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1:08

Years back we published a two

1:10

part series called the Opioid Tragedy.

1:12

We interviewed physicians and economists, substance

1:15

abuse counselors, and recovering addicts, and

1:17

we all talked about how bad

1:19

the opioid epidemic was back then.

1:22

About seventy thousand individuals died from

1:24

a drug overdose. Just in two

1:27

thousand and seventeen. That's more Americans

1:29

than were ever killed by guns,

1:31

car crashes, or Hiv, Aids, and

1:33

a single year. We. Also

1:35

discussed a variety of solutions,

1:37

some of them straight up

1:39

medical solutions. Earpieces order is

1:42

treatable. It's not a death sentence. it's

1:44

a medical condition. and it's treatable. And

1:47

we also talked about harm reduction.

1:49

That's the idea that when it

1:51

is not practical to outright prohibit

1:53

something that's dangerous, it's worth finding

1:55

compromise in the case of a

1:58

dangerous opioid like fentanyl. That

2:00

might mean treating people with a

2:02

less addictive opioid like Buprenorphine. In

2:05

a later episode, we discussed harm

2:07

reduction with Rahul Gupta, director of

2:09

national drug policy in the Biden

2:11

administration. This administration has

2:13

been very clear for the first

2:15

time in the history of the

2:18

United States federal government. We have

2:20

made harm reduction the central tenet

2:23

of how we need to move forward. Gupta

2:25

told us about government funded needle

2:28

exchanges and the distribution of naloxone,

2:30

a drug that can rapidly reverse

2:32

an opioid overdose. There

2:35

have been other developments in the fight

2:37

against opioid overdose deaths, including

2:39

an intensive law enforcement campaign to

2:41

cut down on drug trafficking. Also,

2:44

billions of dollars of settlement

2:46

money has started to flow

2:49

from the opioid manufacturers, distributors

2:51

and consultants who did such

2:53

a good job of selling their

2:55

products. So with all that money

2:58

and all that law enforcement and

3:01

with harm reduction and medical treatments,

3:04

you might think we had the problem surrounded.

3:07

You would certainly think that opioid deaths would

3:09

be falling, but they're

3:11

not. It's horrible.

3:13

It's absolutely horrifying. That

3:16

is Keith Humphries. I'm a

3:18

professor of psychiatry and an addiction researcher

3:20

at Stanford University. Humphries has

3:22

also worked on drug policy for

3:24

the Bush and Obama administrations and

3:27

for Joe Biden's presidential campaign. He

3:29

has watched in horror as

3:32

annual opioid deaths continued to

3:34

climb. Today on Freakonomics

3:36

Radio, I wish we

3:39

weren't doing this, but we are starting

3:41

another two-part series on the opioid epidemic

3:43

to try to figure out why it

3:46

keeps getting worse. Some

3:48

of the answers are very simple. Depression

3:50

feels bad every day. Drug

3:53

use doesn't feel bad. Drug use feels

3:55

incredible. But there are other hidden

3:57

factors that are driving the epidemic, and we

3:59

will... explore those too. We

4:01

will find out which of the proposed solutions

4:04

have failed and why, and

4:06

we'll ask what might work better. We'll

4:08

try to track where those billions of settlement

4:10

dollars are going, and

4:12

we'll ask some questions that may make

4:14

you uncomfortable. For instance, in

4:17

recent years there has been a push

4:19

to destigmatize drug use. Is

4:22

it time to maybe bring back the

4:24

stigma? This

4:41

is Freakonomics Radio, a podcast that

4:43

explores the hidden side of everything

4:45

with your host, Stephen

4:48

Durbner. Most

4:58

epidemics come out of nowhere, do their

5:00

damage, and fade away. Why

5:03

is the opioid epidemic different? To

5:06

answer that question, we need to add

5:08

some context and some history. Opioids

5:10

are perhaps the most abused substance

5:13

in the history of the world.

5:16

That is David Cutler. I'm a professor

5:18

of economics at Harvard. Cutler

5:20

is one of the most prominent healthcare

5:22

economists in the world, and like Keith

5:25

Humphries, he has done his share of

5:27

government service. Cutler was an economic advisor

5:29

in the Clinton administration and a healthcare

5:32

advisor on Barack Obama's first presidential

5:34

campaign. He has also consulted with state

5:36

and city governments. Anyone

5:38

who's interested in helping

5:40

make healthcare work better is someone who I'm happy to

5:43

talk to. What would you say

5:45

if I said, well, I get that you're an

5:47

economist and that you may know

5:49

a lot about certain things,

5:51

but how does that most

5:53

fruitfully intersect with healthcare policymaking,

5:55

especially? An enormous amount of

5:57

healthcare policy has to do with economics.

6:00

For example, what incentives can you give physicians

6:03

so that they do things that you want

6:05

to happen but not things you don't want

6:07

to happen? Or what

6:09

incentives can you use for individuals to

6:11

help them take the medications that

6:13

they should take and not take medications that

6:15

they shouldn't take and not smoke and behave

6:17

healthy and so on? We're dealing

6:20

with incentives. We're dealing with how

6:22

to design a system so that it works. Those

6:25

are things that economics really knows a lot about.

6:28

Not everything in healthcare is just economics,

6:31

but it's also the case that if you

6:33

don't bring an economics lens to issues, you

6:36

often get many things wrong. Cutler

6:38

has recently focused his economic

6:40

lens on opioids, which, as

6:42

he mentioned earlier, have

6:45

been around for millennia. People

6:47

of course smoked opium forever. There

6:50

were wars fought over the right to

6:53

import opium to China. Some

6:55

of what's happened over time is we've gotten

6:58

better at extracting the key ingredients. So

7:01

heroin and morphine are both derivatives

7:03

of the opium poppy, and

7:06

those are more potent. The ancient

7:08

Sumerians used to call this poppy the

7:10

joy plant. Today we

7:13

are dealing not just with natural

7:15

opiates but with synthetic and semi-synthetic

7:17

versions. The one you're probably

7:19

most familiar with is fentanyl, an incredibly powerful

7:22

drug that was developed in the late 1950s

7:24

as an anesthetic. It

7:27

is still widely used in hospitals

7:29

for anesthesia and pain management,

7:32

but it's the street version of fentanyl

7:34

that's causing most of the overdose deaths

7:36

today. A fentanyl overdose

7:38

kills by slowing down the respiratory

7:40

system so much that there's not

7:42

enough oxygen reaching the brain,

7:45

and opioids are extraordinarily addictive.

