Dan Ciccarone on Why So Many People are Dying of Overdoses

type of drug. You know. On this show, we talk about the wonders of drugs, and we can also talk about the horrors of drugs, because so much of this is about the nature of our relationship with drugs, both as an individual um and as communities and societies. Today, we're gonna talk about one of the most devastating aspects of drug use, which is the overdose epidemic, the overdose crisis,

the number of people dying from overdose. A few weeks ago, the US Center for Disease Control came out with its latest report, and it said that last year in over ninety three thousand Americans died of an overdose. That was an increase of almost thirty percent from the previous year. This is a national problem where the overdoses went up in forty eight of the fifty states in the United States.

If you think about how much is being lost if we compare it to COVID, those nine three thousand deaths were about a quarter of the three and seventy five thousand people who died from COVID. But if you look at the number of years of life lost, because so many people who die from COVID are oftentimes quite elderly, where so many people to die of overdose are whole spectrum of ages from their teens into their fifties or sixties.

When you look at it from that perspective, COVID resulted in five and a half million years of life lost, but with overdoses it was three and a half million years of life lost. I mean that's like six So it's really a truly devastating problem. Now, in the New York Times, the headline was a quote from an expert, and it quotes said, it's huge, it's historic, it's unheard of and on precedented. In a complete shame. You don't

see that in New York Times very often. That a quote lands up being the headline of a major article. The author of that quote is our guest today, and that's Dan Chickerni, who's talking to me from Truckee, California, out near Taho. Dan is um one of the world's leading experts in this issue. He's a New Yorker who's been in California for many decades now. He's a professor and a doctor, a professor of Family and Community medicine

at the University of California, San Francisco. He's been studying drug issues as it relates first to HIV A S and now as it relates to overdose. He has one of the biggest and most substantial grants from the federal government to study this issue about heroin, marcus, invential markets and all this sort of thing. I've known Dan for a little bit for about twenty years, but I heard him give a talk at International harmyshi and Comference a few years ago, which is the best talk I ever

heard given on this subject. So he really is my go to guy to talk about this. So Dan, thank you so much for joining me today. I really appreciate your taking the time and your expertise that it's a pleasure to be here, and thank you for the kind introduction. But your introduction to this crisis was excellent, so thank you for that. Well, look, let me just start off with a broad question, which is, what the hell is going on here? I mean, it just keeps going up

and up. It's a devastating problem. We'll get into nitty gritty, but what's your kind of bird's eye view of what's going on in America? It is, well, as I told the New York Times, this is a historic crisis. This is a crisis that's unprecedented. Um, if you look back almost forty years at mortality data due to illicit drugs, we see a log rhythmic upward trend. That's a trend that you would have to deliberately try to make that outrageous.

So why is it that we have exponentially increasing drug overdose trend or log rhythmically increasing drug overdose trend for the past thirty eight years? And the reason is that, um, the drugs are getting more powerful, more potent, more available. Despite our best efforts, they have become more deadly. Well, you know, the standard history that's typically out there now right is that these overdose who started growing in substantial numbers back around the beginning of the century, so twenty

years ago. And I remember even the late nineties. I was aware of this issue when I was running what was then the Lindismith Center then Drug Policy Alliance, and we organized the first international conference I'm Preventing over those fatalities in January two thousand and We did it in Seattle because that part of the Northwest was already seeing kind of the early years of this stuff. But the

standard history that's happened since then is Phase one. The first decade is about prescription opioids, oxy content, per Due Farm and all the other manufacturers and distributors sort of putting this stuff out overly aggressively. You know, you know it's supposed to be be for serious pain. In the marketing for chronic pain, it's getting diverted. Black markets cracked out on that, and then you see the emergence of heroin.

People turning to heroin and heroin markets emerging. And then I don't know if the crackdown on that was that effective, but then Fentinel, the very powerful synthetic opioid, enters the market, and then Phase four in some respects um is COVID, which sort of kicks things up a whole another level. So is that from your perspective, the basic frame for looking at this historically as twenty years or how would

you nuance that to help our listeners understand this. Yeah, So I coined the term a triple wave of epidemic, and so there's three ways of mortality due to the latest opioid related phenomenon. So first wave is opioid pills. We wouldn't have been concerned about excessive prescribing practices or excessive supply and the detailing, the manufacturing, the distributing of excessive, huge numbers of opioid pills if it wasn't for the fact that we saw a mortality curve increase along with

that supply. And we can talk about what the drivers of that first wave were, but um, I will stand by the statement that as we started to curtail that supplies, we said, oh wow, opioid pill overdoses are going up,

