 Hi everyone and welcome to the Addiction Recovery Channel. I'm Ed Baker and I am your host producer. Thank you for joining us today. Today we're in for a treat. We have a distinguished guest, Dr. Dan Chikarone. Thank you Dr. so much for being on the show. It's a pleasure, thanks for having me. Thank you, yes. Dr. Chikarone is a recognized international scholar on the medical, public health and public policy dimensions of substance use, risk and consequences. He's the Justin Minor Endowed Professor of Addiction Medicine at the University of California in San Francisco. For over 20 years, Dr. Dan as he's called has been actively involved in expanding the use of clinical harm reduction technologies and services. And that means naloxone, buprenorphine, drug checking and as we'll see later on in this show overdose prevention sites. He's provided harm reduction based clinical services at several San Francisco syringe exchanges and was on the board of directors for the San Francisco Homeless Youth Alliance. He's been principal or co-investigator on numerous National Institute of Health sponsored public health research projects including his current synthetics in combination also known as SYNC study. And Dr. I will look forward to seeing your publications on that study. Thank you. You know, I guess, you know, we know in America now that there's been a mounting drug overdose fatality for around 39 or 40 years. So it's nothing new, tragic but not new. For the purposes of our show, I would like to first go back to around 2013, 2014, the CDC morbidity and mortality weekly review of that time pointed out what I'd like you to focus on as the first two waves of the epidemic we see today namely prescription opioids and it's confluence with heroin. This let's talk a little bit about what happened back there 2013, 2014. Yeah, so we're in what's called what I've called the triple wave epidemic of mortality where deaths due to prescription opioids occur doing an excess supply. We can talk about reasons for that. Since about 2000 to 2010, a flood of pills, many of which were legit for patient needs but some of which made it out to the street that caused a upswell of use and upswell of consequences including deaths. And then we said, oh my God, we're prescribing too many pills. We need prescription guidelines. We need prescription drug monitoring programs. We need to control the doctors and the nurse practitioners who are responsible for this. We need to cut down the illegitimate practices like the pill mills. And we did all of that as humans do, en masse, in sync. And then the supply of pills on the street and the supply of pills to some legitimate patients as well started to go away. And that led to wave two, uptick in heroin use, uptick in heroin consequences. This happens around 2011, 2012. And based on my summation of a lot of data, there's not heroin to go and meet the needs of people who are now in this kind of zone where they're dependent on the opioid pills. They can't get them. They're switching over to heroin. There isn't enough heroin. And this is where the bomb happens. And the bomb is fentanyl. Fentanyl comes in as a substitute for heroin, as an adulterate of heroin. So we have fentanyl adulterated or substituted heroin that hits the streets, particularly in Vermont, particularly in your Northeast neighbors, particularly in the Midwest and down to the Mid-Atlantic. And that's as of late 2013, 2014. And what do we see? We see mortality skyrocket. And we're still in that era. As of the latest data from the CDC, the fentanyl wave continues the last 12 months, we've lost 100,000 Americans. Due to drug overdose, a vast majority of those are due to opioids, including fentanyl. You know, it's very, you know, I had to use the word interesting because the word interesting, you know, it kind of cuts out the tragic heartbreak of everything that's happening. But it's captivating to look at the process. And I wanna look at it a little bit with you. I wanna focus on the velocity, the acceleration. You know, if we look back to this 2013, 2014, that was when the governor of Vermont, Governor Shumlin, focused his whole state of the state address on opioids. It was unprecedented what was happening here in Vermont. It was impressive as what it was. That was an impressive political move. Yeah, yeah. And back then the number for the 2014 CDC report was it was 28,647, the number was just burned in my heart. And what's interesting is that was a combination mainly of prescription drug overdose deaths, as you just mentioned, heroin overdose deaths as you just mentioned. And in that particular report, and I'm sure you know this, doctor, but I just wanna say it for the audience because it speaks to velocity. In that report, fentanyl was actually noted as a footnote. Fentanyl was noted, it says, quote, there was a rate of deaths involving illicit acetylfantanil nearly doubled between 2013 and 2014. Now, I have a report from the Drug Enforcement Administration from 2015 talking about that same period. And they say fentanyl and its analogs are responsible for more than 700 deaths across the United States between late 2013 and late 2014, 700 deaths. So 700 of the 28,647 were fentanyl. And that's what I mean. I'd like you to focus on that a little bit. So between 2013 and 2014, 700, and focus on that, the velocity. What's happened between 2014 and 2020? Yeah, let me show some graphics. So if I could share my screen, I have some images that will help. Okay, so what we're looking at here is US mortality data for the last century. 100 years of the US death rate, deaths per 1,000 people. And we see 100 years ago, we had an epidemic of a flu virus, the so-called Spanish flu. It's poorly named, has nothing to do with Spain. It's just that Spain at the time had some of the best records in Europe. And so it looked like it started in Spain, but it's not true. But it was a strong influenza virus. The human immune system wasn't ready for it. And it killed an extraordinary number of people. So we see a spike in deaths. 