7:48

Widespread addiction in the US goes

7:50

back to at least the Civil War

7:52

when wounded soldiers were given opium and

7:54

morphine, a derivative developed in the early

7:57

19th century and named after Morpheus, the

7:59

Greek god. of dreams. The

8:01

current epidemic also has

8:03

a medical history. It

8:05

started in the 1990s when the

8:08

American pharmaceutical firm Purdue Pharma

8:10

began promoting a new opioid

8:12

called Oxycontin. The

8:14

big breakthrough was that Oxycontin wasn't

8:17

nearly as addictive as other opioids.

8:20

At least that's what Purdue claimed. But

8:23

that claim turned out to be, what's

8:26

the word I'm looking for here? False.

8:30

By the time this falsehood was widely

8:32

known, Purdue was selling

8:34

billions of dollars worth of Oxycontin

8:36

a year and hoped to continue.

8:39

For many people, the introduction of

8:41

Oxycontin marks the outbreak of the

8:44

modern epidemic. From the

8:46

mid-1990s through roughly 2010,

8:49

you see increasing supplies, just massive,

8:51

massive supplies, like a

8:54

five-time increase in opioid

8:57

prescriptions, opioid use, a

8:59

massive increase in deaths from

9:01

opioids. And these are mostly

9:04

legal substances used by people to

9:06

whom it was prescribed. Much

9:08

of it was used by people to whom it

9:10

was prescribed, but some of it then gets passed

9:12

on to friends and relatives. There

9:15

becomes a black market for it, so

9:17

people who are addicted will buy it

9:19

from others. There are

9:22

pill mills where they'll, in principle, examine

9:24

you, but not really. They'll give you a prescription. You

9:26

pay all in cash. You get the drugs. We

9:31

talked quite a bit in our

9:33

earlier opioid series about this supply

9:35

side story. But despite

9:38

all the death and damage since

9:40

then, despite the anguish

9:42

of millions of mourners and

9:44

survivors since then, the overall

9:47

problem has gotten worse. David

9:50

Cutler wanted to find out why, so

9:52

he started a research project in collaboration

9:54

with the economist Travis Donahoe. Travis

9:57

is currently a professor at University

9:59

of Pennsylvania. And at

10:01

the time we started out, he was a

10:03

PhD student at Harvard in the Health Policy

10:05

Program. You were an advisor to him? I

10:08

was an advisor to him, and he actually

10:10

grew up in West Virginia. If

10:13

there is an epicenter of the opioid epidemic,

10:15

it is West Virginia. So

10:18

he was always, always interested

10:20

in things having to do

10:23

with opioids and pain

10:25

and deaths due to that. I

10:28

grew up in Huntington, West Virginia, which at the time

10:30

I was in high school became

10:32

widely known as a county that had

10:34

the highest adult obesity and depression prevalence

10:36

in the United States. That's

10:38

Donahoe. West Virginia also has the

10:40

highest rate of drug overdose deaths

10:42

in the U.S. Many people

10:44

that I went to high school with, friends, have had

10:47

opioid addiction over time, and there's been a number of

10:49

people that have overdosed. Travis

10:51

wrote his dissertation on

10:54

policies to address the opioid

10:56

epidemic, particularly DEA intervention against

10:58

distributors and dealers and so

11:01

on. There's a lot

11:03

of literature on the opioid epidemic, including a lot

11:06

of very good literature on the

11:08

transition from people using legal opioids to

11:10

people using illegal opioids and so on.

11:14

We were really puzzled first by the

11:16

fact that, like, oh my gosh, how

11:18

long can this thing go on? But

11:20

then by the fact that there are

11:23

reasons why people stopped taking things. People

11:26

learned that smoking was bad for them,

11:28

and they stopped. Not only that,

11:30

they learned that the cigarette companies had been lying to

11:33

them. They were like, well,

11:35

to heck with you guys, we

11:37

don't want to be using this product.

11:40

So tobacco is a very addictive

11:42

substance. Tobacco use has

11:44

fallen well more than 50 percent

11:47

since its peak just after World War II.

11:50

Now talk for a moment about the levers that

11:53

contributed to that, because it wasn't by accident, and

11:55

it wasn't cheap, and it wasn't easy, and there

11:57

was a lot of regulatory and taxation power put

11:59

in there. to UCS? There were

12:01

a lot of public and private

12:04

policies. There were public

12:06

policies around taxation, around regulation

12:08

of where you can smoke. There

12:11

are private policies like employers saying you can't

12:13

smoke in the workplace or you have to

12:15

go outside to smoke. There

12:17

was social pressure,

12:19

peer pressure, no, you can't smoke

12:22

in my house. There's

12:24

what people were taught, just the

12:27

whole attitude, you really want to

12:29

smoke. So it was a

12:31

combination of public and

12:33

private actions that led some

12:36

people never to start smoking,

12:39

some people to quit smoking,

12:42

and others to help people

12:44

stay off cigarettes. The

12:47

net effect is that combustible cigarette

12:49

use is very, very down. So

12:55

why haven't opioids followed the

12:57

same trajectory as cigarettes? That

13:00

question brings us back to this new

13:02

research by Donahoe and Cutler. For

13:05

a 30 year period, opioid overdose deaths

13:07

have been increasing continuously. What

13:09

we want to ask is why has that occurred?

13:11

We know about things that have

13:13

sparked it, we know about things that have

13:15

exacerbated it, but what is it that would

13:17

produce this kind of a continuous trend? They

13:20

recently wrote up their findings in a paper

13:22

with a title that only an economist could

13:24

love, thick market externalities

13:27

and the persistence of the

13:29

opioid epidemic. And what

13:31

is a thick market externality? In

13:34

this case, it describes the fact

13:36

that opioid users end up creating

13:39

more opioid users. What's

13:41

going on here is the idea, well, maybe

13:43

I've hurt my knee, maybe I hurt my

13:45

back or something. If there's

13:47

a lot of opioids around, I'll bump

13:49

into someone who has some, maybe I'll

13:51

experiment with them. Whereas if

13:54

not, or if I have to go

13:56

into the illegal market or I have to deal with

13:58

someone I don't know in some dangerous setting. maybe I'm

14:00

not going to do that. So

14:02

just the availability of

14:05

the substance can encourage others to

14:07

use it. And

14:09

that's what we look for

14:11

and what we find evidence for. There

14:14

evidence comes from several sources like

14:16

government figures on opioid deaths and

14:18

the supply of drugs, but

14:21

also from Facebook. So

14:24

it looks like it's spreading through social

14:26

networks. If one county

14:28

has more deaths, nearby counties have more

14:30

deaths. If one county has

14:32

more deaths, areas of the country that have

14:34

more Facebook friends, then those areas also have

14:36

more deaths. Sometimes the

14:39

literal physical product will

14:41

spread through networks. And sometimes just the idea,

14:43

oh, when I was in pain, I got

14:46

this opioid and maybe you should try this

14:48

opioid. We have a quotation from someone

14:50

who said, oh, yeah, I got a

14:52

call from a friend saying, I just tried this thing.

