 Welcome to Free Thoughts. I'm Trevor Burris. Joining me today is Dr. Jeffrey A. Singer, a general surgeon in private practice in metropolitan Phoenix, Arizona and principal and founder of Valley Surgical Clinics Limited. He is also a senior fellow at the Kato Institute. Welcome to Free Thoughts, Jeff. Happy to be here. Is there an opioid crisis? You know, I don't like to use the word crisis because it's creased this whole atmosphere of panic. There's a problem with too many people dying from opioid overdoses and there's also been a change in the mix of the type of opioids that are causing these deaths. And of course, it's always worrisome to see that each year after year there's an increase in the number of people dying from overdose deaths. So it's a problem. I don't like to use the word crisis because every time our policy makers react to a crisis, they usually overreact and they don't think things through and all of their reactions tend to create a whole new set of unintended consequences that eventually make it into a crisis. Yeah, maybe that's all we got. We were talking about opioids, opiates. We use both of those sometimes. I've heard that I think opioids include synthetics. That's right. We're talking about pills that doctors like you prescribe, like OxyContin, for example, and also heroin and everything in between. I don't know if those are the two. Fentanyl, I guess, would be maybe the outlier. Well, Fentanyl is used medically. Most of the time, the type that is used on pain patients is actually a patch. Fentanyl is about 50 times the strength of morphine. It's made in these patches that allow it to be slowly absorbed over about 72 hours. A brand name for that people may have heard of is called diragesic. We prescribe, let's say, a 25 microgram patch of Fentanyl and last somebody for a couple of days. It's also used by anesthesiologists in the operating room intravenously because it gets the person anesthetized. It's that powerful. It's not prescribed in the outpatient setting in any form other than the skin patch. When you hear about reports in the news about people who are dying from fentanyl overdoses, they're not taking these skin patches and somehow figuring out a way to scrape the fentanyl off of the surface of it and convert that into something suitable for injection. This is Fentanyl making its way into the country in the illegal market. What about Oxycontin? What is that? Well, Oxycontin is long-acting control release Oxycodone. Oxycodone actually has been around for many years. It's an oral opioid that was invented in 1916. Then in the mid-90s, a long-acting form was developed so that you could take it and it could last, let's say, 12 hours as control release. In order to do that, the capsule is made in such a way as to have actually more Oxycodone in it so it could release more of it slowly over a period of time. That's what made it very popular for people who wanted to recreationally use opioids because if you can get ahold of an Oxycodone tablet and get the ingredients out of it, you get a lot more Oxycodone out of it than if you just got an Oxycodone tablet or capsule. When Oxycontin came on the scene, that became probably one of the most popular opioids for people who were recreationally using opioids to try to get ahold of because you got more bang for your buck. But you would prescribe that for people with chronic pain? Usually, it's for people who you know are going to be needing a strong opioid for a long period of time. For a short duration, such as a patient who just had, let's say, an outpatient surgery, Oxycodone or hydrocodone, also popularly known as Vicodin, is usually what you need because the person's not going to need it for more than maybe five to 10 days. Is that like getting your wisdom teeth out or something like that? Yeah. Whereas if you're going to give it to somebody who you know is going to be on pain long-term chronically, then if you could give them something that lasts longer so they don't have to take it as frequently and you know they're going to be taking it long-term, it's more practical. Oxycodone is more practical for something like that. So what happened was because, first of all, the narrative that everyone has bought into, and this is why this is very frustrating to us practitioners, is that the opioid over death problem is a direct result of doctors prescribing pain medicine for patients. So the popular notion is that I write a prescription for an opioid for my patient in pain and my patient becomes a drug addict and then starts resorting to all sorts of illegal behavior in search of the drug. It becomes a dope fiend and then eventually overdoses and dies. That is not what's going on. In fact, the data shows even, I'm talking government data, the National Survey on Drug Use and Health, show that a non-medical opioid use, so that's recreational, peaked in the year 2012 and total opioid use actually peaked in 2014. And according to the National Survey on Drug Use, only about a quarter of people who are overdose victims even have obtained any sort of prescription for an opioid. And of course, that doesn't necessarily mean they actually got it directly from the doctor. They could have been a stolen prescription. It could have been that they were doctor shopping and and malingering in order to get pain medicine. But the point is that at least 75% of the people who are overdose patients are people who are using opioids for non-medical purposes in the illicit market. So I've been trying to point out that the