100 years later. Oh, so then we have 100 years of declining mortality due to technological advances in healthcare and safe water and anti-poverty interventions. And now another pandemic, 100 years later, as devastating as COVID is, it doesn't match up to the Spanish flu pandemic, but it's horrific in and of its own. Our immune systems are not ready for it. They will eventually adjust to it. We will technologically hit it with our vaccines and our medications. But let's look at what happened just prior to COVID. We had three, four years of a reversal of fortunes where overdose, I'm sorry, where death rate went up. What caused this drug overdose? So just to put it in perspective that the level of drug overdose that has happened in this country was enough to increase the entire society's death rate. That's how impressive this was. And if we took COVID away, we would see that line continue. We'd be up to five years now. And we have not had, if you can look at that 100 years of data, we have not had five years of increasing death rates since the 1920s, right? And so that's how, since wars happened, you could probably find World War II in here somewhere, right, or the Korea War. That's how big overdose is. It's like a war. Here's the triple wave, right? So the first wave is due to opioid pills. That's the blue line. The second wave is the heroin wave. That alone would have woken us up and said, oh my God, we've had this paradoxical problem with increasing pill supply and then decreasing pill supply. And there's the fentanyl wave. And that's 2017 data, right? Now we have stimulants coming in and we need to be quite concerned about that. Just look at that green curve. That green curve shows you, let's see, it's gonna be ours to work. That green curve there shows you the acceleration from 2014 to 2017, from 700 to 40,000, I think at the time. And now we're 50, 60,000 deaths due to fentanyl as of the latest data of 2020. You know, that's incredibly, just leave that up there for a second, because it is remarkable to visualize it and to talk about those numbers, you just said from 700 to 60,000 in 2020. I think for the 12 month period ending April, 2021, I think it's up to 68,000 fentanyl related deaths. 68,000 fentanyl deaths, right? So what we call this in epidemiology is an attack curve, whether it's due to an infectious agent or due to a noxious environmental stimulant. We have an attack curve. We have not seen the top of the attack curve. That's really an appropriate term. I hadn't heard of that, an attack curve. No leveling off, no slowing down, no, it just keeps going up. And we can talk about the reasons why, why I think the fentanyl attack curve continues to go up, but it's impressive. It's five years, four years in, I'm sorry, it is seven years in and it just continues to go up. Well, I want to, you mentioned that, I want to get into a little bit later, like the reasons why I think you cite something called supply shock. Besides the social determinants of addiction, we have something that you call supply shock. And I'd like to talk about that a little bit later. But first, this graph again, you notice over there, the way you've plotted it in 2016, 2017, you see a leveling off and even the beginning of a decrease in prescription opioid related and heroin related overdose tests. So what counteracts that is that almost vertical spike in fentanyl deaths. And that to visualize that, to see that, let you know a little bit what we're up against, the velocity and the power of this thing. I'd like you to speak to that. What is it about this third wave, the fentanyl wave that has added such incredible velocity and power that it's almost a vertical increase in the rate of death over the past four years? What, talk to that a little bit, explain that to us a little bit. So a lot of people have talked about, well, fentanyl is an unreasonably strong drug. And it is, it's a hundred times as potent as morphine. If you think that heroin is about two and a half times as strong as morphine, then fentanyl is 40 X heroin, right? And so even if you were dependent on heroin and now you get exposed to fentanyl, you run an increased risk of overdose. Okay, so that's step one. That's kind of the obvious one. That's the one everyone is sort of focused on and picks on. But let's think about some other things, right? One is, when did all these heroin users come from, right? If this was, let's say the opioid pill wave never happened and all of a sudden you take the same number of heroin users and expose them to fentanyl. Yes, we would see the X rate, the death rate go up because again, this potency issue, but these heroin users were new heroin users. That's the piece that is not focused on, right? Where did they come from? They were outpatients. They were outpatients that we abandoned. They were our kids and our neighbors who got into medication cabinets who took pills and then became dependent on those pills, okay? They were pill users or misuses, if you wanna use the CDC's term or non-medical users, I think it's the CDC term of opioid pills, they weren't heroin users. And so when they go into heroin, they make that jump over from pills to heroin. And if we think about the size of the population that was whatever pejorative or medical term you wanna use for the size of the people who are not using opioid pills appropriately, it's huge. It's a huge number of people. Some people estimate it to be about 10 million, right? And now you take one good piece of data out there, 4%. It's not a big number, small number, but it's a small number of a large population, 4% transitioned over to heroin, okay? What we see in the heroin population is at least a doubling or perhaps if we're underestimating that number, some people say it could be a quadrupling of heroin users in the United States during the short period of time. So what happens then is you have a bunch of people who are new to heroin, right? Not only are they new to heroin, they're certainly new to fentanyl. And so that just the physiological risk environment goes through the roof because exposing people to something they cannot handle, all right? And so if we have, for example, we've gone from maybe, if we think about this doubling and tripling, we've gone from about 900,000 heroin users, just shy of a million to a little bit over 2 million. I think the best estimate's about 2.3 million, which is a huge number. I've been studying heroin for over 20 years and I think about 2.3 million heroin users, my mind blows, right, it could be, could be actually