their life. I can—it’s not my job to judge them. I do want to get them into treatment later. But if they’re dead today, what’s the point of getting treatment tomorrow? And so understanding that naloxone or Narcan, it completely reverses the effect of an opioid overdose. Somebody who has overdosed will have stopped breathing. And they have minutes to live before their brain shuts down and the rest of their body also dies. If I give them naloxone right now, they could be walking and talking within 30 seconds. There are very few antidotes in modern medicine. And naloxone is one of them.
And so we said, it shouldn’t just be paramedics and doctors who can save someone’s life. And lot of other jurisdictions have started training the police. We have too, but it’s not just the police. Everyday people are actually in the best—in the best position to save lives, because if your family member is overdosing by the time you call 9-1-1 it may be too late. Or, if you see someone on the street, you can save their lives now. So I write a standing order, which is a blanket prescription, two years ago in October of 2015 to every single resident in our city. And ever since then, we’ve done over 30,000 trainings of—just around the city—where map out where overdoses are occurring. And we do trainings in public markets, in bus shelters, in—really wherever it is that people are.
And within two years, we have saved nearly 1,500 lives of everyday people saving lives of other people that they’re finding—family members, community members, and friends. I’ll also mention, to the point about harm reduction, that we started a needle exchange in our city more than 25 years ago. The percentage of people with HIV from IV drug use in 1994 was 63 percent. That number now is 7 percent. Again, we don’t condone drug use, but it is some—we believe in saving people’s lives now.
That said, what we’re missing is the connection to treatment. It is very hard. You know, we haven’t talked about this here. We talked a lot about supply and why supply of drugs is a problem, but we’re not going to solve the epidemic of addiction of the epidemic of overdose unless we also address demand. Only one in 10 people, according to the latest surgeon general’s report—only one in 10 people with the disease of addiction in the U.S. are able to get the help that they need. What other disease would we ever find that to be acceptable? And so we still—we have millions of people who need treatment. And that demand for drugs will continue to fuel supply unless we can address that as well.
ZBAR: Well, actually, it’s—we could go on for hours. You only have until 2:00. So at this time I’d like to invite members of our council to join our conversation with their questions. As a reminder, this meeting is on the record. So please wait for the microphone, stand, and state your name and affiliation. And please limit yourself to one concise question so we can just allow as many members to speak as possible.
Q: Hi. I’m Mitch Rosenthal. I’m the head of the Rosenthal Center on Addiction Studies. But for 50 years, I started and ran Phoenix House. So I’m a treatment guy. And I like to see people get well.
So, Maria, it brings me to your humanistic point about harm reduction, and asking you to tell us how do you—how do you get the border between harm reduction and enabling straight? I mean, how many people in the harm reduction programs are you really helping to move into recovery. I know that’s the goal, but does the harm reduction get in the way of itself?
SANCHEZ-MORENO: So the data that’s available, from programs in other parts of the world—for, example, the Insite program in Canada, the supervised consumption site, indicates that of—in these places—for one, no overdoses ever happen in these sites, which is lives saved right there. But, two, in many cases—in hundreds of cases they have given referrals to people to go get treatment. And that is an opening that right now does not exist when you approach this from the criminalization lens. So it’s more than—
Q: Yeah, I don’t—I actually don’t find that persuasive, in that I feel that most people who are given a referral don’t go. The fact is that if you look at a treatment program, especially a long-term treatment program, where the most disordered people need to be, most of the time people have to be coerced into treatment by family—
SANCHEZ-MORENO: The data on—
Q: Let me finish. Let me finish. By family, by friends, or by law enforcement. They don’t—they don’t take a referral slip and go and walk three blocks and get into treatment.