14:54

It's the greatest thing ever. You just go

14:56

tell your doctor you have back pain and ask for a prescription

14:58

for it and you'll love it. When you look

15:00

at data on initiation of opioids and other

15:03

drugs, the typical age that a

15:05

person initiates these kinds of drugs is pretty

15:07

young. I would venture to guess that most

15:09

people were not sitting in a void and

15:11

then independently became curious about how

15:13

to use heroin and then went out and figured

15:16

out how to do that. It was probably that

15:18

someone in their network was using heroin as well.

15:20

And then that ultimately influenced them to learn how

15:22

to do it. Do you know

15:24

what is the median age of

15:27

first use of opioids? I

15:29

don't know that I know precisely, but I have seen the

15:31

number 12 to 14 float around. Oh

15:34

my goodness. So yeah, it's quite young. According

15:40

to some fairly reputable government surveys,

15:42

roughly half of the people who

15:45

abuse opioids got them for free

15:47

from a friend or relative. And

15:50

where do all these pills come from? The

15:52

Centers for Disease Control estimates that 57

15:55

million people, that's nearly 20% of the

15:57

US population,

16:00

had at least one opioid prescription filled in

16:02

a single year, 2017. For our earlier series

16:04

on this topic,

16:07

we spoke with Stephen Lloyd,

16:10

a Tennessee physician and a

16:12

recovering opioid addict. I

16:14

asked him how he sourced his drugs. At

16:17

first, it was out of people's medicine cabinets. For the

16:19

longest time, I had a pretty much endless supply. If

16:21

I came in your house and you had an old

16:24

prescription left over, I walked out the door with it.

16:26

And then the other way was doctor shopping. You know,

16:29

all my friends were doctors. And so I

16:31

would just hit them up at different times

16:33

for prescriptions. Today, Stephen Lloyd is

16:35

heavily involved in trying to fight the opioid

16:37

epidemic. We will hear from him later in

16:40

this series. As for the

16:42

new research by David Cutler and Travis

16:44

Donahoe, they estimate that

16:46

spillover effects, social contagion

16:49

basically, can explain roughly 90% of

16:51

opioid deaths. Spillovers,

16:55

they write, are the

16:57

main reason deaths have increased for so long.

16:59

When people in one area use it, they

17:02

tell their friends or they give the substance

17:04

to their friends. And so both within the

17:06

same area and then within other neighboring areas

17:09

and within other areas where they have

17:11

friends, even if they're not neighboring, then

17:14

you see usage and deaths go

17:16

up there. And then you get all

17:18

those feedback effects, like all those echoes, and

17:21

it can get even bigger and

17:23

bigger. And so that either significantly

17:25

minimizes the extent to which it

17:27

dies out, or it actually

17:29

creates this sort of unstable spiral, where

17:33

use one year translates into even more use

17:35

the next year and even more the next

17:37

year. You know, 30 years into an

17:39

opioid epidemic would have been more

17:41

than enough time under usual circumstances

17:44

for opioids to die out. But

17:46

because of these echo effects, it

17:49

just keeps growing and growing. Let's

17:51

talk about the previous

17:53

and conventional explanations for the

17:56

opioid epidemic and the fact

17:58

that it's continued to rise

18:00

in volume and intensity.

18:03

Let's talk first about what others in

18:05

your profession, particularly Angus Deaton and Anne

18:07

Case, have called deaths of despair, which

18:09

I believe is a self-explanatory

18:11

phrase, but also something that probably most

18:13

listeners are familiar with. What

18:16

components of that argument as pertain to

18:18

opioid deaths do you think are accurate

18:20

and which are perhaps inaccurate? So

18:22

their work is incredibly

18:25

important. It's among the

18:27

most important things that has been

18:29

written about public policy in decades.

18:32

The idea behind it is that people are

18:34

in despair, either

18:36

because of physical pain or mental pain,

18:39

or really stemming back to society that

18:41

hasn't worked the way they would like,

18:44

and that that leads people to use

18:46

illegal substances, partly as an out for

18:49

it. So some of the

18:51

specific things, like for example, there are more

18:53

people in pain than there used to be,

18:56

but the increase in pain is nowhere near as

18:58

big as the increase in use of opioids. Now

19:01

David, you have written a paper on this

19:03

very idea, I believe, with your colleague, Ed

19:05

Glaser, correct? That's correct. What's

19:08

happened over time is not that there

19:10

are just more people in pain, although

19:12

there absolutely are, but the

19:14

people in pain are doing different things.

19:17

Once opioids were sort of safe and

19:19

effective, it became, oh, you have a

19:21

toothache? Here's opioids. Oh, you've

19:23

got to hurt back because of work?