deaths are going up. There's a problem. As we started to curtail that and as we started apply downward pressure on that supply, whether it's telling doctors to curb their prescribing practices, whether it was through lawsuits that curtailed the manufacturers and distributors that you know, they're still going on now. As we saw that supply get constrained, we started seeing heroin being picked up, and we started seeing an overdose

curve due to heroin UM. That would have been an epidemic in and of itself if it wasn't for the fact that in hot and synthetic opioids, including fentyyl and hundreds of fentyel analogs UH started flooding the American streets and people who were using heroin maybe depending on heroin, started experiencing a fentyyl adulterated heroin and that increased the mortality risk tremendously. So that's we've three of the crisis,

and that is still going on now. That started the East coast, it's now hit the West coast as UM and the mortality of old drugs overall is being driven a synthetic opioids, including fentanyl and the analogs. So, Dan, you look at the latest report and it's to some extent fentinyl fentinyl fentinyl. What is fentinyl and why is it playing such a massive role in killing people? So fentanyl is a synthetic opioid. In order to understand that, we need to know that opioids come in three forms.

Is natural opioids that come straight out of opium, which is the extract from the poppy plant, that would include morphine and coding. Then we have the semisynthetics, where you change one part of morphine or one part of coding to produce a medicine like hydrocodum um. And then you have synthetics, which are fully they have nothing to do with poppy plant, they have nothing to do with opium, and they are manufactured in the lab Methodone is an example of a synthetic opioid, as is fentyl and the

six D plus fentinyl analogs. So fentinyls is potent synthetic opioid. It is forty times as strong as heroin by weight. It's a hundred times as strong as morphine by weight. It comes in a variety of chemical cousins, we call them analogs, some of which are a couple of times more potent than heroin, some of which reach almost a thousand times as strong as heroin. That would be car

fentanyl and and the other n I l fentanyls. And so when we saw that you jump in Ohio or people dropping like flies, that was because car fentinel all of a sudden hit the streets in a way that people didn't know how to deal with it. Right, car Fentanyl should not be in the human drugs supply. It is meant as a large animal think elephant uh and

analgesic uh. So instead of injecting an elephant with a gallon or two of opioid to help them with their broken leg, you inject them with a normal size uh syringe, but with a very potent chemical to help them deal

with pain or surgical procedure something like that. So, I mean, Dan, when ask why this dramatic jump jump in the last year and over those fatalities as creating headlines, I mean, apart from COVID, is this about people just not knowing the potency of what they're getting, or not knowing that drugs they're getting, or is about all sorts of things getting mixed into the supply? I mean, what do we

know about why this dramatic jump? So we have to understand it is a twenty year historic phenomenon, right, and talking about deaths, those deaths are higher than UM the number of deaths at the height of the crisis. UM. It's surpassed the number of motor vehicle accidents as as the number one cause of unintentional accidental injury. And we need to understand that it's a the reason I use the metaphor of a triple wave, that each wave has a certain energy behind it. We had the first wave

of opioid pills. It increased on the size of the population that uses opioids. Some of those folks got cut off from their supply and moved on to heroin, and we saw it. Even though it is a fraction of the original size of the population, that population was huge. And now we have a historic number of people who are using heroine. Some estimates make it as high as three million active heroin users in the United States. We've

never had anywhere close to that number. You usually the number of the past was half a million or three quarters of a million heroin users. So the population of heroin users has gone up multiple fold. That alone would have been historic crisis in and of itself. A historic crisis of heroin use and heroin consequences now comes along a potent opioid meant to replace heroin, meant to come from an industrial supply as opposed to an agricultural supply

that's forty times as potent as heroin by weight. Right, and the fens we overfocus sometimes on this idea of potents. But it also comes in adulterating heroin. It's not being sold as is. It comes in as a contaminant, comes in as a poison, comes in as an adulterant of the heroin supply in the East Coast. Users don't know what hit them, and they start complaining the heroine is different, it doesn't feel right, it's too strong. When was the last time you heard a heroin user say, oh, the

ships too strong. So it came in as a tsunami. So you have this triple wave of the third wave of which is a tsunami that's bowling people over because they're using it unbeknownst to them. They think they're using heroin, but they're getting something else. And then to add to that that fentel comes in all these different analogs chemical cousins,

