4.24.2019 / FOLLOW THE DRUGS

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CHARLIE: I guess I should try and tell my story a little bit.

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CHARLIE: My name is Charlie. I am from South Burlington, Vermont. My mother was an alcoholic and whatever you know but it wasn't too bad. I played hockey and won a national championship in prep school and went on to play Division 2. Freshman year, I got injured. I get prescribed this medication and obviously as oneself progresses you know you think you know you're the man and you know I'm an athlete, I'm never going to be a drug addict. Next thing you know you know I'm doing heroin. You know I started experiencing withdrawals. That ended up sending me down a deep, dark path that led to an even deeper abyss. I left, I ended up dropping out of college. I lost everything that I've ever worked for. Literally was homeless, ended up going to prison. My whole time was consumed by getting the next fix.

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SEAN RAMESWARAM (Host): Towards the end of last year, the CDC confirmed that the opioid crisis in America is getting worse.

SEAN: More and more Americans are dying from opioid overdoses.

SEAN: Tens of thousands a year. 

SEAN: It’s a crisis that doesn’t seem to have a whole lot of solutions.


SEAN: But yesterday may
have been a turning point.

CLIP <USA GEOFF BERMAN>: Good afternoon. I'm Geoff Berman. The U.S. attorney for the Southern District of New York. Today we announced the first ever drug trafficking charges against a pharmaceutical company. And two of its executives for illegally distributing prescription drugs that helped fuel the opioid epidemic.

SEAN: We’ve talked about lawsuits against Purdue Pharma on the show before. But now, federal prosecutors, for the very first time, have criminally charged a major drug distributor for its role in perpetuating the opioid epidemic in America.

CLIP <BERMAN>: Rochester drug cooperative or RDC is one of the nation's largest drug distributors. From 2012 to 2017 it shipped tens of millions of highly addictive oxycodone pills and fentanyl products to pharmacies that it knew were illegally dispensing narcotics.

SEAN: Prosecutors decided to treat the executives of a major American drug company the same way they treat street-dealers and cartels. They perp walked the CEO!

CLIP <BERMAN>: This prosecution is the first of its kind. It is the first time executives of a pharmaceutical distributor. And the distributor itself have been charged with drug trafficking. Our office will do everything in its power to bring to justice anyone responsible for unlawfully fueling this opioid epidemic. And that includes executives who illegally distribute drugs from their boardrooms.

SEAN: This is one solution. Calling out distributors who knowingly supply opioids to people who don’t need them.

SEAN: But this crisis needs many solutions and Vox’s German Lopez has reported on another critical part of this picture: how to treat addicts.

SEAN: Before we got into that, I asked him to explain how this crisis began.

GERMAN LOPEZ (Reporter): So there's really three waves to this opioid crisis.

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GERMAN: The first wave is the mid 1990s when Oxycontin came out.

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GERMAN: The marketing for Oxycontin and the campaign that Purdue Pharma the maker of Oxycontin really fueled this idea that opioid painkillers are the safe and effective drug.

CLIP: There’s no question that our best, strongest pain medicines are the opioids. These are the same drugs that have a reputation for causing addiction and other terrible things. In fact, the rate of addiction amongst pain patients who are treated by doctors is much less than one percent.  

GERMAN: And doctors bought it. They started prescribing a lot more of these opioid painkillers and that led to his problem not just where patients were getting these drugs and misusing it but it also made it easier for their kids to pick up an opiate from the medicine cabinet and start misusing it or take it to a party and that kind of thing.

CLIP: Death of a 4 year old boy is now being investigated as a drug overdose.

CLIP: The child’s toxicology results are still pending but they believe they will prove the child overdosed on either heroin or prescription painkillers.

GERMAN: It also made its so patients had access to pills and they would sell them to the black market or to their friends. All in all that led to this proliferation of these opioids.

GERMAN: Then there's a second wave

        

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GERMAN: During the aughts, early 2010s. People who got addicted to opioids eventually transitioned to heroin People were caught off on their painkillers. A lot of people were like well I'm still going to suffer withdrawal and they went to heroin for that. The drug cartels took advantage of the situation they saw this giant opioid problem. So they just flooded the market with heroin. 

GERMAN: And then the last wave is the one we're in right now the one that really started off around 2014, I would say

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GERMAN: A lot of this heroin is no longer really heroin. It's fentanyl and its analogues. Essentially synthetic opioids, they’re like opioids you make in a lab. OK. These are super potent. Some of them like carfentanil is used as an elephant tranquilizer.