19:26

Oh, use opioids. Oh, you're

19:28

down and out, and that's

19:30

presenting with psychological pain, but

19:32

also physical pain manifestations? Use

19:34

opioids. And

19:36

so it is true that there is

19:38

this large share of people in physical

19:41

and mental pain. The

19:43

way that the medical system and people have responded

19:46

is different than it used to be, and it

19:48

involved trying to medicalize it and treat it. That's

19:52

problematic here when the treatment is not

19:54

effective and in fact is addictive. For

19:57

God's sakes, if the treatment is worse than

19:59

the disease, it's really a terrible

20:01

thing. One thought

20:03

I had while reading your new paper

20:05

on the social spillovers of opioid abuse

20:08

is that the

20:10

deaths of despair umbrella explains

20:12

many opioid overdose deaths as

20:15

a result of loneliness and

20:17

isolation. But

20:19

what your paper is arguing seems to be

20:21

kind of the opposite of that, which is

20:23

that it's not isolation or loneliness, or maybe

20:25

it is loneliness, but it's not isolation. It's

20:29

actually connection that without

20:31

connection afforded by the internet

20:33

particularly, that this epidemic

20:36

would not have continued to grow. Is that a fair

20:38

read? Yes, the

20:40

connection is absolutely fundamental here. Of

20:43

course, these connections are different than the kinds

20:45

of connections that Anne and Angus are writing

20:47

about, in that they're talking about meaningful connections

20:49

in your life. And

20:52

the internet here is about where can I

20:54

buy something or where can I obtain the

20:56

product cheaply which is a different kind of

20:58

connection? So

21:01

that's one economist, David Cutler, talking

21:03

about how his research, which shows

21:05

that a certain kind of connectivity

21:07

has helped prolong the opioid epidemic,

21:09

can square up with some

21:11

other economists' argument about deaths

21:14

of despair. But

21:16

what does a non-economist think of

21:18

David Cutler's argument? I would

21:20

praise two things about the Cutler paper. That

21:23

again is Keith Humphries, the

21:25

Stanford addiction researcher and drug

21:27

policy advisor. So

21:29

one is it drives non-economists crazy when

21:32

economists show up in a new area and act

21:34

as if no one has studied it before. So

21:36

I actually first looked at the references, have they

21:38

actually read anything about addiction? And they have, so

21:40

that's good. Second thing is

21:43

they are absolutely correct that

21:45

social processes spread addiction much

21:48

the same way as they might spread something like

21:50

COVID. People who are using invite other people to

21:52

use with them. Sometimes they do that because they're

21:54

like, well, I need to sell to keep my

21:56

own habits so this is someone I could sell

21:58

to. But oftentimes, friendship is fun. let's do this

22:00

together. And particularly if you're in the

22:02

early stages of drug use, it can look very compelling.

22:04

You know, if you're deeply addictive and you're homeless, it's

22:06

pretty hard to persuade someone, hey, you want to live

22:08

like me. But you know, if it's like, it's a

22:10

party, you know, so that part is true. But

22:13

Humphries, as a drug expert, also

22:15

has some critiques of the economists

22:17

paper. There's two things in

22:19

analysis that I think are pretty seriously questionable.

22:22

First is, they're trying to explain why do

22:24

we keep having this epidemic after 25 years,

22:26

when the average person

22:28

would say, I don't want to do that. And that

22:30

would help make it off. And second, the police would

22:32

shut it down. But you

22:34

know, other state, there's another epidemic, 25 years

22:37

that has also gotten more severe. And that's

22:39

alcohol. Alcohol deaths are up and they don't

22:41

look at that. Why don't we shut the

22:43

alcohol industry down? Because it's a legal industry.

22:46

And that is a big reason why the opioid

22:48

epidemic has gone on so long.

22:50

They had gold plated protection as a

22:52

legal industry. One of the

22:54

most remarkable things that happened, the Drug

22:56

Enforcement Administration caught distributors

22:59

delivering a million pills to towns with 300

23:02

people. I'm not exaggerating. And you think that's

23:04

going to stop them. The distributors went to

23:06

their friends in Congress and got a new

23:08

law passed that basically stopped the DA from

23:10

doing that. We went back to

23:13

Cutler and Donahoe to ask what they

23:15

thought of these critiques. They wrote back

23:17

to say that they agree that insufficient

23:19

regulation is an important reason that the

23:21

epidemic has lasted so long, but that

23:23

it doesn't conflict with their argument about

23:25

social spillovers. In towns that

23:27

had pill mills like Keith Humphries was talking

23:29

about, a million pills shipped to

23:32

a town of 300, opioid

23:34

deaths continued to rise after those

23:36

pill mills were shut down. And

23:39

Cutler and Donahoe say that alcohol

23:42

may actually have social spillover dynamics

23:44

similar to what they have observed

23:46

with opioids. The persistence

23:48

in demand for alcohol, they

23:50

wrote, would be related to

23:52

its near ubiquity in social

23:54

settings. Think about that for

23:57

a minute the next time you have a drink

23:59

with friends or colleagues. Keith

24:01

Humphries had another problem with the

24:03

economists paper. This one has to

24:05

do with how they measured opioid

24:07

overdoses. They're treating overdoses as

24:09

an index of demand and they aren't

24:12

an index of demand. Overdose

24:15

deaths are a function of how often

24:17

somebody uses and how risky each episode

24:19

of use is. The risk

24:21

he is describing is the likelihood that

24:23

a given drug user will overdose in

24:25

a given year. In the

24:27

90s, people were using Vicodin. Maybe

24:29

it was 1 in 200 and then Oxy raised

24:32

it to 1 in 100 and then

24:34

heroin raises it to 1 in 50 and

24:36

with Fennel, maybe it's as much as 1

24:38

in 20 for a year of use. So when you

24:41

say, oh, deaths are going up, it must mean demand is

24:43

going up. No, actually demand could

24:45

be dropping. The problem is the risks

24:47

of use are going up. The

24:50

number of people who say I'm initiating opioids

24:52

is dropping and the number of people say

24:54

they're using Fennel is nowhere near what it

24:56

was. The number of people who were saying they were

24:58

using the pills back when that was the heyday. It's

25:01

just that it's so deadly. And

25:04

that's really the big issue, the potency of

25:06

the drugs. We will get into that later

25:08

in this episode. Cutler and

25:10

Donahoe told us that their measure

25:13

of demand was not just about

25:15

overdose deaths. Their analysis looked at,

25:17

quote, the total potency adjusted quantity

25:19

of opioids that are sought. That

25:22

is the number of people seeking opioids

25:24

multiplied by the amount they want to

25:26

use. They wrote, there is

25:28

a lack of good data on how many

25:31

people are using various substances and how much

25:33

they are using. Thus, it is very hard

25:35

to know what is happening to the number

25:37

of people in the market for a

25:39

drug like illicitly made Fennel.

25:42

Everyone in the field wishes we knew more. Coming

25:46

up after the break, what else

25:48

do we not know about how to

25:51

end the opioid epidemic? This

25:53

is Freakonomics Radio. I'm Stephen Dubner. We will be

25:55

right back. Pre-Conomics

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27:44

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27:47

as powerful as morphine. In

27:51

the U.S., it's responsible for about

27:53

two-thirds of fatal drug overdoses. As

27:56

I mentioned earlier, Fentanyl started out

27:58

as a hospital drug for anesthesia.