closer to 4 million heroin users. Many, the overwhelming majority of whom don't know what they're doing. They're new to the business, they haven't been around the block, they haven't been taught by elders to inject this way or that way, to go slow, to take small doses, and boom, then the bomb hits, the bomb is fentanyl, right? That's why we're seeing this exponential increase in drug-related deaths, in heroin-related deaths and opioid-related deaths. Well, it's pretty much like a perfect storm. It's a so-called perfect storm, yes. And it's hideous in its nature. You know, back during the period that you're speaking about, I think one of the variables, one of the things that happened was oxycontin began to be manufactured with a consistency that made it impossible to inject and impossible to insulfate. And some studies will track the rise in heroin addiction with the newly manufactured oxycontin opioid that people couldn't no longer inject it. And they switched, a lot of them switched over to heroin. I was practicing clinically in Vermont during that period. And I can say from my clinical experience that there were a number of clients who had opioid use disorder, mainly using prescription opioids, illicitly maintained. And they switched over to heroin. And they switched over to heroin because their supply or their supplier no longer had a sufficient amounts of prescription opioids, but happened to have heroin. And that was what they kind of moved over and began using heroin. And then that was their addiction. You know, I'm glad you brought it up. So a couple of things there. One is oxycontin was an unreasonable drug, right? It was packing 80 or 160 milligrams of a very potent, very likable opioid into a capsule, a capsule that was easily crushed, that was easily solubilized and injected. It could be snorted. And oxy is a big part of the story. It's not the only part of the story. There was plenty of other opioids out there other than oxycontin, but it was a big part of it because it put a lot of medication in one pill. Why? Because it was trying to create a 12 hour pill. And so you're not taking it for minute one or for hour one, you're taking it for 12 hours. And so it's the magic to that pill, the technological advance, the part that's patented by Purdue Pharma is the capsule, which slowly eludes the medication over 12 hours. But now imagine you wanna just crush that pill and take it all at once. Yeah. That's 80 milligrams of a very potent opioid that somebody is injecting. And what do people say about it? Right? They say it's heroin-like. People who have known, who've done both say, oh, I love those oxy, you know, I can do half one or a whole one and it's white light, white heat referring to the 1970s Lou Reed song where he was using heroin at the time and describes it in this classic rock and roll song of white light, white heat. They said, that was oxy, right? Now, we're part of this response to this opioid wave is, oh my God, what are we doing? We're prescribing too many of these pills and oxy's too crushable. So let's make it an abuse to turn formulation, right? And so now you try to dissolve it and inject it. It creates this jelly and the jelly doesn't go in the syringe and it works. Yeah, yeah. And I wish I could pull it up. I don't have the slide in front of me. I'd have to go find it. But I show that using Google interest data, I can show that people are searching as they're searching for oxy, you see this wave up and then the wave down crashes at the moment where they reformulate. People are no longer interested in oxy. What spike do you see next? I correlate it with a spike in interest in heroin. And along with Seymour Hoffman's death and a number of other rock and roll folks who then die of opioid toxicity, right? So the oxy story is a big part of this. And we just happened to write a very early paper in this story of transitions from pills to heroin. It's called Every Never I Ever Said Came True. First author is Dr. Sarah Mars, also here at UCSF. And she wrote a wonderful paper based on an experience that we had in Philadelphia where I was studying heroin. I've always been studying heroin, been studying heroin for 20 years. And all of a sudden I started realizing that a lot of the people that I'm talking to last week, last month, last year were using pills. And I started asking questions like, so how is it that you got to heroin through pills? Because that didn't fit in my understanding of heroin. It's like, yeah, people came to heroin through a variety of pathways, but they didn't come all through oxys or hydromorphone, the opanids, that also got us into big trouble just like oxy cotton. And I started hearing these stories and I remember getting on the phone after one particular encounter and calling Sarah and calling the field leader for my research saying, we're making a shift here, right? Pivot as the current term would be we're pivoting our research. I want to know stories of heroin initiation. And we studied that and we published it as every never. And what we heard was mind-blowing. And it was so mind-blowing. This paper has now been cited, it's a highly cited paper because we were there at the right moment, the right time and that, you know, it's an aha moment, I guess that we've stated in science. And that paper has been very well appreciated and it documents the stories of people who say, I was cut off by my physician, right? I sought street pills. And then when the street pills became unavailable, my dealer, excuse me a second, my dealer offered me heroin and I was off to the races. And I said at first I was going to snort it, I was going to inject it and every never I ever said came true then I started injecting or some people were injecting the oxys and then switched over to heroin as an injectable. So they have it, I would encourage people to check out the paper, it tells the early story. Oh, I will, I will make sure to, I will make sure to read it. And at the end, if you can send it to me or send me a list of your papers, we can prepare a slide to show at the end of the show to the audience that will lead them to some of your research. I'm sure they would love to, love to read some of these things. What? And I've seen that exactly what you're describing I've seen in my practice. And