SANCHEZ-MORENO: The reality is that coercion doesn’t work either. It’s very equivocal data around the effectiveness of coercion. So, I mean, we could disagree here, but—(laughs)—
ZBAR: Bertha, what do you—
MADRAS: Number one, the Insite program that my colleague has referred to, less than 5 percent of people have been through treatment. And they have been running for almost 10 years. So your point is very well-taken, people may get a slip and say here’s a treatment center. That doesn’t mean motivational interviewing or any form of motivation to get them in. The second issue is the drug courts, which we have asked for an expansion of in all 93 federal districts, the drug court data that I have examined in great depth, because I scoured the primary literature when I was at ONDCP and I’ve kept up to date with the National Association of Drug Court Professionals since then, shows—and these are NIDA data—shows that the outcomes are as good or better for coerced treatment compared with things—same old, same old. Now, the most interesting thing is that in some areas in some courts—that have drug courts, people don’t want to take it. They would rather go to prison than to go into treatment.
SANCHEZ-MORENO: That’s right.
ZBAR: Leana, what have you seen?
WEN: So I’ll tell you what I see as an emergency physician, which is that I have patients coming to me in the ER all the time saying: I have hit rock bottom. This is my rock bottom. I want treatment right now. And you know what I have to tell them? I have to tell them: I’m sorry, but the earliest I can get you a treatment slot is in three weeks or a month. I’ve had patients overdose and die while they’re waiting, which I think is testament to the failure of our system. You know, what I would love more than anything is to when people are ready for treatment, I want to get them to get that help. I mean, they’re asking for help. We should be able to do that. We need to expand treatment capacity. And I also strongly believe I the warm handoff. So somebody says: I’m ready for treatment. I don’t want to give them a slip of paper. I want to have them be brought to that treatment facility because they’re asking for help right now.
But I will say that, you know, we need to increase treatment overall. I also think that the harm reduction approaches, coupled with treatment, are so critical because, again, if somebody’s dead right now, what’s the point of getting them treatment tomorrow? I have many people working on—working in harm reduction, working on our needle exchange stands in Baltimore, who are in recovery themselves. They are peers who are in recovery. And they are much more credible messengers than I am. I can tell somebody, oh, drug use is bad. You should get into treatment. But for someone who’s been there, or family members who have been there, it’s extremely powerful. And that’s what I see every day.
ZBAR: OK, let’s take our next question. We’ll have a chance to cover more.
In the back, yes.
Q: Thank you. My name is Nina Schwalbe. I’m with Sparks Street Consulting. And I have a question on a slightly different track around palliative care and the extent to which you see the hysteria and debate potentially affecting access to appropriate palliative care, maybe perspective in policy and in Baltimore itself.
MADRAS: I don’t think it’s an issue at all. I don’t think that that has ever come up on our radar screen, to cut off opioids for palliative care, period. It’s not on our radar screen. It’s not in the recommendations. It’s not even discussed. We constantly have the refrain of there’s no evidence that opioids are effective and safe from chronic pain that’s moderate. But we do not question the use of opioids for end of life care, for cancer pain, for acute post-surgical pain—even though a paper came out this week saying that ibuprofen is just as effective for acute pain. So I don’t think that—I just don’t think that’s an issue. I don’t think we’re ever going to see zero prescription opioids. I will not ever predict that. I don’t think there’s a concern.
SANCHEZ-MORENO: I will say that it does seem that in some jurisdictions, at least, doctors are now afraid of prescribing opioids to people who do need them. And it’s been an issue in the past too. For example, with people with sickle cell disease, who are black, often being unable to access painkillers, even though they’re in acute pain, because they’re perceived as drug seeking, right? There are practices like that, that are troubling. And it’s something to watch out for. I do recognize the commission mentioned the importance of palliative care in its report. And I hope that that’s monitored. But also, to bring in the global perspective on palliative care, there are many countries around the world where opioids are so tightly restricted that people who do suffer from cancer or are at the end of life cannot access pain medication. And they are in excruciating pain. So that’s another thing to look at.
ZBAR: Great. Next question. Yes.
Q: Hi. My name is Nili Gilbert from Matarin Capital.
