 Aloha, and welcome to Hawaii Together on the Think Tech Hawaii Broadcast Network. I'm Kayleigh Ikeena, your host today, and I'm president of the Grassroot Institute of Hawaii, a public policy think tank. In my work at Grassroot, I occasionally get to travel to other parts of the country and meet people who are involved in public policy. Today I'm delighted to have a gentleman who is not only a medical doctor, a surgeon in private practice in Phoenix, Arizona, but also is highly involved in crafting policy which helps us determine how we think about issues related to health, such as drug overdose. My guest today is medical doctor Jeffrey Singer, who's going to tell us a little bit about opioids and why what we've learned to call the opioid epidemic or crisis may not be all we think it is. He'll expose some of the myths and he'll give us a few solutions to the real problem at him. So please welcome to the program today Jeffrey Singer. Dr. Singer, welcome to Hawaii Together. Good to have you on board. Thank you for having me. It's a pleasure to be here. Well, it was great meeting you recently at a conference where thinkers from across the country came to talk about how we can improve our health system. And maybe let me just start off with this question. How is it that you as a medical doctor who's busy practicing the craft of surgery is also involved in national public policy? Well, first of all, I've always had a deep interest in public policy and political philosophy since my undergraduate days. And as my practice matured and I was able to take more personal time off, I started putting that time into delving into research and public policy areas and became affiliated with the Cato Institute in Washington. At first as an adjunct and then in my more recent years as I became older, I worked with my partners and I actually a few years ago reduced my practice to part-time and turned up my activity with the Cato Institute as a senior fellow to full-time. So now I'm working more hours actually in public policy than I was in medicine, but I still love practicing medicine and practicing surgery and interacting with patients. So I'm still doing that. And plus that helps me keep much more abreast of what changes that are happening in the field of medicine because I'm still in it. Well, Dr. Singer, your public policy application sometimes takes you into very high-level discourse on policies in terms of how we operate our national health care system, how we run it in the states, what the industry is doing right and doing wrong. And yet at the same time, you have a deeply personal concern for those who are falling through the cracks, particularly those who are affected by their treatment or their use or misuse of drugs. How did your interest in that develop? Well, first of all, I jokingly say that I inflict pain for a living. I'm a surgeon. So most of what I do for the last 40 years is either addressing people in pain or in order to help deal with their pain and inflict more pain through performing surgeries. So I have to deal with people in pain and give them medications to help them control their pain as a part of what I do. And I see what suffering looks like. And so when this whole discussion about the overdose crisis that's related to opioids came to public attention, it was just only natural that I directed my attention to that because it's what I do. It's a part of my work, my everyday experience. Now you talked about prescribing medicine for the sake of handling pain. Pain is a terrible thing, although sometimes it's helpful in order to determine what's wrong with somebody, but people need to manage their pain, which brings us to the whole issue of opioids. Can you help us start just from ground zero because we're going to talk about opioids today? Define what that is. What are opioids and why do they exist? What are they for? And how do we use them? That's important because a lot of people don't understand it yet. Policymakers make all sorts of regulations about it even though they don't understand it. So first of all, the opium plant, the opium poppy, provides us with certain compounds that help relieve pain. And compounds derived directly from the opium plant, such as morphine and codeine, are called OPS, OPIATES. Codeine, actually when we take it, your body breaks it into morphine and then a byproduct. And it's the morphine in the codeine that gives us the relief of pain. Opioids, on the other hand, are compounds like morphine that have had some chemical modifications to them that usually make them function more quickly or more powerfully. Whatever chemists and pharmaceutical engineers are trying to arrive at, so those are called opioids. And out of those, the most commonly ones we know about are what are called semi-synthetic opioids, which means that part of it is the original opiate. Like, for example, oxycodone or Vicodin hydrocodone, those are semi-synthetic opioids because part of them is chemical additions to it. By us, the rest is the original opiate. But then there are completely synthetic opioids, so they're