source of the opioid overdose death problem is drug prohibition. Because when I go into the supermarket or liquor store to buy a bottle of liquor and I see on the label it says, let's say 80 proof or 15% alcohol, the thought never crosses my mind that it may not be that, that it could be adulterated with all sorts of impurities or laced with something that can kill me. I believe what it says on the label because it's legal and in a legal in a legal market. Number one, they have competitors and number two, I have recourse if I've been defrauded and injured. But when we're dealing with the illegal market, you know, you go to somebody in a subterranean way who says, yeah, I have what you want and you don't know if it's the dose. You don't know if it's pure. That's what's happening. In fact, what we've learned because of the narrative that it's a doctor's prescribing, since about 2010, 2011, all of the policies of both the federal government and the state governments have been aimed at curtailing the amounts of opioids prescribed. So we just heard this past July, the CDC reported that for the seventh consecutive year, prescriptions of opioids by healthcare practitioners have come down. In the meantime, the DEA, Drug Enforcement Administration actually controls the amount of opioids that can be manufactured. So in 2016, they ordered a 25% reduction in opioids manufactured and they've asked for another 20% reduction for this year. So we got the amount of opioids being prescribed is down. The amount of opioids being manufactured is down. In addition, now all 50 states have what they call prescription drug monitoring programs where they're surveilling patients and doctors, doctors prescribing and patients using opioids. And the idea is, and it's successful in doing this is it casts a chilling effect. It makes doctors feel like when they're being watched that they really makes them cut back on their prescribing, even if they have no doubts that they were doing the right thing by prescribing, it's just because they feel that they're being watched and they don't want to get into trouble. So they want to be outliers, as they say. So all of these things have teamed up to cut back on the supply and what's happening, the death rates going up. Isn't that interesting? So that would make most people, I would think, wonder, gee, maybe it's not a matter of doctors prescribing opioids because we're stopping that and deaths are going up. The other thing that has been happening is the mix of the opioid deaths has changed, whereas it used to be the majority were from prescription type opioids. Now the majority is from heroin. And in the last year, the amount in 2015 numbers, over 4,000 of the 32,000 opioid overdose deaths were from fentanyl. The year before was 2000. So that doubled. They're projecting that the 2016 numbers was come out in December. It's going to be even worse, even more heroin, which is now the predominant cause of death, and fentanyl. Now, like I say, fentanyl is super powerful. And here's another irony. A lot of people, they have this myth out there that heroin is so dangerous and so evil that take one hit of heroin and you're hooked for life. I grew up believing that. I was taught that. But the fact is heroin is nothing other than diacetyl morphine. That's the chemical name. It's just a modified morphine. The generic name is diamorphine. It was invented by the Bayer company in Germany in the 1890s. And they named the brand heroin, which I understand comes from the German word heroish, which has something. I don't speak German, but it has something to do with meaning that it's more powerful, stronger than morphine, which it was. It's about two and a half times the strength of morphine. Delaudid, which is perfectly legal in this country. And in fact, routinely in patients for whom morphine's not doing the job of controlling the pain, then we step it up and go to Delaudid. Delaudid's about five to seven times more powerful on morphine. So it's twice as powerful as heroin, but that's legal. And of course, fentanyl's, like I say, 50 times more, 50, 50 times more powerful. You think that doctors, you're talking about Delaudid is mostly used in hospitals, right? No, it's available in oral form and we prescribe it for patients too as well. You think that there would be people using heroin in hospitals and prescribing maybe a pill form if it were invented, if heroin were not prohibited, that heroin would be available to doctors as one of those things. It is. And the rest of the developed world. Oh, it is, okay. Yeah, so it's not even just fantasy land. It is the real world, yeah. It's called diamorphine. That's the generic name, so they don't use the word heroin. In 1924, that equivalent of the drugs are, the head of the Bureau of Narcotics at the time, became persuaded that heroin corrupted morals, unlike morphine. It was morally corrupt, corrosive. So he asked for Congress to completely ban it. And within about 10 years, the number one opioid to which people were addicted became heroin. Economists would have predicted that because, you know, what would you rather push? Something that is totally banned or something that you could find another way to get it. So meanwhile, that didn't happen in other countries. So, you know, since the 1920s in the UK, diamorphine, as I call it, that's available. It's very controlled. It's, but it's used for controlled pain patients, terminal cancer patients. And in fact, since the 1920s, they have been, they've had heroin maintenance therapy