We haven’t yet discussed the role of pharmaceutical companies in this crisis. Certainly, dozens of lawsuits have bene filed from municipalities all around the country at this point, and certainly a huge amount of revenues have been generated over the years. I would love to know where you see the role of pharmaceutical companies in the crisis, and whether there are any measures beyond revenues that we might look at in assessing the level of responsibility in contributing to the crisis.
MADRAS: I would not like to weigh in on the lawsuits, but I can certainly weigh in onto the role in the originators—as the originators of this crisis. They sponsored, and one company in particular is Purdue, sponsored 20,000 teaching events for the American Pain Society, for the American Pain Association, for patient groups, activist groups, and so on, for a physician—medical association meetings, and so on—20,000 of them. I remember the number that they spent on these, but I won’t cite it here. They were part of the problem. They even sponsored events with the Joint Commission on the Accreditation of Health Care Organizations, which accredits quality of health care services. So they were a very critical issue. And there are many lessons to be learned about this with regard to when you put a lot of big money behind a movement, and you listen only to the patients that want certain drugs and not listen to counter-voices, these are lessons learned for the future.
WEN: If can add—I mean, I certainly agree that big pharma has a huge role to play. I mean, I remember in medical school having—not even questioning why was it was that pharmaceutical reps are there trying to teach us—which I think is quite offensive actually, that we shouldn’t be learning from scientists and doctors but from drug reps. I also think, though, that it’s not only—so I do think that big pharma should be held to account with resources and everything else. But I also think there are other actors as well, including the federal government. And I have to say this, in—President Trump recently, in the last couple weeks, called the opioid epidemic the—a public health emergency which, yes, semantically sounds correct, that it is a public health emergency. But by declaring it a limited public health emergency it did not have the full weight of the federal government behind it. And therefore, this declaration came with no new resources.
And I find that to be very troubling, because when we talk about the opioid epidemic, in the U.S. at least, we know what works because we look at municipalities within the U.S., we look at international examples. We know evidence-based practices that need to be scaled up. We know that resources are needed. I mean, in the time that we’re having this conversation nearly 10 people in the U.S. will have died from overdose. This is clearly an epidemic that has a solution. If there were Ebola and we had antibiotics available but we weren’t giving them, I mean, there would be a national outcry. So why aren’t we don’t this—why aren’t we committing the resources to it now?
Not only that, but—
ZBAR: A question along those lines, and it ties back a little bit to the pharmaceutical companies and innovators, I mean, we are at a place where you’ve got some companies developing—whether it’s abuse deterrent formulations or digital treatments for addiction or novel approaches for medication-assisted treatment—are any of those having a near-term impact? Are any of those particularly—are you hopeful about any of those?
MADRAS: You’re asking me? Well—
MADRAS: —I’m very hopeful. The reason that there was no money allocated in our commission report is that we charged many federal agencies with very specific responsibilities, including CMS, Medicare, Medicaid, including the CDC, including the FDA, and so on, asking them to step up and do certain things. The issue is that once the report is—right now it’s going through vetting through all these agencies—we are going to have comments coming back to us. The dollar signs we were unable to allocate because we didn’t know how many of these are in fact doable, legal, and so on.
We’ve heard, for example, from the insurance companies, they’re part of the problem. They wrote off—they approved prescription opioids indiscriminately for patients. Ninety Percocets for a dental extraction, 30 Percocets for a sprained ankle that goes away in a day. They approved those without any question. But they put stumbling blocks in the way of medication-assisted treatment that required preapproval. They put stumbling blocks on treatment-assistance. So there are so many players in this. It’s a complex problem.
The second, I just want to finish with regard to treatment. Mitch Rosenthal is one of the heroes of this nation because he’s devoted 50 years to developing proper treatment. I have been to treatment centers all over the United States. And I have also done a table for NIDA, for the National Institute on Drug Abuse, matching principles of evidence-based treatment with what’s out there for the 14,000 treatment centers that exist.
And the mismatch is dreadful. It’s less than 30 percent. So to say we just got to throw money at treatment without developing quality standards for what is good treatment, what are good outcomes, what re outcome measures, what is the accountability of treatment centers, I think is folly. Because if half the people go into treatment and fail, people are going to say we’ve wasted more money.