people, you know, you know, John Kelly from Recovery Research Institute I had Dr. Kelly on last month and we talked a little bit about this. And, you know, it seems to me and he agreed that when you look at stigma toward people who use drugs, if there were a totem of stigma, people who inject drugs would be on the very bottom. They're the person who are most stigmatized against. And people don't really understand why a person would inject a drug. I mean, we all have kind of a visceral inborn like aversion toward sharp objects in the side of blood. And ever since we're kids, when you go for a vaccination, you don't look and why would somebody want to do that? And when you analyze it and look at it a little bit you find out that people do it because it's the most effective route of administration. It's the quickest way to end withdrawal and it's the most efficient use of the drug molecule. People, you know, don't understand that. They just think that people inject drugs somehow because they like to when it couldn't be further from the truth. You know, so thank you for studying, you know, this particular population for 20 years. We need to know as much as we can that's based in science about them because they're the ones that are dying at an incredibly accelerating rate. So I wanna- Let me just tell you a little bit about why I do that, right? So in public health, we think about our numbers studies, right? That would be epidemiology. That's the study of populations, right? And it's very numerical based. So one problem we have with social epidemiology is that we can't get to why questions. Can't get the questions of mechanisms because it would make the surveys way too long, right? We can find out who, we can find out how much we can't ask why. So when the question is, why do you inject or why would you transition from pills? Which you would think kind of safer, right? You know the dose and all that to this unknown of heroin, right? So in order to answer why questions that's why we do the street-based research. That's why we do what's called ethnography, the study of culture. And I love combining the two. I love numbers for the breath, but I like the stories for the depth and for the mechanism. And you add those two together, you can make interventions, right? If you only make interventions based on numbers, we've seen this innumerable times. If you do studies based on numbers, I'm sorry, interventions based on numbers, you're kind of guessing at what to do for the intervention. Cause you know who to apply the intervention to, right? But you don't know how you need the mechanism. You need to understand what people are actually doing out in the risk world in order to intervene on it. And so you need social studies like ethnography or cultural anthropology to get us there. So that's why I combined the two. That's fascinating, Dr. And thank you for mentioning that because to me, to me that throws light on the harm reduction community. And that's the community that's face to face with the people we're talking about. That is the people we're talking about. And those are the people who hear the stories about why? Because people who use drugs trust them because they know that they're not going to get persecuted by them and they tell them why. You know, it's just a beautiful, a beautiful world. And the same with good clinicians, right? We know that the clinicians who are good who are tuned to their patients who listen carefully, they also get to the why's and that's why they're better clinicians. Yes, actually, absolutely, absolutely. You know, so just a quote by Lou Reed, I'm a Lou Reed fan, you know? Me too. And I remember everybody putting everybody down and all the dead bodies piled up in mounds. And that was from 1966. So in 1966, I think I said we're China white. There were people dying. I was a kid in the Bronx, my friends were dying. And it was like an epidemic of the 60s. It didn't come again until what we're talking about, but it had happened before. You know, one of the things that I think of often, just as an aside, is like the medical profession, somehow inundated America with pharmaceutical opioids. And I just boggles my mind how they were convinced by marketing cells personnel, that somehow these opioids really weren't that addicting. Does that make any sense to you? How could that possibly happen? Well, I think we've already used this metaphor once. I hate to use it again, but you know, there was also a perfect storm in the whole opioid pill wave. You know, obviously there's the profit margin. There's the technological advances of being able to make extended release tablets, capsules or capsules like OxyContin. And there was also this perceived need, perceived need that pain is going up in America, it is. I mean- Well, that's a vital sign, that's a vital sign. We have a lot of chronic pain in this country, right? So between the supply and the profit motive, between this idea that Americans have a lot of chronic pain and now you add a kind of a liberalization of culture, perfect storm, right? The liberalization of culture meaning that if you listen to the historians like David Courtwright, they'll say we've always had a degree of opiophobia for good reason, right? Cause you know, history will tell us about when we made morphine for the first time. Would we say deaths due to morphine go up? When heroin came out briefly as a pharmaceutical, heroin deaths went up. So we put heroin back in the illegal category, we made morphine a controlled substance. But every time we release a new narcotic is the general term, right? Like when benzodiazepines came out because we were an anxious society in the 1950s. What did we see? We see an abuse wave to the benzodiazepines when Adderall first came out. An abuse, actually, right? We might still be in an Adderall abuse wave. These psych of active chemicals when they come out, they're used because we like them and they fit a certain purpose and medicine makes progress, right? But there's side effects. And one of the side effects is not just individual side effects, public health side effects, and that is increased use, misuse, diversion into the population. And so we have to learn to live with that. We have to learn to cope with the fact that we have technological advances and we have