28:00

and pain relief. The World Health

28:02

Organization still lists it as an

28:04

essential medicine for the management of

28:06

cancer pain. Here is Keith

28:08

Humphries from Stanford. It's

28:10

terrific. I worked in hospice for

28:12

a number of years for people with late-stage bone

28:14

cancer. Fentanyl pats can give them relief when nothing

28:16

else can. And it had

28:18

been recognized for a long time that

28:21

this could really be a blockbuster on

28:23

the illicit market. And some criminal gangs

28:25

tried to introduce it. There was an

28:27

outbreak around 2000. There was another about

28:30

five years after. But they were domestic

28:32

groups. They were small. And

28:34

law enforcement was very good at jumping on them right

28:36

away and shutting them down. But that

28:38

changed as the booming black market

28:40

for fentanyl in the U.S. attracted

28:43

foreign suppliers. We live

28:46

in a globalized economy, right? And

28:48

China, which has a massive chemical

28:50

industry, a massive pharmaceutical industry, and

28:52

an export-led economy, has a

28:55

lot of people who wouldn't mind earning a little extra

28:57

money on the weekend. And they started to do it.

28:59

And that combines with the technology or the internet that

29:02

they began selling. What are called precursors. The

29:04

stuff I used to make the fentanyl over

29:07

into North America. For example,

29:09

into Mexican suppliers. Also, sometimes just

29:11

sending fentanyl directly in the mail.

29:13

Fentanyl is so potent that you

29:15

could, let's say you had a dealer in Dayton, Ohio, you

29:18

could put it in an envelope that was something that might

29:20

have a Christmas card in it. Plus,

29:22

this is not like in the old days where

29:24

maybe, you know, Guinea-Bissau is

29:26

growing a plant that's turned into drugs.

29:28

And a superpower can pressure Guinea-Bissau. You

29:30

can't really pressure a nuclear-armed superpower like

29:32

China to do anything. Has

29:34

the supply to the U.S. been significantly constrained

29:37

or not? The most important thing that's

29:39

happening in drugs is the departure of drugs

29:41

from in their agricultural base that they had

29:43

for thousands of years. Let's say

29:45

you're running a heroin business and I'm running a fentanyl

29:47

business. What do you have to do? Well, you got

29:49

to get some arable land, probably in

29:51

a place with weak government, dodgy local politics. Afghanistan

29:53

looks good. Right, but now you have to pay

29:56

off a warlord. And you got to find peasant

29:58

labor and you got to protect the farm. You

30:00

got to make sure no other war word burns the crop

30:02

and then you got to get across the border Well, that

30:04

means either smuggling costs or bribery costs and you got to

30:06

put it in a boat and it's big and it's you

30:08

know Bulky and thousands of miles and then the Coast Guard

30:10

grabs it and then you got to wait for the next

30:12

growing season And then there's a blight or a drought whereas

30:15

me. I just like hey, I need some fentanyl bill

30:17

Can you whip it up in the sink? Yep have

30:19

it for you in a couple hours So

30:21

I'm gonna put you out of business my production

30:23

costs are about one percent of your

30:26

production cost and that is what is

30:28

happening Right now in California heroin is

30:30

very hard to find. I know people who have

30:32

you know, addicted So I can't get it anymore

30:35

So a lot of the traditional things that countries

30:37

used to do to suppress the trade are irrelevant

30:39

What do you pull up plants? There are no

30:41

plants when a drug is that potent

30:44

and that cheap? It's hard for

30:46

government and law enforcement to do much about

30:48

it. I testified to the Senate

30:50

about this just recently Understandably

30:53

they want fentanyl kept out of this country

30:55

But it's so compact that our

30:58

entire Consumption at least the Rand

31:00

people who are very smart this kind of stuff

31:02

think it's only like five or ten metric tons

31:04

a year That's a truck a

31:07

truck. That's pretty easy to hide stuff

31:09

that small. So it's very hard to keep it

31:11

out of the country Most

31:15

of the Fentanyl that

31:17

comes into the country comes

31:19

through legal border crossings that

31:22

again is David Cutler the Harvard

31:24

Healthcare Economist this is

31:26

not people bringing quantities of fentanyl

31:29

with them through illegal immigration It's

31:32

basically coming into the country

31:34

through a legal method And

31:37

then from there going through the supply

31:39

chain to wind up being distributed to

31:41

users It gets either

31:44

incorporated into heroin or pressed into

31:46

pills that say it's oxycontin when

31:48

it's not or

31:50

combined with methamphetamines or Any

31:54

number of other ways and then

31:56

people die from that and

31:58

I assume the concentration is far out of

32:00

whack, yes. The concentration is

32:02

far out of whack and the potency

32:04

varies a lot from batch to batch

32:07

because you have to dilute it. And

32:09

so that's part of a high level of deaths

32:11

is I may be used to a certain dose,

32:14

but if you don't mix it correctly, I

32:16

may get more dosage than that and

32:19

that can be a big problem. Now,

32:21

I know very little about

32:24

drug dealing, but I don't understand

32:26

why it would be that drug

32:29

sellers, drug dealers would

32:32

want to include a fatal substance because

32:34

they're killing their customers. Can you explain

32:36

that? There are different versions

32:38

of the answer to this. One

32:41

version is exactly yours, which is they don't

32:43

mean to, but they sometimes do by accident

32:45

because the mixing isn't so great. A second

32:49

version is what

32:51

you really want if you're in the market

32:54

is you want to know that the person

32:56

has a potent batch. And

32:58

so it doesn't hurt if the batch

33:00

has killed someone else. That

33:03

may attract more customers to

33:05

you. Gosh, if someone died

33:07

using a given dealer's fentanyl,

33:09

that must mean it was pretty good.

33:14

The current supply of street drugs in

33:16

the US like cocaine and methamphetamine contains

33:18

a lot of fentanyl.

33:22

In a recent study of drug users in New York City,

33:24

more than four out of five people tested

33:26

positive for fentanyl, but only one

33:28

in five said that their fentanyl

33:30

consumption was intentional.