ZBAR: I think—I think—I know Leana has something to add to that.
WEN: There is a gold standard for treatment. The CDC, WHO, AMA, every major medical organization in the U.S. says that the gold standard for opioid treatment exists, which is a combination of medication-assisted treatment, psychosocial counseling, and wraparound services—that the combination of these services reduce the incidents of illness, reduce criminal activity, also reduce overdose deaths. The evidence exists. We do have problems of access to treatment. Actually because of Obamacare, the Affordable Care Act, 1.6 million more people are able to access substance use disorder treatment. So gutting it or gutting Medicaid will have profound consequences.
But you know, I think that it would be misleading for us to say that the—that the treatments don’t exist, because there are millions of people in long-term recovery. We also have to recognize that addiction is similar to other diseases. If a patient comes in with diabetes or heart disease, it’s possible that that person will say, well, I’m going to change my diet from now on and always be compliant with my medications. But there will be many others who may not be compliant and may have relapses. And we have to recognize that relapses are a part of recovery, and that we need to be ready for people, of whatever part of the spectrum they come in.
MADRAS: Why do only 30 percent or less or physicians that have buprenorphine waivers exercise them? We don’t have the workforce because a lot of people are not interested in getting into treatment, into the treatment community, and helping people. We have to solve many problems before saying these are the gold standards. The gold standards are not reduction to practice. Reduction to practice is the critical piece to this.
SANCHEZ-MORENO: I just wanted to add, I think one of the—
ZBAR: Yeah, well, do you want to make your point quickly, and then we’ll get to more questions.
SANCHEZ-MORENO: One of the—one of the good things about the commission’s report is that it endorses medically assisted treatment. And so I’m very pleased to see that. but I want to underscore that most drug courts have, in the past, not used medically assisted treatment. And part of the problem with using drug courts is that their treatment is ultimately being supervised, decisions are being made, by criminal justice experts not medical professionals. And that can lead to very serious problems down the road. And it’s also the fact that in many cases people who relapse in drug court are treated as people who failed out of drug court, when relapse should be treated as part of recovery. And so people fail out of drug court. And this is part of why people would rather go to prison than go to drug court. Because when you fail out of drug court you actually face a longer sentence than you would have in the first place, so.
ZBAR: Let’s get as many additional questions as can. Yes.
Q: Mark Kleinman from the Marron Institute at NYU.
You mentioned earlier that if we could reduce the number of people using alcohol in combination with the opiates, we could reduce the death rate. As anyone estimated the reduction in opiate mortality we’d get next year if we tripled the federal alcohol tax now? That seems to me like a number somebody ought to run.
ZBAR: Not sure if we have the specific answer to that one.
SANCHEZ-MORENO: (Laughs.) We haven’t.
ZBAR: Yeah. In the back, yes.
Q: Hi. I’m Chris Glazek with The New York Times Magazine.
So I want to return to Portugal briefly because, you know, the number that everybody cites in the media constantly is that when Portugal implemented decriminalization, that drug overdose deaths decreased by 85 percent, and it ticked up slightly since then but it’s still, like, a fifth of the European average. I mean, that’s not harm reduction; that’s harm obliteration. But are those numbers wrong?
MADRAS: Well, the numbers that I’ve seen recently are that the death rates are rising quite dramatically. And they’re rising all over Europe because of fentanyl, in fact. Fentanyl is hitting Sweden, which has a very strong anti-drug policy. It’s hitting many countries in Europe now. So I do think that fentanyl is throwing quite a wrench into all those numbers. It’s a new drug. It’s different. It’s not new; it’s very old. But it’s a new problem, a new challenge.
SANCHEZ-MORENO: To be clear, the overdose rate in the U.S. is way, way higher than in any of these other countries. But, yeah, fentanyl may be driving an increase in overdoses, but imagine how much higher the overdoses would be if people weren’t able to access safe consumption sites and get their drugs tested, and so on. So you have to consider those two things.