manufactured right in the test tube to resemble the opioid plant, the opioid product. For example, methadone is a synthetic opioid fentanyl, very strong synthetic opioid that's used a lot. We've used it to perform anesthesia on people that's an anesthetic. It's used in critically ill patients. And it's also made mostly, it's not in a powder form. It's usually made in like a patch that you put on your skin, just like a nicotine patch. And it slowly gets absorbed through the skin on a patch for people who need it in a more outpatient kind of setting. Usually people with very severe pain. So that's kind of, I just kind of gave you the spectrum of opioids. So when we talk about opioids in general, we usually mean the opiates and the opioids. The opiates are the ones that have not been synthetically modified in any way. So how do opioids and opiates actually get into the population? I can imagine that there are two avenues in general. One is they're prescribed by medical practitioners for the management of pain, and that's how people get them. The other way I would think is that, or what would be an illicit acquisition of these drugs and use of them. How extensive is that as well? Well, first of all, the opiates have been around for centuries. I mean, they were written about back in the days of Homer. The word morphine comes from Morpheus, which I believe was the Greek god of sleep. So they've been around for a long time to deal with pain. And even back in the 1800s, it was very common for people to have opium elixirs. A very popular one was known as laudanum, which people would take for painful conditions. In the 20th century, we began to make these improvements. So for example, oxycodone, an opioid, was developed around 1913. Methadone was developed in Germany in the 1930s. Hydrocodone was also developed in the early part of the 20th century. So we began using them to treat pain. Heroin, which is actually an opioid, is called di, the chemical name is diacetylmorphine. It's a morphine with two acetyl molecules added onto it. The generic name is diamorphine. That was, for reasons that we still don't understand the equivalent of the drugs are back in 1924, decided that it corrupted your morals. So you had Congress ban it totally. But in most of the developed world, diamorphine, as it's called, is on the formulary and used for pain management. Heroin is just a brand name that was given to it by Bayer, who developed in the 1890s. So anyway, they've been used by physicians to treat pain for decades. In the early 1970s, when President Nixon started the war on drugs, a big advertising campaign was undertaken. And in the colleges and in the medical schools, we were basically indoctrinated into fearing these compounds, not just us but the general public. So when I got out of medical school and started practicing surgery, I was, by nature of my training, very, very stingy with giving pain medication to my patients. But it worked on both sides of the bedside, so I remember making post-operative rounds on my patients and seeing them in obvious agony, sweating, pasty, hyperventilating, rapid pulse. And I'd say, you look like you're not, but talk to the nurse. I have pain medicine ordered for you. And a patient would say, no, no, no, I don't want to become addicted. So they had this fear that we had because we were all being taught this. Also starting in the early 70s and going into the 1980s, the, I don't know if you could see it, going into the 1980s, numerous studies were coming out of numerous highly regarded medical universities saying, you know what, given in the medical setting, there actually is a very low risk for overdose and a low risk for addiction. We're really making people suffer needlessly. So throughout the 70s and 80s, there were so many different studies. And even the head of the National Institute on Drug Abuse in the late 1980s was saying, you know, doctors, this isn't the rational fear of this drug. Given in the medical setting, it's actually safe to use. We should be using it more liberally. And we began using it more liberally. And by the way, they were right. Contrary to what you hear today, study after study, in fact, just a study done by Johns Hopkins and Harvard one year ago, almost exactly to the day, looked at over half a million patients followed eight years from 2008 to 2016 who were given prescription opioids for post-operative pain. And they found what they call a misuse rate, which is even more rigid criteria than addiction rate. And misuse includes, for example, you had a leftover percocet that you had for your operation and you get a terrible headache, so you decide to take the percocet for that. That's counted as misuse. They found a misuse rate of 0.6%. And numerous very respected studies have shown an addiction rate of about 1%. And the overdose rate in study after study is less than one half percent. Well, let me just pause with you here for a moment. What I'm hearing from you is that the general perception that we have a high level of addiction and misuse in terms of opioids and opiates may not be