if you will. That undulation and potent, say also asks adds hugely to the risk because what causes overdose, amount of opioid over your tolerance, and so you're messing with people's tolerance by undulating the supply. So it's all those forces that have led to three maybe even more than because that's an under account death last year. Add on COVID, add on the fact that our interventions have not been powerful enough, potent enough to meet this historic foe, and

then we have a historic crisis. You know, I came across I mean, let's just dig in a little further. I came across the report recently, I think, put out by the Rand Corporation, which has a drug policy analysis unit, and there in their analysis they found that, you know, paradoxically, when the pharmaceutical companies, under pressure from the government everybody else, started to crack down and reformulate oxy content so it was harder to kind of crush the pill and inject it,

the result was actually an increase in overdose fatalities. Yeah, that's that's quite unfortunate. And I've actually produced a graphic just using Google that as Google search terms for oxy cotton went down, and they went down because they got re formulated from the original crushable formula, which we called CS to the op formula, which was non qrushable. You see Google search is for heroin go up. It's just beyond ironic. And so what we call this in drug

policy we call this the humble term of the balloon effect. Right, And we try to squeeze supply on one end of the balloon, it bubbles out in another part of the balloon. And the important part of the balloon metaphor that I like to remind people is not that the fact that the other end of the balloon has gotten bigger. It's gotten bigger, usually in an unpredictable direction. Think about when you squeeze a balloon, you don't know where the rubbers

weakest on the other part of the balloon. It not only bubbles out overall, but it might bubble out in a funny direction. And that's exactly what we're seeing here. We're seeing paradoxical effects of the war on drugs. So, now, Ethan, you and I could really get into this, because this starts to really explain why fentonel even came about in the first place. Right, What is it about interdiction? What is it about supply reduction that produces a thirty year

exponentially increasing curve in illicit drug mortality. Yeah, I remember there was a moment with fentonel. I think there was some lab in Mexico maybe fifteen twenty years ago that was started supplying fentanyl and started to come into the US or some overdose associated with it, and then in a rare case of law enforcement being successful, the US and Mexican authorities shut it down and the federal went away. But now federals coming in from China, China directly, China

via Mexico, China via Canada. It's coming in small packages. I mean, there essentially is no supply side solution to this at this point. Right. A subtitle of one of my papers UM a few years ago was the end of introdiction. I think fentonyl proves that point. There's a lot of us who have been kind of cynical about supply side interventions and and whether there worth the money or whether they're actually effective at all, um, and the evidence is going against them. Do you think about it.

One of the main goals of introdiction is to stop the flow of drugs sufficiently so that the price at the end market user, the retail user, goes up. Well, let's look at the data. Heroin for the last twenty or so years has never been cheaper at the retail level. So what does that say about interdiction Using their metric of trying to curtail supply so that the price goes

up and purity goes down, they have failed. Because heroin, if we if we use a standardized measure, which is price per milligram pure keeps bouncing along at rock bottom prices for the last decade or so. Now at the same time, because of interdiction, there's been a honing effect, right, And the honing effect is that there's exclusive markets of heroin worldwide. So in North America, we have producers in Colombia and in Mexico, and both of those bring heroin

only to the United States. That's what I mean by honing. They're kind of exclusive supplier to wholesale to retail markets. We used to have four suppliers in the United States. We used to have Southeast Asia, Southwest Asia, and Colombia and x Go. Now we only have two suppliers. And guess what, the Colombian market just dried up. So now the only way we get heroin in the United States

is from Mexican suppliers, Mexican CTOs, colinal trafficking organizations. So the end game that the interdiction folks are hoping for is that, well, now we just have one chest piece and knock off the board. Left unfortunately made an end run around that, and what is the end run. The end run was fentinel adulterated heroin importing from a whole new player. When you think of illicit drug producers in the world, right, you just ask the general waties. They'll say, oh, Afghanistan, Pakistan,

there's like Colombia. They might say Mexico. No one's gonna come up with China. Well, China is a balloon effect. It's an invention in supply. So what we have now, we have a whole new supply of powerful opiate. It's immune to interdiction effects. There's no crops brain, there's no large shipment that could be busted. It comes in smaller packages.