programs for heroin addicts in the UK. They really formally developed as a project in Switzerland in 1994. But on a small level, heroin maintenance therapy had been underway in the UK since the 1920s. So there are many countries, in fact, one of my colleagues in my medical practice is an immigrant from Singapore. And he trained in Singapore. And he was telling me how very strict the drug laws are there. I think he said, you can go to jail for life if you found possession of marijuana. Yeah, marijuana. You can't chew gum there. I mean, you know, I definitely can't smoke weed. Yeah. So I said to him, yet you guys prescribe heroin for your patients in the hospital. And he, you know, I was teasing him. He didn't, he didn't know that. So he looked, you know, he looked at me like, what are you crazy? And he said, heroin, what are you talking about? I said, oh, maybe I was wrong. I thought, I thought you use diamorphine on your severe pain patients in the hospital. And he said, Oh yeah, we use diamorphine. That's heroin. Yeah, that's heroin is just a brand name. So that's the point. The point is that we just arbitrarily decided because of the totally unsubstantiated suspicion that it corrupts moral character to ban heroin. There's no reason why if one hit of morphine for your post-surgical pain or one hit of the lauded doesn't cause you or a fentanyl patch doesn't cause you to immediately become a drug addict. Why would something that's basically the same is on the same spectrum? Why would it be any different? And of course, you know, there's evidence going back decades of people who are true recreational heroin users lead a perfectly normal, happy, productive life and occasionally engaging heroin use for their own because they want to work for recreational uses and they don't become addicts. And that's been well documented in the medical literature. But these are these are the myths. And unfortunately, these myths are very influencing the policymakers. In terms of recreational use, you don't actually hadn't thought about it that way, but you don't hear much about recreational use of morphine or delotted, even though they give you many of the same effects, if not more of heroin. Fentanyl has been coming in, but mostly in adulterating heroin supplies. But because morphine and delotted are controlled and legal, it seems that that's the reason why heroin is easier to get. Would you agree? Because it's not if it's illegal. According to the CDC, Thomas Frieden back a few years ago, he said that the street price of heroin was about a fifth of the street price of prescription opioids, which is so what's happened is I mean, I'm aware of people. I even know people on a personal level who tell me and have shown me actually that they keep a little stash of Vicodin. And every once in a while, just like I like to have a cocktail at the end of a long stressful day before dinner is to relax, they like to take a Vicodin. I even have told them, you know, I don't think that's an ideal thing if you want to relax. Well, they like it. They take a Vicodin maybe once every week or so, you know, and then they keep it hidden in their drawer because they didn't get that by getting a prescription from a doctor. They got it somewhere. But in any case, that's the way these things are. That's what we see. When we go back to the doctor prescriptions, it kind of, people might be thinking, oh, Dr. Singer is definitely downplaying this, but the numbers are shocking and the maps are shocking. And you look at states like New Hampshire or you have some counties with addiction rates that are unbelievable, never seen the level of overdose deaths. And it definitely was true that starting in the 90s with drugs like OxyContin, doctors were prescribing more opiates than before, correct? Yeah. Well, first of all, I remember, because I'm old enough to remember, when I graduated medical school, that was at the height of the war on drugs. So it was actually drilled into us as medical students, you know, drugs are evil, drugs are bad, narcotics. So most of the prescribing habits of me and my peer group were very restrictive. So we were really stingy with the pain medicine. Then around the end of the 80s, early 90s, a lot of articles started appearing in the medical literature and a lot of people started speaking out about what was then called, came to be called opiophobia, where we were afraid to prescribe opioids irrationally and patients were voicing patients afraid to take it. When I prescribed, they tell me they're in pain, I give them a prescription for an opioid and they, they won't take it because they're afraid to become an addict because of what we've all been indoctrinated into believing. So anyway, in the early 90s, we were basically exhorted to loosen up, be more compassionate, don't be so afraid of the opioid, take care of your patients are in pain needlessly. And so we changed our prescribing habits. So as we changed our prescribing habits, obviously more opioids got into circulation. And if more opioids are in circulation, there are also more opioids that can get what, what they call in the narcotics in the drug enforcement business diverted, you know, prescription, prescription pads could be stolen or just sold by the person who got the prescription medicine cabinets can be raided, whatever doctors. So the fact that more opioids were being prescribed would lead to you to think that more opioids are available to for whatever purposes you want, including recreational purposes. Then when we started to see