side effects, technological advances. We make fast cars, people die in fast cars. So then we put in anti-lock brakes and airbags to moderate. And that's where harm reduction comes in. So I know we're gonna talk about that, but that's how you deal with these technological advances is we cope with them, we learn to moderate the really bad effects of them. It's almost a history of unintended consequences. Exactly, we're always tripping over our feet in terms of unintended consequences of technology. Name one technology that has not had unintended consequences. We can create social media because there was such a wonderful thing, people are gonna chat and interface digitally and now we see it's connected to teenage suicide. I mean, technological advances and paradoxical effects. So we have 700 deaths attributable to fentanyl over the years 2013, 2014. Then up to April, 2021, we have 68,000. So the velocity is way out of control. We have heroin. We still have pharmaceutical prescription drugs. And now we have what you're calling the fourth wave. We have methamphetamine. Let's talk a little bit about methamphetamine and what's happening with methamphetamine. Well, the first thing is we'll go back to the historians and is this notion, it's a little bit vague, but we kind of have this notion that there's undulations in drug culture where we seem to undulate between, oh, this was an up decade and this was a down decade. Oh, let's have another up decade. Let's have another down decade. So we alternate between heroin and then crack comes along and then meth slips in for a little bit and then we're back to pills. Well, guess what? We've just had a 20 year run with downers. It kind of makes sense that a stimulant wave comes along. And so let me explain sort of two phenomena with it and go from there. One is the idea that cocaine and heroin make a great combo. You're just gonna have to accept that. That's a lot of research, but just accept the fact that when you combine the two, the cocaine just kicks a little bit of that heroin in a more pleasurable direction. That's the so-called speedball. That to me is obvious, it's cultural, it's traditional, it's historic. It doesn't surprise me in the least the fact that we're having code. And when people say, well, it's cocaine, debts are going up, are they purely cocaine debts or are they cocaine plus heroin? Most of them are cocaine plus heroin and most of the heroin is contaminated with fentanyl so it's cocaine plus fentanyl. So it's not cocaine itself, right? The methamphetamine is a little bit of a surprise, right? And then that's basically, that's the synchran. That's what I'll be spending the next five years of the government's money researching why methamphetamine and fentanyl, why methamphetamine and heroin because that's the so-called goofball. The goofball is not historic, it's weird, it's fussy, it's unusual for people to use it, only experts use it. Why? Because methamphetamine is so strong it bulls everything else out of the way. So you wasted your money on the heroin or whatever you wanted to combine the meth to because meth is super strong, it's always been super strong. It happens to be even stronger now, we could talk about that if you want, which is kind of crazy. Be patient with me. Yeah, let's get into it in a minute if you want. But the fact that half of methamphetamine deaths are co-occurring with fentanyl or heroin is absolutely fascinating. It's hard for me to impress how fascinating that is, it gets back to your use of the term interesting. Well, as a researcher, I look at terrible things and they're also fascinating. I understand that as a scientist, that's the way you're built, I understand that. I think it's fascinating. The goofball phenomenon is absolutely fascinating. Why? How? Who? What way do you do it? How do you overcome the problems that people had in the past and all of this is mind-blowing and we're going to investigate it? I will look forward to that study, Dr. One of your colleagues, Rick Rossin, recently told me that on the West Coast specifically, methamphetamine is like, I think 80% involved in 80% of the drug overdose deaths. Down in LA, yeah. It's really high. Is that true? Yeah, it's super high because meth is what we would call endemic in the West Coast. You go all the way back to the health angels who were manufacturing, distributing it. There's something about West Coast culture where methamphetamine has always been part of the mix here. You go to the Northeast where you are, people, they've read about methamphetamine, but no one's actually seen it, right? Up until recently, that's true. Up until recently, so now we've seen it recently. And so what's fascinating, unfortunately, is fentanyl is heading to the Western half of the United States and methamphetamine is going to places that it hasn't been before in the Northeast. I remember reading a paper last year about black tar heroin and how because of black tar heroin being popular on the West Coast, fentanyl is difficult to mix in with black tar heroin. So there were less fentanyl deaths on the West Coast, but somehow now they figured out a way to do it. So now you're tapping into my true expertise. There's no one who has black tar heroin more than I do. That's how I started in research. 20 years ago I was studying black tar heroin. So black tar heroin is not a choice. The country is segregated into these types of heroin. I've spent many years studying the heroin flows and how the cartels do what they do. For most of this timeframe that we're talking about is to say the last 20 years, East Coast gets powdered heroin from Columbia and the West Coast gets black tar heroin from the Mexico criminal trafficking organizations. If I ever use a country, I don't mean to blame the whole country. It's the illicit elements within that country. That's switched now, right? Mexican CTOs, criminal traffic organizations control the whole United States, whether it's marijuana, methamphetamine, powdered heroin going to the East Coast with black tar heroin going to the West Coast. But they've kept the cultural divide alive. And that is, it's either through separate cartels or because they've just kept the supply chain the way it is, black tar heroin still only comes to the Western half of the United States. Folks