When I spoke to Congress a couple of years ago, between my representatives and myself, there's a space between those two desks, and I said, all the fentanyl that came in could fit into twelve industrial oil barrels that could all be seen right in front of us. Now, how do you stop that flow across the Pacific Ocean from a friendly training partners like China? The not on our enemy list can go and invade them and and bring military advisors there to stop the flow. So that is

what I call the end of interdiction. We've played the endgame, and what we got was a super powerful and dangerous drug on the American streets. Yeah, although you know, even with heroin. I remember, I think was Senator moynihan who kind of got smart about this at some point. He pointed out, like all the cocaine being consumed in America back twenty years ago could be in like a half dozen or something shipping containers. I mean that there was

essentially no way to stop this. And people are realized Mexico has been the source of at least a third of the heroin consumed the United States for like seventy eighty years. So which you say there is at Fentinel just kind of pointed out the absurdity of the interdiction. The supply side control strategy was always apparent, even though the idiots and the Pentagon and law enforcement kept insisting on it. Fedital just kind of made it the absurdity

totally clear. I mean, how many FedEx packages can you stop coming in from, whether it's China directly or China the in Mexico or what have you. We'll be talking more after we hear this ad. Let me ask you this question. And I know there's no really reliable to

answer this question. It's a it's an impossible question, but I'll throw it at you, okay, which is imagine if Produe Pharma, with its oxycontent and its competitors, that Johnson and Johnson's and all the other firms had never started over supplying opie it's pharmaceutical opioids twenty years ago, in late nineties, early two thousand's right? Do you think we still would have had this opioid epidemic? Wouldn't have happened anyway.

There's two ways to look at it. So the opioid crisis, this trip away, a phenomena of pills, the heroin defense and al that would not have happened. So supply does lead to overuse. So I'm as a supply side thinker, I can with two halves of my brains say on one half says supply matters, right, supply actually does lead.

It's just pure economics. You bring in a cheaper good and people are going to use it, right, And in fact, that's one of the reasons why heroin and methomphetamine are so cheap right now, is because we have free trade agreements across the American borders NAFTA and KAFTA that not only bring down the price of illicit goods, but they also bring them the price of illicit goods. But it's contrastraining supply that has been problematic. We have not been

able to do it. But let me get back to your question, right, and that is if opioid pill supply stayed at sort of normal levels. Now normal levels are still high for American compared to other countries, but let's just push that aside for a second, would we still have had some kind of drug overuse problematic use cycle. The answer is probably yes, right, and the reason is because we have myasthmic drivers in America. So what does

my asthma? My asthma means that there's a syndrome of issues that caused suffering and that leads to something that public health is concerned with, you know, whether it's poverty or social and economic inequities, disparities and access to health care or in health care utilization. Right, America has these false zones in which problematic drug use. Now we're not talking about recreational drug use here, we're talking about problematic

drug use falls into the cracks off. And so what issues do we have in America that that might be creating these law scale cracks that might be fomenting problematic drug use. Um, we could spend another hour on. Let's just look at one issue in particular, and that is the disenfranchisement of working class Americans. The whole idea of you jobs going overseas, the whole idea of loss of hope between a generation of a parents generation and the

kids generation. Um. And there have been some good economic work showing that economic disenfranchisement of particularly you know, Midwest, we think about sort of the this might be a derogatory term, but for lack of a better term than the so called rust belt where industry left left some decaying disenfranchise communities. Well, guess where pills and heroin and

fencinel fell into. And I can say that if you took the pills in, heroin and fentral away, that some other miasma condition wouldn't have fallen in to those cracks. And so I'm a balanced thinker. I think them both supply side, but I also think in terms of demand side, and if interdiction is an endgame, right, if we if we've run a ground with our forty year war on drugs, we need to pay attention to the demand side. We need to pay attention to those false zones, to the

cracks in society. Need to make America more resilient, not necessarily to drug use in general. We've we focus our resiliency on that don't use drugs, don't use marijuana. Right, What if we just focus on resiliency to problematic drug use, to drug use that's used to solve, to soothe, for people to self medicate with. Right, Let's bring it back to a robust medical system. Let's bring it back to

a robust public health system. Let's work on fixing those cracks in society and making any more just and equitable society. M we know. I think also if you look at the recent data of who's dying now, we so much associate this with the kind of white middle lower middle class,

declining income group in these kind of Midwestern states. At the same time, it's worth pointing out to other things, you know, I mean I live on the upper west side of New York and about a block for me, on the very expensive apartments that lines the west side of sand Hill Park, Central Park West, there is a building there probably average department caused five, ten, fifteen million dollars, right,

very wealthy families. I know of at least four families in that building who have lost a son to an opioid overdose. So you can see it can hit the kind of upper income folks as well in a way. But at the same time, if you look at the data that's coming out in the last year, I mean, overdose has always been a problem among poor black and Hispanic people in the cities and elsewhere. Remember New Mexico used to have a big problem, but it's also in