the case. Is that what you're suggesting that we have a mistaken perception of this? Well, there is a high level of misuse and abuse. So maybe I was... Okay. I'll let you clarify that. The general perception that the drugs in themselves are highly addictive and have a high overdose potential is wrong. Now, people tend to use the word addiction and physical dependency interchangeably. A lot of people don't realize there's a big difference. So, for example, opiates and opioids, just like a whole bunch of other kinds of drugs, if you take them steadily, you can develop what they call chemical dependency on it and you can't stop it abruptly or you can go into a very painful withdrawal and some types of drugs you can go into withdrawal that can be fatal. So, for example, if people are put on beta blockers for high blood pressure and they've been on them steadily, you can't just stop that. You can die. You have to be gradually weaned off of it. Same thing with antidepressants, with tranquilizers. Well, opioids are like that too. So a lot of people who've been on opioids for long term, if they're stopped abruptly, they start getting into withdrawal symptoms, but that doesn't mean they're addicted. The actual addiction itself is a disease. It's a disease on a molecular and genetic level and people have a genetic predisposition to it. For example, if you're chemically dependent on opioids and you get detoxed from it, then I've had patients repeatedly say to me, by the way, after my surgery please don't give me, let's say, Percocet because the last time I got dependent on that and going through the tapering off process was a living hell. I don't want to go through that again. Well, that person is not an addict. An addict just like alcoholism is a kind of addiction. An addict keeps craving. It's a compulsive disorder where in the face of all sorts of destructive things happening in their lives, their marriage breaks up, they lose their job, they're getting all sorts of health problems, they can't stop. Even if they want to go back. Well, Dr. Singer, we're going to go to a break but what I sense from you is that we need to clarify what it is we should be afraid of in terms of an opioid epidemic and what it is we should not be afraid of. It looks like you're able to parse that pretty clearly. When we come back, I'm going to ask you to clarify that a little more what we should be afraid of and what we shouldn't be afraid of and then let's talk about some of the public policy ramifications. We'll be right back in just a minute. My guest is Dr. Jeffrey Singer who is a private practice surgeon as well as a senior fellow at Kato Institute and we're going to talk a little bit more about opioids and opiates in America when we come back and compare what's going on with regulation to what happened to alcohol during the prohibition era. Don't go away. We'll be right back. Hey, Stan the Energyman here on Think Tech Hawaii and they won't let me do political commentary so I'm stuck doing energy stuff, but I really like energy stuff so I'm going to keep on doing it. So join me every Friday on Stan the Energyman at lunchtime, at noon, on my lunch hour. We're going to talk about everything energy, especially if it begins with the word hydrogen. We're going to definitely be talking about it. We'll talk about how we can make Hawaii cleaner, how we can make the world a better place, just basically save the planet. Even Miss America can't even talk about stuff like that anymore. We got it nailed down here. So we'll see you on Friday at noon with Stan the Energyman. Aloha. Hi, I'm Rusty Komori, host of Beyond the Lines on Think Tech Hawaii. My show is based on my book also titled Beyond the Lines and it's about creating a superior culture of excellence, leadership, and finding greatness. I interview guests who are successful in business, sports, and life, which is sure to inspire you in finding your greatness. Join me every Monday as we go Beyond the Lines at 11 a.m. Aloha. Aloha. We're back with Dr. Jeffrey Singer clarifying what an opioid epidemic is and what it is not. And I'm going to read off a couple of statistics that are commonly known now or commonly distributed and ask Dr. Singer for his thought about them. In 2017, we're told, 49,000 of 72,000 drug overdose deaths were caused by opioids. That gives them a big, big part of the danger seen in terms of drug use. Drug overdoses are the leading cause of death in Americans under 50 and two-thirds are attributed to opioids. Are these figures right by your understanding and what are your thoughts about that? Yes, they're right. We have to understand what that means. Again, we're using that word opioids in a very general term. So just to jump ahead real quickly, as doctors and patients became less fearful of opioids, prescriptions of them for pain increased dramatically. The more prescriptions that are written, of course, the more are available to be what people call diverted into the black market for non-medical users to use. So by the late 90s, early 2000s, prescription-type opioids became the favorite