in Vermont are not gonna find black tar heroin. Powdered heroin, a brownish powdered heroin or maybe grayish that cooks up like iced tea colored solution. That's what you see Chicago, Eastwood and also in the Southern United States. Texas is divided, sometimes it gets black tar heroin sometimes it gets powdered heroin. Now, I've written a number of papers saying that black tar heroin does this, it does that at least the abscesses, it protects you from HIV all of which were a standby. They're my key papers over the last 20 years. So for example, black tar heroin because it has to be heated because you have to rinse your syringes out because it's sticky, it kills syringes very quickly, it causes people to lose their veins so they have to inject in muscles. All these things decline HIV. So my first big shot paper was in 2003 where I described that HIV patterns in the United States were based on the type of heroin that was available. That black tar heroin inhibited HIV from going into the injection population west of the Mississippi River. And we have a model now that shows that a mathematical model. Other people have tried to replicate our studies and pretty much agree with it. Now, does that idea translate to fentanyl? I'm not so sure, right? I'm not so sure that black tar heroin can't be cut with fentanyl. But that's the current story that's out there that fentanyl went into East Coast heroin because it's powder meets powder. Black tar heroin is a solid chunky heroin and could you put a powder in there? Sure. Could you turn it into a liquid and spray it on the black tar heroin? The black tar heroin would absorb it? Sure. But it hasn't been done, right? And so the fentanyl phenomenon on the West half of the United States is different than the heroin-contaminated problem on the East Coast. And that, of course, is fascinating in and of itself. So how people are using fentanyl on the West Coast? What forms does it come in? Those are open research questions as of this moment. Believe it or not, we actually don't have a handle on why, how fentanyl in the Western half of the United States. We know the death rates are going up. West Coast is late to the fentanyl party. Fentanyl problems started 2014 in the East Coast. West Coast, it's more like 2018. So four-year delay. But now that it's here, what do we see? We see that attack curve that we talked about earlier. Attack curve, that term is going to stick with me. And fascinating, too. Very, very interesting information that you're sharing with us. I'm sure my audience is going to be very, very happy about this. So fentanyl is moving to the West Coast. Methamphetamine is moving to the East Coast. And what we have is like a tsunami of overdose fatality. I like you, like in Vermont, I mean, this great little brave state of mind, where we're really getting beat up. And we've put everything, I mean, the response in Vermont is exemplary. We have so many programs in place. We've had a compassionate response to people who use drugs. We've embraced many harm reduction interventions. And in spite of all that, in 2020, Vermont had the highest rate of overdose death in America. We're getting beat up with everything we're doing. And it's very sad what's happening here. Now, there's a growing movement in Vermont at this point to implement overdose prevention sites. And it seems to be extremely controversial politically. It's very, very difficult to get support for something like this. But in the face of all the research, like the Health and Human Services recent report was unequivocal about supporting setting up overdose prevention sites for research purposes and finding out how they work and where they work. New York State, our neighbor state, has just opened two overdose prevention sites, one in East Harlem, one in Washington Heights. Rhode Island has two. They call them harm reduction centers, but they're overdose prevention sites opening in March. What is your feeling about this, like politically and medically? What are your thoughts about specifically overdose prevention sites with the tragedy that we're seeing in America today? So what we spent the last 40 minutes talking about is a crisis that has hit this country. And when you're in a crisis, you have to recognize that some of what you've done in the past is not going to work. Now, the first impulse is, OK, we've done this in the past. Let's just magnify it. And that impulse is good. So if we know naloxone works, we just need more of it. If we know that buprenorphine is an easier, more efficient treatment modality because you can expand beyond addiction medicine specialists into primary care, we need to expand it. So that impulse is good. And it's happening. Both of those are happening. But they're not happening fast enough or robustly enough or durably enough to moderate this attack curve. And why is that? We have to remember that our main strategy for dealing with the drug problem in this country has been shame and stigma. We want to say, that's a bad behavior. Don't do it. And maybe that works for the eighth graders. Maybe that works for the young adults who say, oh, let me not do the bad thing. I'll just stick to marijuana or something like that. But shame and stigma bite us in the butt once we have somebody with a problem. Because what do they do? They don't show up in the emergency room unless they're desperate. They don't come to the hospital unless they're desperate. They don't seek care because they're embarrassed because they've done the bad thing. And now they feel like a bad person. We need to completely unwind that. We need to recognize that the disease of addiction is no different than diabetes. It's no different than heart disease. Diabetes is a metabolic problem caused by genetics and excessive caloric intake. One's behavioral. The other you can't do very much about. How do we treat it? Do we shame people into changing their behaviors? Not anymore. Maybe we did that in the 1950s or go back to these medical TV shows, Dr. Kildare or Marcus Welby. Don't you realize you're harming yourself? You don't do that anymore. You're like, come on in. Let's talk. I got medication for you. I got a behavioral counsel for you. How about we do both? Because two together is going to work really well. I've got a nurse who can show