this increase in the number of people dying from opioid overdoses, the government responded by getting restrictive. There's a lot of other ways. For example, in 2010, Purdue, which is the manufacturer of OxyContin came out with what they call an abuse deterrent formulation because the people who use OxyContin recreationally, like I said, has a higher concentration of OxyCodone. So they'd either crush it and snort it, which was popular, or they'd dissolve it and inject it. So they came out with a formulation that couldn't be crushed. And if you tried to liquefy it, it became this gel that was not suitable for injection. And within, and of course, they patented that. And then within about six months, they replaced all OxyContin that was out there with this abuse deterrent formulation. The FDA encouraged that and they have guidelines and policies where they're encouraging pharmaceutical manufacturers come up with abuse deterrent formulations. Now, a couple of things to keep in mind. Number one, pharmaceutical companies love this because this provides an opportunity for them to evergreen their patents because the abuse deterrent formulation gets a new patent and comes sometimes very conveniently at the time when generics are starting to cut into their profits because their patent on the original OxyContin wore off. Well now, all of the competitors making generics, they can't make the abuse deterrent formulation until that patent wears off. So that's why the pharmaceutical companies are very happy to comply and try to come up with new abuse deterrent formulations. I can't blame them. But we've seen other things occur, which is if you're trying to access this on the first of all, when I prescribe OxyCodone or OxyContin for my patient, I know that they take it with a glass of water. I don't have to say that, by the way, don't crush this and snort this. They never intended to and never even cross their minds because that's the setting that we doctors prescribe it in. So we're talking about people trying to use recreationally. So what happens is when they find that they can't use it that way, they just go on to something else. And that's exactly what's been happening, moving on to more cheaply available and easier to use heroin or heroin laced with fentanyl. In fact, a study came out in June of this year, economists at Notre Dame University, it's a national Bureau of Economic Research working paper, and they studied the substitution of heroin for OxyContin, starting with the appearance on the scene of the abuse deterrent formulation in 2010. And interestingly, they found a one-to-one substitution. Really? Yeah. So as OxyContin became abuse deterrent, then everybody moved over to heroin, and that's all. Meanwhile, some state legislators unwisely are encouraging, actually passing laws requiring insurance companies to cover the abuse deterrent form. And what they're trying to do also is encourage to replace all of the generics that are out there and all of the non-abuse deterrent forms with abuse deterrent forms. Well, like I said, getting back to the ever-greening of patents, that means that people who are paying out of their pocket for pain medication, because they're in pain, suddenly are paying more than they have to because the only product available is this newly-patented abuse deterrent form. They can't buy the cheaper generic. In addition, by requiring health insurance companies to cover, because in many states, the health insurance companies will only cover the generic, not the abuse deterrent form, but by passing laws requiring them to you raising the cost of the insurance company, which of course makes the premiums go up. So I'm clear. Are you against the abuse deterrent form? Do you think that that was so, I mean, you said the numbers and it might have pushed people into heroin, but so you think overall it was bad that they have the abuse deterrent form? Well, yeah. Let me put it this way. Actually, there are several studies, besides this Notre Dame study, showing that it tends to make people just substitute. It's sort of like you push in a balloon at one end and the air comes out at another. I just think that I'm sort of ambivalent about abuse deterrent forms. If you want manufacture abuse deterrent form, make it available on the market, fine. I don't think that the FDA should be promoting it, encouraging it. I think they should take a neutral position. Go ahead and do it if you want. Let the consumer and the prescribing doctor decide, you know, on a case-by-case basis. If he wants to prescribe the abuse deterrent form, maybe the practitioner's got a little concerns about a patient that he's wondering if this patient's really in pain. Maybe the patient's trying a doctor shop to get some drugs for recreational use and the doctor decides. I think I'm going to prescribe the only the abuse deterrent form for this guy. That should be, you know, on a case-by-case basis. I just don't think that we, as a matter of policy, should be encouraging that abuse deterrent forms replace the regular forms and also we shouldn't be forcing insurance companies to cover it because we're just adding to the cost of health insurance. So let's talk about the doctors here. There's a fear. Is there a fear now amongst doctors about prescribing opiates because the DEA might come after you? Oh, absolutely. Yeah. Do you know, I mean, is this so common that everyone knows someone? Are they really going after doctors? Because this idea of doctors as pushers is quite prominent. And it's got to be