drug for drug abusers to use for the euphoric effects that they enjoyed. The policymakers concluded that we've got to get those doctors to stop prescribing opioids. So for the last several years, all the policies have been aimed at restricting opioid prescriptions all over again like it was in the old days. So since 2010, for example, the total prescriptions of opioids are down over 60%. In the meantime, the overdose rate keeps going up year after year after year. But if you look behind those numbers, it's true 49,000 deaths in 2017 were what they called opioid-related. So 75% of those were either heroin or fentanyl. And out of the prescription opioids that made up that number, 30% of them had fentanyl with the prescription opioid, and 68% of those people who used prescription opioids non-medically had multiple other drugs on board when they overdosed, including drugs like cocaine, methamphetamine, alcohol, and tranquilizers. If you just want to narrow it down to overdose deaths in 2017 just due to prescription opioid pills, it only amounted to 10% of the deaths. So 90% were not. So we're talking about people for the most part who are using drugs in a black market. And the black market, of course, is black market because it's drug prohibition. So as the availability of these prescription opioids that we doctors were prescribing for patients started to dry up, the drug dealers just filled the vacuum with cheaper and more easily available drugs like heroin and fentanyl. And fentanyl is coming into this country largely through the mail. It's manufactured overseas in laboratories, for example, in China in a powdered form, which is not the form in which you make it in this country. The nation's DEA Drug Enforcement Administration tells us that 99% of the fentanyl they seize is what they call illicit powder fentanyl coming in from overseas. And then the dealers use pill presses and in their laboratories, they press them into counterfeit prescription opioid pills. So you have people on the street who are drug users and they think they're buying Vicodin, but they're actually buying fentanyl disguises Vicodin. In fact, that's exactly how Prince, the famous musical artist, died. The coroner told us last year that he liked to abuse Vicodin, that he never once went to a doctor for his Vicodin. And the dealer got in what he thought was Vicodin, but this time it was fentanyl disguises Vicodin. That's why the overdose was fentanyl's 50 times the potency of heroin, 100 times the potency of morphine. So a little bit of Vicodin could be so powerful that you stop breathing. In addition, because of drug prohibition, there's a rule in the economics called the iron law prohibition. When it's prohibition, the dealers try to make more and more potent products to smuggle in, because if you're going to take that kind of risk, you want to be able to get more use out of the little bit you could smuggle and smuggle in smaller amounts. That's why during the alcohol prohibition they weren't smuggling in beer and wine, they were smuggling in whiskey. Well, the same thing, this has led to smuggling in heroin and heroin mixed with fentanyl to make it stronger. So all our policies are misdirected because what they're doing is they're making doctors prescribe less medicine for their patients in pain. Some patients who are on chronic pain and for whom the opioids have been actually allowed them over the years to have a meaningful life are finding themselves cut off by their doctors who are afraid themselves that they're getting trouble with the law. And meanwhile, it's not doing a thing to make these abusers stop abusing. In fact, it's driving those abusers to more dangerous drugs and therefore it's driving up the death rate. What I'm hearing you say, Dr. Singer, is that the epidemic of overdose and misuse of opioids will not be solved by restricting physicians from prescribing. In fact, doing so is actually the wrong medicine. The other thing I'm hearing you say is that government regulation is actually exacerbating the problem as prohibition had done in terms of alcohol use in our country. And you're saying that government regulation is actually responsible for a greater black market with a more dangerous product. Now, with that taking place, what are your views about liberty and the use of law in the area of drugs? Especially, go ahead. Well, prohibition, obviously, when you make illegal something for which there's a willing seller and a willing buyer, you don't make it go away, you just drive it underground where everything becomes more dangerous, even in the criminal justice area. Since it's illegal, then dealers can't go to court when they have them dispute over territory. They have to have gang wars. So it gets dangerous in all sorts of ways. In Portugal in 2001, they finally came to conclusion they had the highest overdose rate at that time. They said, let's try something altogether different. And what they did was they decriminalized all drugs. Now, they didn't legalize them. So technically, the drugs that people would get were still gotten