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CLIP: It’s called carfentanil, and in the US people are dying and overdosing from the toxic opioid.

CLIP: It was just like, you went from being coherent and then like, you just, like, it’s like a blackout.

GERMAN: You can look up federal agencies warning that this can be used in the chemical attacks and that sort of thing. Like the dangerous thing with fentanyl is that sometimes it's still advertised or sold as if it's heroin. But because fentanyl is so much more potent than heroin if you're a drug user and you're like I'm going to use the same dose I did last time. If you're using fentanyl that's going to be way more potent or risk of overdose is going to be way higher and that's what we've really seen in the past few years it's like tremendous spike in overdose deaths because Fentanyl has come in and really just completely shaken up these street markets.

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SEAN: And who's dying? Who is this affecting? Is it spanning communities and socioeconomic groups in America? Or is it sort of more focused?

GERMAN: For most of the opioid epidemic it has by and large hit white Americans the hardest.

SEAN Hmm.

GERMAN: That's starting to change, there are like rising overdose deaths in black communities as well now. But for the most part it has hit white communities the hardest.

SEAN: How has that changed the conversation around opioid addiction? Comparing it to crack, which mostly affected black Americans and led to mass incarceration?

        

GERMAN: In the 1980s and 1990s. Crack was all over the news.

CLIP <NEWSCASTER>: It was once the rich man’s drug. But as crack cocaine is cheap and abundant, and perhaps most tragically, threatens the future of the poor and the young.

GERMAN: It's typically framed that Nixon started the war on drugs but Reagan is really the one who transformed a federal system into this massive war on drugs machine.

CLIP <PRES. RONALD REAGAN>: Drugs are menacing our society, they’re threatening our values and undercutting our institutions. They’re killing our children.

GERMAN: And that was all in response to crack.

 

CLIP <PRES. GEORGE BUSH>: Our most serious problem today is cocaine, and in particular crack.

GERMAN: Reagan and Bush, they were not just going against drug traffickers and drug dealers. They were going against drug users and they were very explicit about that in their drug plans.  

CLIP <BUSH>: Who's responsible? Let me tell you straight out: Everyone who uses drugs. Everyone who sells drugs. And everyone who looks the other way.

GERMAN: This tough on crime push included even Democratic politicians. So the Clinton administration passed this 1994 bill that was really focused on treating drugs and crime in a harsher more punitive way.

CLIP <PRES. BILL CLINTON>: Gangs and drugs have taken over our streets and undermined our schools. Every day we read about somebody else who has literally gotten away with murder. But the American people haven’t forgotten the difference between right and wrong.

GERMAN: Hillary Clinton who supported the bill at one point made this remark calling people “superpredators”

CLIP <FMR. SEN. HILLARY CLINTON>: They are often connected to big drug cartels, they are not just gangs of kids anymore. They are often the kinds of kids that are called superpredators. No conscience. No empathy. We can talk about why they ended up that way but first we have to bring them to heel.

SEAN: I’m guessing the tone has changed for this opioid epidemic?

GERMAN: Obama and Trump have really taken a more public health approach towards this issue in that most of the money that they've actually put towards this has generally gone to treatment and generally gone to harm reduction strategies, like providing naloxone which reverses opiate overdoses, to police officers, fire departments that kind of thing.

SEAN: Okay.

GERMAN: There are some quirks with Trump.

SEAN: Mm-hmm.

GERMAN: Sometimes what his administration and Congress are doing doesn't match what he is saying. Earlier this year he talked a lot about giving the death penalty to drug dealers. And that's definitely concerning but it's much more public health oriented than it used to be. It's now basically a cliche to say that we can't arrest.

CLIP: We can't arrest and incarcerate addiction out of people.

GERMAN: That's something that you've heard the drug czar's office under Obama repeatedly say.

CLIP: Not only do I think it’s really inhumane, but it’s ineffective and it has cost us billions upon billions of dollars to keep doing this.

GERMAN: If you compare that to like the 80s and 90s, if somebody said we can't arrest our way out of the problem back then they would be laughed out of the room.


SEAN: Hmm.

GERMAN: It would just be taken as like, that's inconceivable. Of course the criminal justice system is not only going to play our role here. They're going to take the frontline main role.

SEAN: How much do these very different approaches, I mean it’s literally black and white?