true, though, that some doctors probably are some bad apples, right? Some doctors are pushers, right? Yeah. I don't think everybody knows someone. I don't know any. We all read stories. There's certain places that were hotbeds of this, like in Florida, and we see these news reports, so we're all aware of it. I can tell you, the overwhelming majority of doctors, just like in every other field, are ethical people who want to do the right thing. There's always going to be some bad apples in every field. You can't have a perfect world, and you shouldn't design policy based upon the exceptions to the rule. We had pill mills. I mean, that was a real thing, or maybe it still is, I'm not sure. They're disappearing because of these guys being arrested for pushing basically without... There were some dishonest doctors who were just writing prescriptions and clearly, basically, were drug dealers using their medical license as drug dealers, but that's the exception. What concerns doctors is, for example, in my state of Arizona, so we have a prescription and drug monitoring program that's been in effect since 2011, and every quarter, I get a report from the state board of pharmacy telling me how many prescriptions I wrote for various categories of narcotics in the last quarter, and placing me on a graph with respect to my colleagues and my specialty, and then it labels me either normal, outlier, or extreme outlier. Now, interestingly, we've all noticed this on my colleagues. It tells you the number of prescriptions written, but it doesn't have it broken down by the number of patients. So if you happen to have a busy practice, you're going to write more prescriptions. That doesn't necessarily mean... Per capita, so to speak. Per capita, yeah. It doesn't have it down that way. It just has my number of prescriptions written. That's weird. Yeah, it is. So, meanwhile, one thing for sure is you don't want to be an outlier because even though technically it says in the report, this is just for your informational use, so you could see where your practicing pattern is with respect to your peers and your specialty, and use it wisely, that sort of thing. But you're always in the back of your mind, they're watching me. One thing I don't want to be is on a list of outliers. So everybody has... We talk at the coffee machine, the water cooler, and the doctor's lounge, everybody's saying that they're very nervous about this. I'm close to an outlier, yeah. Yeah. Let's take a step back to the bigger issues on this because we were talking before we started recording about Jacob Sullivan saying yes, and the sort of positive aspects of drug use. And I think that in order to really look at this crisis, I'm putting that in scare quotes. And think about it the right way. We have to first understand in a way that this seems a lot of people attacking the opiate thing and saying we have to stop this. First, understand that these drugs do a lot of good for people. We have to look at the other side. I guess there might be addiction on a higher level because suddenly people who are in pain, they have access to things that take the pain away or at least mitigate it to some extent, which is the most of the use of this. It's doing a lot of good, correct? Right. And this is not obviously going to be the official party line of the medical profession, but now speaking as a libertarian physician, it's important to bear in mind, number one, addiction is actually on a molecular level, a particular behavioral disease. Not everybody becomes addicted. There's a difference, first of all, between becoming chemically dependent on a drug and addicted to a drug. If you become chemically dependent, obviously you experience withdrawal symptoms when the drug's taken away, but once you overcome that, you're done. Examples, when you have a hangover after having a lot of alcohol the night before, that hangover is actually a form of withdrawal from the alcohol. And that's why a lot of people tell you that if you have the hair of the dog that bit you, you know, you have like a Bloody Mary, it gets rid of the hangover, be sure, because you just gave yourself some more of that chemical. So that's one thing, whereas addiction is different. Addiction, you're thinking about the next dose while you're receiving this one. You're craving the substance, even when you're withdrawn and detoxed, you go back to it. That's why you see a high recidivism rate among narcotics addicts or alcoholics who have been, you know, detox from their substance. So just like you wouldn't call people diabetics on insulin addicts. They would be chemically dependent. They're chemically dependent, though, because they'll get... Yes, but they're not addicts because they don't have the... I mean, if you took it away, they might rob a convenience store to get it, right? I mean, if you took it away, they'll probably go into insulin addicts. But you know what I'm saying? If you took it away, here's one, benzodiazepine, they're very addictive from what I understand. You get addicted to that, yeah, for sure. And people take those consistently. Is that distinction really? So you seem to be describing addiction as like... No, because one is behavioral disorder and one is more of a physical condition. But you could have the physical condition and then behavioral disorder with it? Absolutely. You could be addicted and dependent, but there's an addictive behavior. So that's why some people, regardless of what substance they're taking, they could have a tendency and it's kind of