MADRAS: Well, so much more to say.
ZBAR: Other questions? Yes, in the back.
Q: Hi. I’m Lindsay Hayden. I’m a physician as well.
I just had a question. So I trained in the U.K. And I know that you mentioned the demand side, which clearly needs to be addressed. But on the supply side, you know, as a doctor there is no way I would have been allowed to write scripts for a month’s-worth of opioids. I mean, literally a week and then people have to come back and see you again. I was wondering—and, again, apologies for my ignorance of the American system—why that hasn’t been able to be implemented here in any way, shape, or form? And why—you know, physicians are still allowed to write scripts, ad nauseum, without any oversight?
MADRAS: Well, first of all, the practice of medicine is a state issue, not a federal. So we have to remember the approval of drugs and the control of drug protection is federal, but the states regulate their own practice of medicine. There are a number of states currently that have limited first prescriptions to seven days. And some of the states are toying with three days. And to your point, on average of the 30 countries that are the highest prescribers of opioids in the world, the United States ranks number one, and it’s on average five times more opioids that are being prescribed in the U.S., compared to the average of those 30 countries.
And, as I said, marketing, patient advocacy, all these issues that went into this dramatic crisis—what I call a national nightmare—was unique to the United States. We had an opioid epidemic starting in the 1840s. It lasted until 1910. It was medically induced. And it disappeared because of regulation. Then we had a period of about 70 years where there was generational remembrance. And then a five-sentence letter to the New England Journal of Medicine changed everything.
WEN: I think that things are changing. It’s changed since I was—since I was in my residency training to how, where physicians are finally talking about the role that we have in the opioid epidemic, how can we restrict our own practices. The CDC put out guidelines last year to call for more careful prescribing of opioids. So I do think that tide is turning. I think that this is a good call for us, though, to say, yes, the issue is complex and yes there are many inputs. But there are specific things that groups can do. Physicians can do something. Patients, we can all be asking questions of our doctors.
So I have—I’m a new mom. I have a—I have an 11-week-old baby. And I was very fortunate to have a very normal birth and I wasn’t in pain afterwards. Actually, I felt so terrible in pregnancy that I felt much better once I gave birth. (Laughter.) But I was prescribed opioids leaving the hospital. And I was wondering why are you—first of all, why are you giving me opioids? (Laughter.) But why are—why am I being offered opioids at all when I haven’t required any pain medications my entire hospital stay. Why am I getting opioids on discharge?
So I think that there’s something that we as patients can do to say, do I really need this? And we know that people are also misusing opioids that they find in other people’s medicine cabinets. So let’s get rid of our own opioids that we have. And I think, critically too, we need to ask for resources, because resources are needed. You know, there was—there were questions raised before, about, well, we can’t just throw money at a problem with the solution, I would argue. But in this case, we have the solution.
For example, we mentioned Narcan or the opioid antidote in my city. We have been very successful at saving lives because of Narcan. However, I actually have to ration this medicine. I have 10,000 units to use between now and July of 2018. So every month I have to make a decision about who gets this medication. I mean, that is the definition of rationing. If I have 10,000 units today, I can give them out by Monday. So when it comes to resources and what we can do to save lives, there are actually tangible things that we can do. It’s not throwing money at the problem. It’s using it wisely in an evidence-based manner to save lives.
MADRAS: Yes, I agree.
ZBAR: Great. Yes, in the back. Please.
Q: Oh, hi. M.L. Flynn from NBC Nightly News.
ZBAR: Oh, can you wait for the microphone, please? Sorry.
Q: Sorry. Hi. M.L. Flynn from NBC Nightly News.
How do we get our hands, though, around—how do we tackle synthetics like fentanyl? I mean, what’s the best strategy?