GERMAN: It's really hard to ignore that when we have a drug overdose crisis involving black Americans, we take this punitive approach.

SEAN: Yeah.

GERMAN: When we have a drug overdose crisis involving white Americans, we tend to take this more public health view. And there are studies out there that show that at least in terms of how people like the general public and lawmakers view black people they tend to have like really discriminatory thoughts like they are more likely to be criminals or less innocent and so on and so forth.

SEAN: Yeah.

GERMAN: If you're a policymaker you are more likely to know someone who died of a drug overdose or struggled with addiction now, because a lot of these politicians tend to be white and in segregated white communities and that kind of thing.

SEAN: Mmm-hmm.

GERMAN: If you've never seen it firsthand, it's really easy to draw caricature in your head of what that's like.

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GERMAN: But if you see that your brother or your best friend or your dad or mom or whatever is now struggling with addiction, that makes it personal. And you do not think wow my brother is suffering, I want to send him to prison. You're going to start doing this in a more empathetic and sympathetic way like OK how would I save my brother's life here. Right. That's essentially happened on a mass scale here, like these lawmakers, who pretty dominantly live in white communities…

SEAN: Yeah.

GERMAN: Have seen this up close and personal and it's made them think of the issue in a more empathetic and sympathetic way.


SEAN: We’ve got a crisis. How to treat it? German’s been traveling the country looking for solutions. What he’s found after a quick break. I’m Sean Rameswaram. This is Today, Explained.

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SEAN: German Lopez, you’ve traveled the country looking at different solutions for this opioid epidemic. What have you found? What’s the solution?

GERMAN: The main solution for opiate addiction are these medications. There’s buprenorphine which is also known by its brand name suboxone, there’s methadone and then there’s Naltrexone. 


SEAN: OK.

GERMAN: The first two in particular buprenorphine and methadone are the most common ways to treat opiate addiction. These are essentially medications that make you no longer have cravings and withdrawal.

SEAN: Yeah.

GERMAN: And that's because they themselves are actually opioids. But the idea is that they're safer opioids and taken on this like medically supervised regimen. And they’re supported by all sorts of health organizations: the CDC, the World Health Organization, and the American Medical Association. So there's a lot of support for these medications and they're really backed by the research.

SEAN: But to be clear that is sort of just like treating addiction with another lesser addiction?

GERMAN: It is often framed that way as if it's replacing one drug with another.

SEAN: Yeah.

GERMAN: But that's not the right way to look at this. The problem with addiction is not drug use. People use alcohol all the time, they drink caffeine all the time. The thing that makes addiction a problem is when that drug use becomes compulsive and so expansive that that's all your life is about, like it starts hurting other aspects of your life. So maybe you stop showing up to work and that kind of thing. So we can take these medications, which are opioids, but they're not using these in a way that's leading to all these other problems.

SEAN: How does this work state to state? Are there places that have figured out how to give people these other drugs... methadone, buprenorphine.. in ways that are better than others?

GERMAN: In Vermont they have something called a hub and spoke system.

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GERMAN: Generally what this means is that it's integrated addiction treatment into the rest of the healthcare system.

SEAN: Okay.

GERMAN: So the hub is an intensive care unit essentially. OK. That's where people who are they might have just overdose, are really at a bad point with their addiction, that they do not have a handle of their condition at all. That's where they'll go and they'll be seen there daily. The spoke is actually just doctors’ offices…

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GERMAN: ...that do this more long term care where they'll like make sure this person is on buprenorphine. Some patients go there every week, monthly, even longer times just to get their buprenorphine. And that's essentially their long term care.

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SEAN: Okay. Vermont has this hub and spoke system. Which is essentially normalizing addiction treatment. Integrating it into everything else. That doesn’t seem that crazy. How did they come up with it?


GERMAN: So in the 2010s Vermont started seei
ng what’s happening with the opioid crisis. John Brooklyn was really the architect of this program.

SEAN: Architect of the program. But also a doctor? Doctor John Brooklyn?

GERMAN: Yeah. John Brooklyn.

JOHN BROOKLYN: So the original idea for the hub and spoke, I presented to the state of Vermont saying let's create these centers of excellence, addiction excellence.

GERMAN: I mean he really described it plainly as like yeah this is just like how we would treat any other health care problem and I thought OK let's let's make sure we're doing this. But for addiction.