the cities. But when you look at the data last year, you see the most dramatic increases in over those fatalities are happening among blacks and Hispanics. Just explain what's going on there. Yeah, So let's start with the earlier phase of the crisis, right, So, when it was pills, you know, wave one of the Triple Waves that showed inequities in

access to medication. So so the fact that it hit middle class, upper middle class, white more than it hit brown and black folks in America shows that they had greater access to pain medication. And that's is well substatiated in the literature. There's that there's disparities in access to pain medication as it moves towards and and and the pain has been so widespread ethan, I mean, this is

this is why I use language like crisis. You know, I'm not just calling this an epidemic, which you know, the epidemiologist and me would say, hey, let's just call it an epidemic, which is a rising curve of something, in this case, a rising curve of death. But I call it a crisis because we're out of control and because we don't fully understand what tools we need to apply to this. Right, we lack deep understanding and we lack a strong sense of intervention. But let's talk about

the disparities that are happening now. Right, So, as we moved towards Heroin, as we moved into the we we've three the fentinel crisis we are seeing in the inner city more rapidly increasing rates of death among black and brown populations. What's going on there? Based on my ethnographic work where I spend time in the inner cities, I've been extensively to Baltimore. I've been to Chicago a few times. I spent a lot of time, of course at my hometown of San Francisco. I've been to New York a

few times. What's happening there is there was some resistance to fencyl Right, if you're African American and you lived in Baltimore, you knew how to get good heroin that wasn't adulterated with fentanyl for a couple of years, and then the gauntlet fully got dropped and you couldn't find anything but defenconyl laced heroin. And so the African American death rates going up now because they're u accustomed to it. They didn't like it for a while. They have no

resilience to it. Um Now shift over to San Francisco. San Francisco has just recently begun seeing fencyyl. It's being sold as is. And I can't fully explain this ethan, but our African American opioid related mortality rate is skyrocketing. It's much worse than it is for whites. I don't understand it. I don't understand in a in a free flowing fentyyl market, why African Americans might be choosing the fenyel. This all needs to be explored. COVID simply got in

the way. We weren't able to do research last year. But this is what we need to do in San Francisco. We need to find out why it is that the opioid death rate among African Americans is so high in San Francisco. Yeah, so, I mean, Dan we typically think about the United States is one great, big national market, but there are clearly substantial regional variations in terms of overdose and even drugs. I mean, so, is the US

not really a national market? Is what California gets different than what Louisiana gets, different than what Maine gets, different from what Ohio gets. So the overdose due to fentonel and other synthetic opioids went up far more dramatically in the Midwest, Northeast, down to mid Atlantic, over to Appalachia regions um far ahead of the rest of the country. So they were of that area got hit in fourteen so that's your our first indication that supply is different

than the supply of fentyyl. And this is again fentyel adulterating heroin was different. And if you say the northeast quadrant of the United States, then it's spilled over to the south. And now it's spilling over to the west. And why is it different, Well, where is it coming from? Well, defending is coming from China, but it's being put into

the heroines through the Mexican criminal trafficking organizations. Right. Those criminal trafficking organizations have been multiple, right, And the reason why they're multiple is because some of the bigger ones have been successfully toppled and that leads to fragmentation of them. So now there's a bunch of little carteltos or or smaller c t o s and they've just divided up America. You know, Sinala has been sort of the big one. Uh,

it's still kind of fairly large and monolithic. But Sinelo has been split up by the arrest and next tradition of its leader was held in Chicago jail right now, and um, the so lower cartel has become fragmented and more creative and and splitting up the country and and again my research has been curtailed. I'm not getting much from the D A, from O, N, D C, be from from height I mean, uh, to tell me, you know why it is that fentinel's hitting the western half

the United States. But my suspicion is that it's less cartel based. This seems to be more fentel being sold as is um. I'm not sure that it's cartel based. It might be entrepreneurial based. It might be local people buying it directly from China and selling it. I I really don't know. But there's a lot more mystery. And so here we are five years into a fenil epidemic, and there's still mystery. There's still things that need to be explored. There's still things that we should have and

could have been on top of. But for some reason, we lack sufficient curiosity, we lack sufficient understanding of drug flows to really make a public health impact. And this is one of the things that I'm pushing. Since I am a supplied side thinker, I've been pushing anyone will listen to me, D O J HIDA, D A C d C to say, listen, this is a poisoning crisis. Fentinel represents an unfeseen and historic foe. In order to understand it better, we need to understand the supply of it.