33:34

Given this widespread contamination

33:37

and the massive overdose risk and all

33:39

the other suffering that opioids

33:41

have caused over the past couple of decades,

33:44

it may be tempting to take

33:46

a hardline stance against drugs. Full

33:48

stop. Keith Humphries is

33:51

more measured than that. I

33:53

think people rhetorically, there are people say

33:55

all drug use is bad. But

33:57

from a science viewpoint, when you realize

34:00

what is a drug and how broad that

34:02

category thing that is, you realize very

34:04

few of us go through our life without taking drugs.

34:06

Do I have to put down my caffeine right now?

34:09

There you go. I mean, I've often

34:11

brought that up. You know, I love caffeine. I don't

34:13

have a problem with it. If I had to choose

34:15

between caffeine and my children, I could make that decision.

34:18

But I would miss them. I would really miss them.

34:20

I've been in meetings where people condemn the evil of

34:22

drugs and then they all go out and have a

34:24

drink as if alcohol weren't a drug. We go to

34:27

a doctor and we get drugs that save our lives,

34:29

right? When you realize that drugs

34:31

are not just the thing that's in the paper

34:33

connected to a crime story about, you know, a

34:35

deal gone wrong and somebody got shot, you

34:38

realize it's almost a universal human thing to take

34:40

drugs. So really what we're arguing about is when

34:42

do we take them and how and for what

34:44

reasons and how it's monitored. I have been a

34:47

proponent of a medication called naloxone, which is

34:49

an opioid antagonist. So what that means

34:51

is when you take an opioid, it binds

34:53

to a particular receptor in your brain and

34:55

naloxone essentially goes to that same receptor,

34:57

knocks that opioid out. Now

35:00

is there any possibility that somebody might

35:02

take more opioids knowing their friend was

35:04

there with naloxone? That is

35:06

definitely possible. We know risk compensation happens and lots

35:08

of behaviors people drive more quickly when they have

35:11

their seatbone on. However, the

35:13

equation is risk compensation

35:15

minus how effective the

35:17

safety device is, right?

35:20

So if I think how much more risky drug

35:22

use would naloxone cause? I'd say it's a pretty

35:24

small amount. How different is it to overdose with

35:27

naloxone and without it? Oh boy, that's a huge

35:29

effect. When you have somebody who

35:31

literally is dying a few moments later, they're

35:33

breathing again, which is pretty incredible.

35:36

When I say harm reduction, is that a phrase

35:38

that you generally embrace or do you feel it's

35:41

come to cover too much ground perhaps? Well,

35:43

if you want, you know, five definitions of harm

35:45

reduction, talk to three people. So

35:48

I try as I do with lots of words people

35:50

argue about a lot. I often will start saying, well,

35:52

tell me what you mean by that. I hope none

35:54

of us wake up in the morning trying to do

35:56

harm, right? So we'd like to have less harm. And

35:59

it's. shouldn't be overdrawn, as some people

36:01

do, the distinction, say, between harm reduction

36:04

and treatment, because the truth is many

36:06

people who go to treatment end up continuing

36:09

to use but less in a less dangerous

36:11

way, and a number of people

36:13

get in contact with harm reduction. That ultimately ends

36:15

with them deciding that they don't want to use

36:17

drugs at all. Sometimes the difference

36:19

gets overstated. The clans start to fight with

36:22

each other. I just look at this

36:24

as a public health, public safety thing, like what is the impact,

36:26

and if it's what I consider a good impact, and I'm in

36:28

favor of it. This

36:32

gets us into another tricky area

36:35

of drug policy. Some

36:37

people who argue for harm reduction think

36:39

the best way to get there is

36:41

to decriminalize drug possession. That would remove

36:43

some of the stigma of drug use.

36:46

It would allow for more safety regulations.

36:48

It would free up law enforcement resources

36:50

for other problems. One

36:52

US state, Oregon, recently

36:55

tried decriminalization. At

36:57

the end of 2020, the people of Oregon

36:59

voted in the general election to remove

37:02

all criminal penalties for drug use.

37:05

And practically speaking, also reduced penalties for

37:07

drug dealing. So that changed

37:09

the character of the state, and there

37:11

was unfortunately a big increase in overdoses.

37:13

And I notice I go to Oregon

37:15

a lot more public drug dealing, which

37:17

has bad effects on neighborhoods. Now,

37:20

it was also a pandemic, right? So things

37:22

could have easily gotten worse anyway. But

37:25

the faith that the advocates had

37:27

that if you removed all pressure and

37:30

you removed all shame from

37:32

sitting on a park bench using fentanyl,

37:35

then people would seek out care proved

37:38

to be completely incorrect. Did

37:40

that surprise you and others in the field? Me,

37:43

no. I just think about the

37:45

neuroscience. I think about the biology of reward.

37:48

Is that that would have been true if

37:50

the condition were, say, depression. Depression

37:52

feels bad every day. People are so happy

37:54

to get rid of depression if you can

37:56

get rid of it. Drug use doesn't feel

37:58

bad. Drug use feels incredible. In

38:00

those short moments, you get this great reward. I mean, that's

38:02

why. You say, why does this person give up their family,

38:05

their health, their home for this? It's because in the short

38:07

term, it feels great. And

38:09

so most people who seek

38:11

help are under some pressures. There's some

38:13

countervailing force. The spouse says,

38:16

you keep doing this. I'm taking the kids and

38:18

I'm moving out. You know, Bosch says, you show

38:20

up high to work one more time, you're fired.

38:23

And you're saying making things more easily

38:25

available does not increase that countervailing force.

38:28

No, just the opposite. And there was also sort

38:30

of rhetoric. It's wrong to think anything negative about

38:32

it. We need to fully destigmatize the behavior. But

38:34

you know, when people come in for care, it's

38:37

very often because they do feel ashamed. They feel

38:39

like, you know, I'm letting my family down. I'm

38:41

letting myself down. So I don't

38:43

want to say, are you a fan of stigma, but

38:45

do you see a useful role of stigma in the

38:47

way society thinks about drugs? Absolutely. So

38:49

when I was growing up, I grew up in West

38:51

Virginia in the 60s and 70s. Two

38:54

things considered funny are not considered funny anymore.