on the black market. But they decided we're not going to treat like a crime, we're not going to arrest people. If we see somebody using drugs, we're going to try to coax them into getting help. And now, 17 years later, they have the lowest overdose rate in the entire Europe. They have 6 opioid overdose deaths as opposed to the US, which has 312 per million. As people became less afraid of being treated like criminals, they would actually come up to the police and say, get me help. And so what they put their efforts into, instead of locking people up, was into allowing for the flourishing of harm reduction programs. And there were all sorts of techniques of harm reduction. Some have been in effect in proven sister 60s, such as what's called medication assisted treatment like methadone maintenance programs. Or more recently, similar to methadone, it's a thing called Suboxone, where a doctor places you on a medication that you take orally. Enough of it gets absorbed, it's an opioid, but enough of it gets absorbed, so you don't go into withdrawal, but not enough of those gets absorbed to give you the cloudiness. So you're clear headed. So now, you're no longer worried about these withdrawal symptoms driving you to use a drug, and you get your life stabilized. Then, these rehab centers can now work with you to help rein you gradually off of that product. And also, work with a lot of the problems you have. Because for example, we know that more than 50% of substance abusers have other psychiatric, what they call co-morbidities, such as bipolar disorder, clinical depression, ADHD. These problems coexist. And to think that you could just cure a person's addiction problem, which is a medical problem, without trying to address all the other psychological problems in that same patient, holistically, you're really fooling yourself. And then there are other things that stop the spread of disease like needle exchange programs where there are groups that give you a clean needle and syringe in exchange for the one you're using. So it's been shown to stop the spread of needle exchange programs or the kind of rehabilitation that actually uses opioids to actually get somebody off of them or reduce their dependence on them. Aren't these therapies facing a whole labyrinth of laws that work against them, particularly in terms of needle exchanges and so forth? In your own state, there are laws about the quote-unquote paraphernalia associated with drugs. It's very frustrating. For example, in my state of Arizona, this is going on right now. So for several years, in the Phoenix area and the Tucson area, two biggest metropolitan areas, there are voluntary charitable organizations. This is all charitable money where they go into communities where they know there's a lot of IV drug use. And they open up their station wagon and the people come, they give them their used needle and syringe, and they get a new clean one in exchange, as well as they're giving these test strips so they get tests to make sure that their drug, whatever it is they're using, isn't laced with fentanyl. And the police actually like this. They prefer this, too, because the police are very afraid. They often get stuck with needles when they're either rescuing or arresting people, and they don't like the thought that these needles are contaminated. Unfortunately, in our state, and as in many states, there are state laws against the distribution of needles and syringes in Phoenix and in Tucson, is the police, because they support this idea, they made it a practice of basically looking the other way, pretending they don't see it. But technically, they're violating the law themselves by not enforcing it. We're trying to get legislation passed in our state this session. We tried last session, and we were unsuccessful last session, and we're having a hard time this session because there are a bunch of legislators who say it's just a wrong thing to do to enable drug use. And that's because they need to change the goal. This drug use is not a vice. It's a disease. Well, with that, I'm going to ask you to give me a summary in just 30 seconds because we're at the end of our program. Can you tell me what you think Americans need to tell their legislators in a quick 30 seconds? Okay, well, Americans need to tell their legislators because now almost everyone has a friend or relative who's dealt with this. We're dealing with a disease, not a vice. And our goal should be changed. Instead of the policy being that we want to force people to not use things that we don't approve of, the policy should be we want to stop people from dying and spreading disease. So we need to shift from a war on drugs to a war on drug-related deaths. That should be our focus. That's a great summary. Dr. Jeffrey Singer, I want to thank you so much for listening to the wisdom that you have to share. And if you enjoyed this program, be sure to share it with friends. We have it up on YouTube and at thinktechhawaii.com. My name is Keli Akeena with Think Tech Hawaii's Hawaii Together. We'll be back again next week. Aloha.