built into the genetics. They could have a tendency to become addicted to their substance, whereas the majority of the population doesn't, which is why you'll see documented episodes of people using substances like heroin, cocaine, other substances that have a record of getting people addicted. And they use them regularly, recreationally, without any addiction problems, because they don't have that biological condition that gives them this behavioral disorder. But going back on the question of... So if you... Some of these long-term pain suffers, you know what I'm saying? They have benefits from this. Do they become at least chemically dependent? But it seems like if they're really in pain, it could be worth it. Right. And that's the whole idea. That's why we see commonly people are maintained for years on things like oxycontin, long-acting, control-release, morphine pills for their pain. So they are chemically dependent. If they don't get their pill within a certain period of time, they start getting withdrawal symptoms and also their pain gets severe. But that's... That's why it was a trade-off. That's a trade-off. In fact, opioids, as opposed to a lot of other chemicals, are relatively safe. Alcohol, long-term use can kill the liver, the pancreas, the brain, is related to certain cancers. Opioids, aside from causing constipation because it slows down the gut, there's been really no... Demonstrating the long-term effect. Organic damage that it can cause. Which is why we are comfortable having people on methadone maintenance, indefinitely methadone, is about the same strength as heroin. It was invented during... It is? Yeah. It was invented during World War II by Germany. Why are we supposed to be a substitute for heroin? Well, because what's better about it? Well, when you take it orally, it gets absorbed from the gut and levels that bind with your opioid receptors enough so you won't experience withdrawal symptoms. But not enough to give you the high, because the whole idea here is you're not allowed to enjoy it. Okay, yes, of course. So that's the problem. That's the problem. It corrupts the morals, isn't that what they said in 1924? Yeah, exactly. And the idea of methadone maintenance is that you get used to not... It's sort of behavior modification. You're blunting the withdrawal symptoms, but you're getting used to not feeling the high, and then it's hoped that over time you could be tapered off the methadone and now you don't crave the high anymore. And you're over your addiction problem. That's the idea behind medical assisted treatment, whether it's methadone or suboxone or others. But beginning back to your earlier point, I would argue as a libertarian, if a person is getting pleasure out of the mind-altering characteristics of a particular drug, whether it's opioid or mushrooms or LSD, or Xanax, or marijuana or Jim Beam, as long as they're not in any way directly threatening my rights or safety, to each his own. Who am I to say that that person is wrong, that person has a right to... They're obviously deriving a pleasure, so there's a value in it for them. If they have a relationship with a substance that is self-destructive and has become irrational, then you know they're probably suffering from the addictive behavioral disorder. That's a different story. Can you, as a doctor, prescribe an opiate to someone merely to satiate their addiction problems? I mean, if you know they're an addict and they don't have pain, are you allowed to prescribe an opiate to them so they don't go with Charlson? That's where I could get into trouble, because I'm being watched by my prescription drug monitoring program. First of all, when I write the prescription for an opioid, there has to be a reason why I'm writing the prescription in my medical records. I have to have a diagnosis, and the diagnosis can't be that he doesn't want to go into withdrawal. But that's an interesting distinction, right? And I'm actually doing work on it right now, because this has been a fight for a very long time since the Harrison-Arcotics Act of 1914 that we're going to make a distinction. First of all, the distinction between medicine and dope and an illicit drug is not exactly clear, obviously, as we talked about with heroin. But also this question of why isn't withdrawal a sort of disease, a medical problem, that you can alleviate as a doctor? I've said that. In fact, when I gave that hill briefing for the Cato Institute back in June, I remarked to the group, it's okay for me to have a person on methadone maintenance. Why can't I have them on oxycontin maintenance? In fact, pain specialists do have people on oxycontin maintenance, but they're doing it... They have special permission? Well, they're treating pain. They're featuring a diagnosis of pain. They're not treating the chemical dependency. It's a fine line, right? Obviously, the patient who's a chronic pain patient, when he starts to withdraw from the oxycontin, he develops worsening pain and withdrawal symptoms. But he's being treated for his pain condition, not for his chemical dependency. Officially, I'm talking about here. Listeners can't see the sarcastic look in my face while we're talking. But I would argue, if it's okay, if the government gives permission to doctors to prescribe suboxone for people who are addicted and don't want to go into withdrawal, or gives permission for methadone maintenance clinics to be established, then there's a rigorous application process and all that that you have to go through. But let's say it