38:56

One was drunk driving and the other one

38:59

was hitting your wife. People joked about these

39:01

things. Now they're deeply stigmatized. And I'm glad

39:03

because that is a signal to people that

39:05

there are wrong things to do. So

39:08

there has to be some pressure. And I

39:10

say that same time saying like I've always

39:12

been against forever throwing people

39:14

into a cell for the mere act

39:16

of using a substance. But there's plenty

39:18

of smarter things we can do than that. After

39:23

the break, what are some of those

39:25

smarter things? I'm Stephen Dubner and this

39:27

is the first episode in a two

39:30

part series about why the opioid epidemic

39:32

is still getting worse. If

39:34

you like listening to Freakonomics Radio and

39:36

learning along with us, I

39:38

hope you will tell other people to listen to it.

39:40

That is a great way to support the podcasts you

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app. That helps too. Thank

39:49

you much Lee. We will be right back. Freakonomics

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42:37

In 2020, the Stanford drug policy

42:39

expert Keith Humphries led a

42:41

commission between his university and the

42:43

Lancet medical journal in Britain. It's

42:46

one of the most influential journals in

42:48

terms of global health. People read it

42:50

everywhere and they create commissions to look

42:52

at global health challenges. And so there's

42:54

the Lancet Commission on diabetes, the Lancet

42:56

Commission on the health of children, the

42:58

Lancet Commission on malaria. And

43:01

then usually they wanted to do one just

43:03

on a couple countries, the US and Canada,

43:05

and that was because of our opioid crisis.

43:08

It was so bad they said, this isn't global yet,

43:11

but let's do something about it now. The

43:13

commission was asked to come up

43:15

with solutions that would cut opioid

43:17

deaths from pharmaceutical marketing to medical

43:19

education to policy. Humphries

43:21

has even more suggestions. You

43:24

want to make drugs as hard to

43:26

get as possible. You cannot eliminate them.

43:28

That is impossible, but you can certainly

43:30

raise search costs. There's a thing

43:33

called drug market intervention that the police, community,

43:35

health do together to close down open air

43:37

drug markets. Why do those markets exist?

43:39

They are not to serve the people in the neighborhood. If

43:41

you were in the neighborhood, you would know the dealer, the

43:43

dealer would know you. They're so that

43:45

people from outside the neighborhood can rapidly find

43:47

a dealer and dealer can rapidly find customers,

43:49

and that just has all these destructive effects.

43:51

You can close those down, and that's something

43:53

that's definitely helpful. That's one

43:56

suggestion. What else does Humphries have? With

43:58

the seven, eight million... people at any given

44:00

time who are on probation and parole, we

44:03

should be drug testing and alcohol testing all

44:05

of them regardless of what they're arrested for

44:07

and giving rewards and penalties based on their

44:09

use, immediate, swift and certain awards. I'm not

44:11

talking about violating them back to their original

44:13

sentence, but you could have things like if

44:15

you go through a week and you don't

44:17

use cocaine, we'll knock a week off the

44:19

end of your parole sentence. Or the other

44:21

way, I'm afraid we're going to add another

44:23

week on your parole because you didn't

44:26

do that. Humphries himself has done some

44:28

work on a program like this for alcohol

44:30

abuse. It's called 24-7 Sobriety. It

44:34

was invented by a county prosecutor named Larry

44:36

Long, a remarkable guy. He was

44:38

seeing people he grew up with in a small town

44:40

in South Dakota cycling through the court over and over

44:42

with alcohol problems. And he felt bad for them because

44:44

he knew, you know, we threaten you, we take away

44:47

your car, we throw you in jail, nothing works. And

44:49

he said, the problem isn't driving, the problem is drinking.

44:51

24-7 Sobriety is a court-mandated program

44:54

for people who have been arrested

44:56

multiple times for drunk driving. It

44:59

involves constant and frequent testing.

45:02

Every morning, you have to come in and you blow

45:04

a breathalyzer. If it shows negative,

45:06

you get a immediate award. Have a great

45:08

day, Keith, you know, another day of freedom.

45:10

If on the other hand, it's positive, there's

45:12

an immediate consequence. You're arrested on the spot,

45:14

not maybe, certainly, and you are held in

45:16

a cell for just one night. But it

45:18

starts that night, immediate. Now, you think in

45:20

a way, a lot of these folks have

45:22

been in prison, why would they care about

45:24

one night in the jail system? It's

45:27

because it's a swift and certain consequence.

45:29

And all those other consequences in criminal

45:31

justice are very probabilistic and distant. So

45:34

when I heard about this program, I was in the Obama administration, I

45:37

thought, oh, come on, half these people are going to show up drunk

45:39

and the other half are going to be rampaging around the countryside. And

45:42

I went there the first morning, I remember this

45:44

in Sioux Falls, and watched 200 people go

45:47

straight through. All 200 showed up, all 200

45:49

blew negative. In South Dakota,

45:52

they've done over 10 million tests and the success rate,

45:54

meaning the proportion of times people show up and are

45:56

not drinking, is 99.1%. The

46:00

24-7 sobriety program also produced

46:02

a significant reduction in repeat arrests

46:04

for drunk driving. violence

46:06

against women also went down dramatically. When

46:09

you take alcohol out of somebody's life,

46:11

other good things happen. So

46:13

that's one set of ideas that Keith

46:15

Humphries thinks could help cut opioid deaths.

46:18

What else? We could definitely have

46:20

a decent addiction treatment system, which we do

46:22

in some places, but not in most of

46:24

the country. Treating addiction

46:27

like a serious chronic illness, meaning

46:29

it would be core to our

46:31

healthcare function. I think we've come to

46:33

that with smoking. Your doctor now is

46:35

very comfortable talking to you about your tobacco use and also,

46:37

you know, do you want some nicker red gum or do

46:40

you want to try some Zyban or whatever? We need to

46:42

do that for all the other substances as well. We

46:45

need to save as many lives as we

46:47

can in the meantime. Naloxone is, you know,

46:49

a lifesaver, syringe service programs that reduces

46:51

the spread of infectious disease. That is

46:53

certainly a very worthwhile thing to do

46:56

as well. And then the last

46:58

thing is, particularly opioids, you have to remember

47:00

that the American opioid crisis didn't start on

47:02

the streets. It started in hospitals and doctors'

47:04

clinics. And we need

47:07

to do a much better job

47:09

regulating legal producers of drugs. It's

47:11

interesting how common it is to

47:13

assert that if only these things

47:15

were legal, we wouldn't have these

47:17

problems. Remember, the biggest problems we have

47:19

are all with legal drugs. Eight million

47:22

human beings a year die from smoking on this

47:24

planet. That's ten times more than all the illicit

47:26

drugs put together. So you've got to regulate adequately.