you how to inject insulin if we get there. And I know insulin is embarrassing, but we're going to do this together. Addiction, wouldn't it be amazing if we tried to treat addiction the same way? But until we get there, until we get the full cultural shift that says, hey, this is just the brain disease, folks. This is just a chronic illness, just like hypertension and diabetes. We're going to treat it with medication, compassion, and behavioral change. Until we get there, what we need is to accelerate harm reduction. And if we're in a crisis mentality that says, we have a crisis, our knowns are not working as well as we want them to. We need to go to the unknowns. We need to go to the creative level. And this is where overdose prevention sites come in. And Europe and Canada are way ahead of us. So do we really need to reinvent the whole evidence base? No. Let's just look at the European Canadian data. What do we see? We see decreased mortality. No one has ever died in an overdose prevention site. They used to be called supervised consumption spaces or supervised injection facilities. No one's died. 10 years of experience, whether you're Sydney, Australia, or Bonn, Germany, or Vancouver, Canada. No one's died in one of these. They're medicalized, which means that, OK, we're going to allow you to use drugs. We're going to observe you in the moment. And then we're going to have a conversation afterwards. That conversation can go anywhere you want. You want treatment for your abscess? Great, I'll help you with your abscess. Want to know how to get into treatment? I'll help you with that as well. Any trouble with housing assistance? We'll help you with housing. So it's an attachment game. It's a retention thing. Can we bring people in on their terms and start to engage them on our terms? Our meaning, medicine and public health. Conversation happens. Trust building, retention, engagement. Good things happen out of that. Doesn't matter whether it's diabetes. Doesn't matter whether it's teenage pregnancy you're trying to address or drug addiction. So as an engagement philosophy, harm reduction works in supervised consumption spaces or overdose prevention sites are the right answer. Question about placement or size or scope or how to pay for them, those are the challenges. The legality of them. We need to think about federal rights versus state rights. So states in the Constitution have the right to administer health care. So all we need is the feds back out of the way and say, okay, this is a state's rights issue. This is a medical and public health provision. Just like the same thing we're having with COVID in reverse, right? The feds can't come in and say mask mandate. They can't come in with vaccine mandates. Why? Because vaccines are a state's rights issue, right? So California can do vaccine mandates and mask mandates and other states won't go there and the feds can't do anything about it except they can apply some financial leverage through Medicaid reimbursements and the like, Medicare reimbursements, right? Why don't we make overdose prevention sites a state's rights issue? Attorney General can just step out of the way, right? I take some of this from Brandon Del Pozo, from Burlington, the police chief up there, maybe former police chief, I'm not sure he's still, who said, okay, I from my understanding from all the experts, both locally and nationally, that buprenorphine is a good thing. So what I suggest is that we ignore buprenorphine diversion and sales on the streets because people are helping each other, right? I'm in charge, we're not gonna arrest people for buprenorphine possession or diversion. And that works, at least, again, to the degree that some of these measures work, right? I talked with him years ago and I said, we need overdose prevention sites. He's like, no, I don't, it's not happening in Vermont. Well, guess what? It's gonna happen in the United States. It's too good an idea. And look, our wonderful colleagues in New York and Harlem and Washington Heights are doing it. They're literally sticking their necks out to see whether the feds are gonna chop them off, right? And when they don't, right? And San Francisco's gonna open one, Seattle's gonna open one. I hope Baltimore opens three. I hope Philadelphia opens three. I hope Vermont opens them, right? And what are we gonna see? The sky's not gonna fall down. People are gonna be engaged. People are gonna be helped. You're actually gonna bring some of your nuisance issue inside. You're gonna see as much public injecting. You're gonna see as many discarded syringes. So Burlington needs one and it needs one right away. Thank you. Thank you. That is so encouraging to me and it will be encouraging to my audience also. Guess what? You also will save money because people won't be using the hospital and the ER as much. You're going to- Yeah, the ambulance. You're going to endocarditis. There's a whole bunch of other diseases. Yeah. Save society money. So how much it costs? Think about the money savings on the other side too. And I do believe that there's money coming into the state from opioid wholesale distributor settlements and eventually the central families. There will be money coming in. So we're going to try to earmark that money for the right populations. It's interesting that you mentioned Brandon Del Pozzo. I know Chief Del Pozzo. I sat on his or attended his community stat meetings when that whole change was happening that you talked about and it was beautiful. It was Chief Del Pozzo. It was our district attorney, Sarah George, the state's attorney. It was the attorney general, T.J. Donovan, the mayor, Mayor Weinberger conspired. Conspired and said we're not going to enforce law when it comes to someone possessing small amounts of buprenorphine. And it eventually went to the state legislature and was passed into law. And they're no longer prosecuting for that, which is beautiful, beautiful. The next step here is, as you know, is overdose prevention sites. And the forces are mounting, you know, as we speak. And I do believe that 2022 we'll see one open here. I certainly hope so. Yeah, yeah. So thank you. Can you take a picture of one? Share my slide again. Oh yeah, yeah. So in my, I've given this talk recently to a national audience. This was just