does get permission for that. So then it's kind of arbitrary. The only difference between methadone and oxycontin is a couple of molecules. That's it. They're all in the same category of drug. They all have the same long-term lack of deleterious effects on the organs. Now, some are more beneficial than others if you're trying to do a substitution. Just because of the nature, like, for example, studies suggest, the jury's still out on this, but a lot of studies suggest that methadone is more effective than suboxone because it binds to more of the opioid receptors than suboxone does. So it gives a more complete satiation, sense of satiation than does suboxone. So a lot of studies have suggested that more people stay on methadone maintenance than stay on suboxone programs. They tend to have more of a smaller retention rate than does methadone. So each of these opioids has different characteristics that make one be more advantageous than another, but they're all basically the same kind of chemical. And that's why the word is super interesting when you hear people talk about, you know, we have to stop these addicts or something like that. They're using addicts, and so that's a word that makes people think of bad people. Yeah, addicts are vice, isn't it? Yeah, addiction is a vice. And it seems to me that we can ever really deal with this quote-unquote opioid crisis until we accept the fact that it's okay for some people to be addicted to opioids. I mean, in general, we accept that for nicotine to some extent. We accept that for, I mean, I get headaches if I don't have coffee. Yeah, we jokingly say I'm addicted to coffee or I'm addicted to chocolate. These things are actually- Are people- True things. Can people be contributing members of society? Which is, I'm rolling my eyes when I say that because I find that to be a very loaded phrase. But can people be contributing members of society and be opiate addicts? We see it all the time. First of all, we see it with alcohol. Very commonly in the workplace, I'm sure we all know of people that we suspect might have a drinking problem. Maybe they show up for work and they smell from the alcohol or when we do get together socially, they tend to drink a lot. But they show up for work. We don't ask questions. They perform well and we don't see them drinking on the job. So we just keep a- we mind our own business. So we see that all the time. But even with opioids, in fact, my specialty's iconic figure, William Halston. He was considered the father of American surgery. He was a professor of surgery at Johns Hopkins and created the residency program as we know it today. He invented the concept. Many of the earliest major operations were designed by him to this day. There's the Halstead technique of this, the Halstead technique of that. I mean, he's a historic figure. He was a morphine addict. Originally, he was a cocaine addict, actually. I jokingly say, oh, that explains why we have to start our first surgery a day at 7.30 in the morning and we have to show at 5 a.m. for rounds. Now I get it because he started that on go cap. He was a cocaine addict and there are books written about this. A number of his colleagues had an intervention. They took him on an ocean cruise because they were worried about him. And it was popular in the 19-20s to treat cocaine addiction by substituting your addiction with morphine. It doesn't make sense to me, but that was what they thought back then. So they ended up getting him addicted to morphine. And that was kind of a well-kept secret among his closest associates until he retired. He used to come home from a long day of work and take enough morphine to prevent his withdrawal symptoms and take enough in the morning to again prevent it. And he was a great professor and academic and surgeon and nobody really knew about that until afterwards. So if we accept that addicts... I think I'm going to stop using that word. I want to use a different word, dependence. That's an okay thing. If we can accept that and we can say that maybe just the raw number of opiates being used is not a good indicator of only badness, that people are getting pain treated or getting pleasure from it and they're contributing to society. If we can accept that, then we have to still deal with this death problem. And we taught before we started recording that that really should be the focus is how to stop people from dying. And that's going to... What do you think that ultimately that's going to take? I wish that all of the people in the public policy arena who are passing laws just switched their focus to that. Instead of saying we can't allow people to have... You know, underlying their approaches, we can't allow people to engage in these vices. But if instead they say we need to have less people dying, well, what is the source of people dying? It's drug prohibition. Just like... You don't know what's in it. You buy a Percocet pill or an oxycodone pill on the black market and we see more and more cases of these pills are being imported from, let's say, China and then they're being also laced with fentanyl. You think you're taking an oxycodone, you're taking a fentanyl, you stop breathing because it's so powerful. Actually, just to stop you for a sec. Do we... Do you know, actually, when we make qualify that as an overdose death, do we do enough toxicology to say, okay, it was fentanyl laced oxycodone or do we just look at the jar and say, oh, there's an oxycodone jar he overdosed with oxycodone? Well, in the last several years