47:29

What about the demand side? The consumption

47:31

is very skewed. So you have very

47:33

high consumption people. Those are great targets

47:35

for treatment. Often, in fact,

47:37

the first line treatment is an opioid, which

47:39

strikes some people as, you know, how would

47:41

you treat an opioid with an opioid? But

47:43

they're dramatically safer opioids like buprenorphine and methadone

47:45

relative to fentanyl that give people stability, and

47:48

they can do things like, you know, hold

47:50

a job, be with their families and that

47:52

kind of thing. Every time you take

47:54

one of those folks out, it's a huge hit

47:56

to demand. And then there's the investments

47:58

need to be made on the prevention side. side. This

48:00

is the thing that is the

48:02

hardest to get everybody interested in because

48:05

we are consumed understandably by the suffering

48:07

that is right before us. But

48:10

if you look at other epidemics that people my

48:12

age have lived through, you know, COVID, HIV,

48:14

AIDS, those were not solved

48:16

by saying, let's wait till people get really

48:19

sick and then spend a lot of resources

48:21

to try to help them. They were ended

48:23

by getting people into recovery who were sick,

48:25

but even more importantly, stopping new cases. Right.

48:28

So what's the version of vaccine and the

48:31

opioid problem? You do as

48:33

much as you can to avoid exposure,

48:35

particularly when people are young. We

48:37

still have a problem of like one in eight

48:40

people go into an emergency room with a twisted

48:42

ankle comes out with an opioid prescription. We still

48:44

have doctors prescribing opioids to teenagers for headaches. So

48:46

you want to reduce that exposure, but you also

48:48

want to reduce the demand. And

48:50

I emphasize that time in life, by the

48:53

way, because the neuroscience shows our brains are

48:55

the most plastic and changeable when you're young

48:57

as anyone who's trying to learn a language

48:59

in their fifties knows. Right. So

49:01

just like you can pick up your French or Spanish

49:03

really fast when you're a teenager or even

49:06

younger, that is where most addictions start. If

49:08

you make it to 25 without an addiction, you

49:11

will probably never develop one. That's

49:13

where prevention and health promotion comes in. When

49:16

I say that a lot of people's eyes

49:18

glaze over, they think about their which was

49:20

very broadly distributed and didn't really-

49:22

And not successful. And not successful. And you can

49:24

couple that with the picture of the egg. This

49:26

is your brain on drug use. I always thought

49:29

that egg would make stoners hungry. Sorry.

49:33

That's a way to flip the discussion. But

49:36

thinking about that, that's

49:38

what prevention is. It's kind of like thinking

49:40

the candy radio shack 80 is what computers

49:42

are about. That's a very long time

49:44

ago. And since that time,

49:47

there's been really well-developed prevention. Can you

49:49

just describe generally what sort of program

49:51

that is what you're talking about? You're

49:53

going into this period of life when kids are about 10,

49:55

11, 12, and

49:58

you're making investments in their core- capacity.

50:00

You don't walk in and just say don't

50:02

use drugs, but you're helping them things like

50:04

how do you learn how to recognize and

50:06

manage your emotions? What are some ways to

50:08

cope with challenges? How do you connect with

50:12

pro-social kids? How do you connect to adults

50:14

getting them connected to community structures that they

50:16

can do instead of drugs? That might be

50:19

cultural, civic, religious, athletic organizations, whatever, where

50:21

there's joy and there's fun and there's

50:23

connection, but it's not centered on substances.

50:26

Are drugs even part of that

50:28

conversation? Absolutely. This is unhealthy as

50:30

is alcohol as is tobacco, but

50:32

it's a lot harder than that.

50:34

And the reason that matters is all

50:37

the things we worry about with kids, the

50:39

risk factors for them overlap like 75, 80

50:42

percent. So there's programs like we want

50:44

to stop eating disorders. We want to stop depression.

50:47

We want to stop self-harm. We want to stop

50:49

smoking. But the thing is like why do kids

50:51

do all those things? And it comes back mostly

50:53

to these core things of inability to deal with

50:55

emotional inability to connect with others. And so you

50:57

focus on those and then for one

50:59

kid the benefit is he was going to become a drug

51:02

user as a teen. He won't. But for the other kid,

51:04

that kid was never going to become a drug

51:06

user, but she was going to be really depressed

51:08

or have bad body image and self-harm and she's

51:10

not going to do that. So you see all

51:13

these benefits as people go through and 10-year studies

51:15

now and more likely to graduate from college. Less

51:17

likely to be carrying a gun as a teenager.

51:20

So those are the kind of investments we need to

51:22

make in kids. It'll help our drug problem. It'll help

51:24

a lot of other problems too. Keith

51:29

Humphries plainly has a lot

51:31

of ideas about how to

51:33

best fight the opioid epidemic. Many

51:36

of them involve government oversight and

51:39

support, which given his policymaking background

51:41

makes perfect sense. Next

51:43

time on the show, we will get

51:45

a different perspective. I think

51:48

the opioid epidemic is this generation's

51:50

HIV and AIDS. If

51:52

you parallel that to what we're seeing with

51:54

the opioid epidemic, there are so many similarities.

51:56

What's the biggest thing that prevents people from

51:58

getting treatment right now? Stigma. Also,

52:00

with billions of dollars of opioid

52:02

settlement money now flowing to states

52:05

and cities, how is it going

52:07

to be spent? To use

52:09

these monies to replace the status

52:11

quo would be the largest travesty

52:14

I could imagine from a financial

52:16

perspective. And also from

52:18

a victim's rights perspective. That's

52:22

next time on the show in the

52:24

second part of our series about the

52:26

continuing opioid epidemic. Until then, take care

52:28

of yourself. And if you can,

52:30

someone else too. Freakonomics

52:33

Radio is produced by Stitcher and

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entire archive on any podcast app,

52:39

also at freakonomics.com, where we publish

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transcripts and show notes. This

52:43

episode was produced by Alina Coleman,

52:45

with help from Ryan Kelly. Our

52:48

staff also includes Augusta Chapman, Dalvin

52:50

Abou-Aji, Eleanor Osborne, Elsa Hernandez, Gabriel

52:52

Roth, Greg Rippon, Jasmine Clinger, Jeremy

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52:57

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53:00

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53:02

Lipinski. Our theme song is Mr.

53:04

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53:07

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always, thank you for listening. If

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