talking about harm reduction. And the slide, the photo here you see is of an overdose prevention site. This was one of the more famous ones, one of the more studied ones in the world. This is the Insight Facility in Vancouver, British Columbia, Canada. And what you see is boots. Those boots have mirrors. They have clean surfaces. They've got syringe disposal boxes. You can see them in yellow. And on the left there, what you see is a counter with a nurse or other health professional. There could be a doctor, could be a nurse practitioner. And they're observing, right? And they're assisting. Now they can assist in the actual injection. I think there's some places that might allow injection assistance, but not in Vancouver. But they can administer naloxone if needed for a witnessed overdose. They could give oxygen, because again, they're nurses. And they can also do bandages and wound care. It's a lovely facility. You can see this is, it's a fairly large one. They don't have to be this big. I've seen ones that are intense. I've seen ones that are in vans. I've seen ones that are a smaller scale to the size of the population they need. This just happens to be downtown Vancouver where they need a big one. But there you have it. Beautiful. And it's sort of rings of dignity and compassion and worth. And you're worth the investment. We're gonna build this place for you and it's gonna work and it's gonna be a state of the art because we care about you and you're important. It's like the opposite of stigma. You mentioned the opposite of stigma. Nora Volkov talks about internalized stigma. She talks about anticipated stigma. People with substance use disorder are anticipating being prosecuted, prosecuted, punished, yelled at, pointed at. Then they don't come out of the shadows easily. We have here in Bronx and we have safe recovery which is just a wonderful place where clients come and they trust the people who work there. They feel comfortable there. They reveal the whys there. They just feel at home there. And it's a very beautiful thing to see. This particular population, and I think you'll agree, people who inject drugs, it's really severe substance use disorder are least likely to come forward. And it's part of that perfect storm. They isolate, they inject alone and they die alone. And with an overdose prevention site, they're no longer alone. So as you said, worldwide, there's never been an overdose fatality. I mean, how successful can you get? Yeah. And the other thing I'll say is that this fits into a paradigm shift where we go from a monolithic supply reduction thing. We're just gonna try to shove the genie back in the bottle, keep the drugs at the border, militarize, crop spray. We've tried that for 50 years, right? And if you look at the economics of drugs, where drugs have become increasingly plentiful, increasingly cheap and paradoxically, increasingly more potent over time, right? One can only say that it's an utter failure, this monolithic. I'm not saying there isn't a role for supply reduction, but this multi-billion dollar complex of trying to shove the genie back in the bottle has not worked. What if we had a multi-billion dollar complex where we manage this like our two big killers in America, which are heart disease and cancer, we put in the infrastructure of the love, the compassion, the wherewithal, the technology, new medications, right? New invitation for people to come in. What if we did that to the drug problem? Quite likely it'll work. Because then we could also raise more resilient kids and try to avoid these adverse childhood experiences which lead to adult drug use, right? The fragmentation in our society could start to heal our communities and make them so that drugs are a manageable part of the culture and not the crisis part of the culture that they currently are. Yeah. I think New Hampshire, you know, Rhode Island is working toward a defilanization law. As far as drugs, I know that Oregon has taken profound steps in decriminalizing possession of drugs. Was it in Oregon? Yeah. Yeah. And just to be clear for the audience, right? We're not talking about legalizing the substance. It's like everything we do in behavioral health, right? Not putting people in jail. We blame the behavior but not the person, right? In this case, we can still blame the drug. We can still make the drug illegal but not the consumption of the drug, right? That's where we failed as a philosophy is when we blame people for consuming the drug, we create a negative spiral. We need a positive spiral now where we embrace the user fully, right? And that could be my teenage daughter or my young adult son all the way to a person that has severe substance use disorder. We embrace them, we educate, we hold their hands, we march into the process. It is not easy having diabetes. It is not easy having diabetes and yet we don't badger people and make it worse. We embrace and we help. And that's what we need to do in the addiction field as well. Thank you so much. Thank you so much. I think that you include, I think you cite Dr. Ju Young Park. Yes. In one of your papers. She was on the show a number of months ago and as I listened to you speak, I think one day, maybe in 2022, I'd like to invite you and Dr. Park on but specifically to speak about the social determinants of addiction. To talk a little bit about that. Oh, she wrote an extraordinary paper on that. Yeah. Did that work? Yeah. I think I'll be in touch with you in 2022 and we'll talk a little bit about that. I wanna thank you with all my heart. And I've read your papers, not all of them, but I'll get my hands on more of them. I've read your papers, I've followed you a little bit and I'm just so grateful that you've made this your life's work and it's so important to you. And I wanna thank you. I'm honored to have you on the show. Thank you, Dr. Me too, Ed. The honor is all mine, the pleasure is all mine. I'm grateful for all that you do as well. So thank you for having me on. Thank you. Okay, so to my audience, we'll see you next time. We're gonna have Rick Rossinon, who's another researcher in this field but specific to Vermont. We're gonna take a close look at what's happening in Vermont. So happy holidays to everyone and we'll see you, we'll see you next time. Thank you again, Dr.