actually, this is about 2006 or so, they've been getting more specific. There have been a lot of articles written about how, depending on who the medical examiner is, some are more conscientious than others and trying to distinguish. But they've been... Since the attention has focused on this, efforts have been made to get more uniform toxicology when autopsies are performed. So we are starting to be able to differentiate. But that's the cause of the deaths is drug prohibition. And we know from experience in countries that have decriminalized drugs like Portugal, the death rate has gone dramatically. In fact, in 2015, the overdose death rate from opioids in Portugal was 6 per 100,000. In the United States, the same year as 312 per 100,000. So these are all opioids. And apparently the Portuguese equivalent of the drugs are, says they estimate there are 25,000 heroin addicts in Portugal. Today, there were 100,000 when they started decriminalized drugs there. So obviously, that would be the smartest thing to do. In this political environment, that's probably what they would say is a bridge too far. So then, okay, well, at least let's stop killing people. So why don't we focus... All of these efforts that are right now are focused on restricting doctors from helping their patients in pain and restricting the production of legal pharmaceutical-grade opioids. Instead of putting all those efforts into that, why don't we put them into harm reduction programs so that people will be less likely to kill themselves. Harm reduction programs such as, in addition to medical assisted treatment programs like methadone, maintenance or suboxone, there's needle exchange programs so people aren't spreading hepatitis and HIV. Even better, there's safe injection rooms. They've been around for 25 plus years. They're in every country with the United States in the developed world. The idea there is with a clean needle exchange program, which is very prominent in this country. You go in, you're given a clean needle and syringe, but then once you get out of the street, if you're a minority in inner city, you're arrested for possession of paraphernalia. If you're white in the suburbs, you just maybe you sell it or after you use it, you give it to somebody else. So it's not perfect. Whereas with a safe injection room, you go into the room, you inject there, and then you leave. The needle is then discarded by the people who run the place. And not only that, but you have the bonus of somebody being around there with Narcan. So if you overdose, because again, you're using an illegally obtained substance, so you don't know really what's in it. So let's say you overdose. Well, there's somebody there to detox to give you the antidote of Narcan, which doesn't happen with needle exchange programs. Actually, the CDC is okay with that. They encourage what they call safe syringe programs. So it's kind of a generic term, whether you do clean needle exchange or safe injection room, it comes under the safe syringe program. They think that's a good idea because it stops the spread of disease and death. But in this country, for example, when the city council of Seattle in the beginning of this year voted to have a pilot program for a safe injection room, a whole bunch of the state legislators have put it, try to stop it because it quote unquote sends the wrong message. So there's resistance on that kind of cultural level here in this country. That's a good harm reduction program. Several countries about half dozen have heroin assisted treatment programs started in Switzerland in 1994. It's still going 23 years later and it's in Germany, the Netherlands, the UK, Canada, Belgium is about to start a program. Spain has had a program. And in this case, what they find is people who have not been able to be retained in methadone maintenance programs because, like I say, it's hard to keep people, there's a lot of dropouts. What they did in Switzerland, they say, if you have failed a methadone maintenance program and you're an addict for at least two years, you're 18 or older and you're willing to surrender your driver's license, we'll let you come in here up to three times a day and inject diamorphine, which is not conscious, it's not the illegal market. This is the pure stuff because it's made there. You know, it's available and we'll give you a clean elixir and you inject yourself, you sign in, you sign out. 23 years later, the 20% of the people who signed up in 1994 are still in the program. It has a very successful retention rate. Average rate is three years and what they found is a 62% reduction is street crime. The sale of heroin on the street has pretty much disappeared because a lot of these people were selling heroin to support their habit. Well, now they don't have to. And interestingly, in Switzerland they reported a teen heroin use has come down because when the kids see these people going in and out of clinic to get their injection, it doesn't look cool. So it's kind of lost its appeal. Also, a lot of these people have gotten to work in Germany. They started a program shortly after Switzerland and they reported 40% of their clients have full-time jobs. So, you know, these are things that we could think of if we can't bring ourselves to end drug prohibition, at least let's stop making people die because the drug prohibition is what's making people die. Thanks for listening. This episode of Free Thoughts was produced by Tess Terrible and Evan Banks. To learn more, visit us on the web at www.libertarianism.org.