BROOKLYN: If someone just had a coronary bypass and they were seen at the local French fry shop eating a double bacon cheeseburger and smoking a pack of cigarettes the doctor wouldn't say Hey man I'm not taking care of you anymore. They be like you have to go back to the hospital and see the cardiologist. There should have been some kind of a network that you can refer that person to to help him get stable.

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GERMAN: And to Vermont's credit it actually saw, based on early data drug overdose deaths drop in 2017 which is very different from the rest of the US where drug overdose deaths spiked.

SEAN: Vermont’s not the only state with an opioid addiction problem. Why aren’t more places doing this?

GERMAN: I went into Vermont expecting to ask this question of like OK, so what was the hardest thing about setting up as a hub and spoke system? And I would expect this response of oh well it costs money to set up these hubs, these spokes and get doctors prescribing these drugs.


SEAN: Yeah.

GERMAN: But that wasn't the biggest problem. The biggest problem by far was stigma. After like decades of saying this is a criminal justice issue, lawmakers and the public still have stigmatising attitudes toward addiction. They don't see it as a health problem. They still see it as a moral failure on the person’s part.

BROOKLYN: You don't have the understanding of the science that's universally accepted. It’s still debatable whether you should or shouldn't be on medication and so when you have that kind of debate you're going to have a lot of people who just kind of fall back and say ah, you know it's it's their choice to do this kind of thing.

GERMAN: If you look at like major medical organizations like the American Medical Association, they will tell you that this is a health issue and you need to treat it like a public health issue as a result. But when you're trying to tell lawmakers that after these years of thinking yeah we'll respond to drug problems with prison. It can take some time to like really walk them through why that's actually not the right approach. Why you should set up this health care system to take care of addiction. That’s apparently what was the biggest hurdle in Vermont, is just walking policymakers through why this is important.

SEAN: And clearly it worked. So how is Vermont paying for all this now?

GERMAN: Most of the funding for this actually comes through Medicaid.

SEAN: Huh.

GERMAN: Because Vermont first of all got a waiver through the federal Medicaid program to actually help set up these hubs and spokes and that kind of thing.  And then most of its patients are actually on Medicaid.

SEAN: How does that compare to other states?

GERMAN: A direct comparison is New Hampshire which is directly neighboring Vermont. It's consistently been one of the worst states in terms of drug overdose deaths. And part of the problem there is there are just large swaths of the state that do not have accessible treatment at all.

SEAN: Hmm.

GERMAN: If there is a treatment clinic it might be weeks or months of wait times before you get care. And this is really important for addiction because the time when somebody says I want to get treatment, it's a really sensitive period. I mean first of all somebody has had to admit that they have a problem which is not easy. Yeah. And then second of all they're starting to go through withdrawal and that kind of thing. Withdrawal is really terrible. It's like imagine the worst flu. Mix it with like horrible anxiety. These people if they say I'm going to get treatment and they face these weeks or months long waiting periods and they have to go through this full withdrawal process, there's a really high chance they'll relapse. And once somebody relapses, there's also a chance that they will just say OK I'm not going to treatment anymore. 

SEAN: Is there a way that fixing this could make financial sense?

GERMAN: The White House actually put out this report where they said that the opiate epidemic cost five hundred billion dollars in terms of economic output. If we're talking about like tens of billions of dollars in federal funding to take care of this issue if we avert another 500 billion dollars from going away that's a massive return on investment. We have the solutions and like treatment and medications and so forth and it's just we're not using them.

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GERMAN: We're talking about hundreds of thousands of people dying over the next decade due to opioid overdoses. And if federal lawmakers don't do something, if state lawmakers don't do something about that that's a lot of people dying on their watch.

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CHARLIE: What ended up happening was, after my like third attempt at rehab, I had decided that OK you know I'm going to try this suboxone thing.

CHARLIE: I took it illegally off the street. When I came in, I finally got my name called and the list. It was a very long list. It absolutely changed my life.

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CHARLIE: I'm still very lucky and put in a lot of work. I went from literally dying, overdosing, homeless, sleeping in the airport. Now I'm lead account executive for a financial services firm and I have a condo, two dogs. I take care of my mother and you know I pay my bills.

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CHARLIE: It's crazy man it's absolutely crazy you know. And I tried multiple times. At first I thought oh you know I'm never going to be on Suboxone I'm never going to be on it. Obviously it's not just the Suboxone but it gives you a crutch and it gives you some hope. Now you're able to not be sick and have a normal stable emotional sense, physical sense. I think that if I did not have the Suboxone I certainly wouldn't be here today.

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