MADRAS: Well, there’s—fentanyl is very different than even heroin, for the following reason: In heroin production one can take a drone over Afghanistan, or over Mexico, on the western edge of some of the provinces in Mexico. I’ve seen those photographs in meetings. And you can wipe out—you can eradicate the supply. With fentanyl, it is produced in a lab, it’s fully synthetic. The synthesis now is very few steps, so it’s very easy to make. And it is shipped in small envelopes. And 2 ½ milligrams can either make you high or kill you. Two-and-a-half milligrams is a couple grains of salt. So one envelope can service 50 people. There are no postal tracking of these shipments. FedEx does it. The U.S. Postal Service does not. Every single one of these things I’ve mentioned is a recommendation here. And that is adequate tracking.
None of you may remember that in 2006 we had a fentanyl overdose crisis in the United States. It lasted until the beginning of ’08. We had over 1,000 deaths due to fentanyl. And heroin deaths have been steady, steady, steady, and suddenly there was this dramatic spike, which alarmed me. And so we created a taskforce to try to deal with it. And then the spike disappeared back to baseline, until it started to increase in 2010. The super lab in Mexico was the prime source—
ZBAR: It may be—it may be worth pointing out another of the challenges with fentanyl, and synthetic fentanyl, is the derivatives, and the ability of labs to basically create many derivatives that are impossible to track in most toxicology screens, and also have very vague legal status.
MADRAS: That’s right. So, in any case, this super lab was taken out. End of problem. But fentanyl—
ZBAR: Can I—
MADRAS: —carfentanil now is raising its head as number two after fentanyl. There are multiple derivates. If you look at a patent, you can see you can make several hundred of them. And that’s the problem.
ZBAR: So recognizing the challenges, what seems to be working, Maria and Leana?
SANCHEZ-MORENO: Well, what seems to be working, I’ll say, is going back to education and drug checking and all of these other harm reduction measures that I mentioned before. I don’t think most people want to take fentanyl or carfentanil, knowing that it can kill them. It’s in their heroin supply. It’s adulterated. And people don’t know it’s there necessarily. So that’s one part of it.
But I just want to flag that, you know, I think we need to do some hard thinking here about our overall approach to the drug supply, because—I worked on Colombia for many years. I’ve seen the U.S. pour billions of dollars into enforcement and trying to arrest, extradite, kill, stop drug suppliers in many ways. And I met many of them. I met many of the drug lords in Colombia. And they always had somebody else in the wings who would take their place when they were arrested because the illicit market in drugs is so profitable. And you’re talking about countries sometimes there are no other—you know, there are few other opportunities. And this is just incredibly appealing.
So we’re up against something that is very, very hard to eliminate entirely. So what are alternative approaches? And when you talk about going after heroin, and then how heroin leads to people creating synthetics. And, you know, if you go after fentanyl, people make carfentanil. This is a standard progression. You know, you squeeze the market in Colombia and coca production moves to Peru. Again, big questions.
WEN: Supply and demand, that unless we stop the demand for drugs—I mean, the people in my city who are dying are people who have been using heroin for years. And now fentanyl is mixed in, and they’re dying. So I think it’s hard for us to stop the opioid or the fentanyl overdose deaths without addressing demand.
I’ll mention one more thing too, that I think hasn’t come up yet but I think is important for our conversation, which is around education. A lot of people want to say—and it’s become a very bipartisan phrase—to talk about education. But education, when it comes to the “just say no” campaign, is not going to work. And here’s why, if I go to any of my schools in Baltimore and I ask people, students, is heroin good or bad? Unless the kids are trying to be snarky, they’re not going to say heroin is good. They know heroin is bad. The problem is that people don’t turn to drugs because they think it’s fun. They’re turning to drugs because they’re treating something else.
And there is deep childhood trauma in communities like mine, but in communities across the country and around the world, there’s deep trauma and adverse childhood experiences. We know that children who experience trauma are much more likely to have substance use disorders. And in order to stop the opioid epidemic, we also have to be investing in our children and promoting general well-being and providing social services, because if we can’t ensure that the life that the child is going to grow up to be is a good one, they’re going to want to escape from it using drugs or something else.
ZBAR: OK. Well, we have a tradition at the Council of concluding on time. So I want to thank our panelists for a terrific discussion. (Applause.) Thank you.