So let's start sharing data. We could use it for public health. It's called an epidemiology. We'd call it surveillance, right. Don't you want to know where the poison comes from, what products it's in, what its potency level is, what its purity level is, And that's what information we lack here on the West Coast. We're operating blindly in public health.

We're operating blindly in the e r S and we're only counting the quote dead bodies as they lie, which is a hundred and fifty years UM old process of doing public health. We should use technology, We should use modern surveillance, modern toxicology to understand supply better. By the way, all those initials that Dan was reeling off O N d CP refers to the Drugs RS Office Higher refers

to another federal drug enforcement collaboration. I think most people know what d e A is, um but you left out one of them, which is not a National student on drug abuse, And uh, you know I one of the people I talked to for Psychoactive. Is Nora Vocale the head of it to National stud on Drug Abuse. I think the interview with her will run after yours,

But I gave her a hard time about this. I mean, you, thank god have one of the big grants to do the ethnic, graphic and statistical and all the sort of work that's necessary to dig into this. But there should be a hundred people like you being funded, whereas there's only five or ten. I believe you know. And I'm asking the question like, who knows what retail drug sellers

know about what they're selling? How much do retail drug sellers actually know about whether there's ventil in their drug, what it's being cut with, or what about the people one level up from them? What do we know about where stuff is being mixed and where stuff is being cut? And these are not impossible questions to answer. One could be interviewing people who are behind bars for drugs selling and offering them confidentiality and some money in order to

tell you what's going on. One could have that type of research, but it's not happening. We'll be talking more after we hear this ad. Until fentanyl came around, the large majority of people who quote unquote overdosed. It wasn't because they just took too much actual content or too much heroin. You typically have to mix it with alcohol

or benzos or their tranquilizers. Fentanyl changes the game. But before Fentonel, there was almost no effort on behalf of either federal or state authorities to educate consumers of these illicit drugs, don't mix drugs or if you do, know the consequences. So, I mean there's an element of gross policy failure and gross public education failure on the part of the government when it comes to these sorts of things.

I actually call it a blind spot, right, and that is we seem to like the tools that we have, which is, if somebody winds up in the emergency room, where somebody winds up in the morgue, we understand what that body died from, right, We understand the chemistry of that body. But that is a profound misunderstanding of what you do in poisoning crises. Right, That's only one way of looking at it. The other way of looking at

it is what is the person doing? So you bring up the whole conundrum of poly drug use, of mixing different drugs. That's poorly understood. As you pointed out, it's one of the blind spots. But the other blind spot is what's going on in terms of the wholesale and retail supply of drugs. We could ascertain that through UH interviews, We could ascertain that through acquiring some of those drugs,

or for example, any urban setting. Right now, there are thousands, if not tens of thousands of CIS drug samples that were obtained through criminal justice proceedings, you know, small busts that are being held as evidence against that person that could be analyzed right now. I could go to the Baltimore Crime Lab and say, can you analyze a hundred specimens from last week and tell me what's in them?

What mixtures? Is the fencinyl contaminating the method? And fetamine is that in the cocaine of which different types of fen anmals were present last week? Right I could have a great understanding mapped out across all of Baltimore with a couple hundred drug samples tested last week of the Baltimore crime Lab. I could do that in San Francisco. I could do that in New York, actually do the Chicago.

I could understand supply from a poisoning point of view, from a exposure point of view, right, And so now we would have a more complete understanding. We would understand exposure, we would understand use, and we would understand the end result of use, you know, landing up in the hospital to e er or the morgue. Right. But we only have one of those three legs of our three legged stool. So as you suggest that it's a failure to failure

research policy, it's a failure of public policy. Here's the other big failure, other big blind spot, ethan, Can you tell me how many active heroin injectors there are in the United States right now? Yeah? One million, four d sixty thousand, eight hundred and twelves. How many are there? How many are there? We don't know, right, We have

no idea. The answer is unknown. Now, why is it in a growing epidem where the severe consequences including death, that we don't understand the size of the at risk population? Basic epidemiology one oh one? What is the size of the population at risk? We don't know that. And every time I meet with the CDC, I mentioned this, and I say, shame on you because you don't know the answer to this question. Right, who should know the answer to the question sentence for these controls and the answer

to that question, and they refuse to do it. You fund five, six, a dozen researchers from around the country to do capture recapture studies, we can have the answer, right, but they refuse to fund those studies. Neither refuses to fund those studies despite the fact that we're in an epidemic. And what a crisis means, ethan, what a crisis means is that we don't understand based on our current tool set. So what you do then is you start getting creative.

What other tools have we ignored? What other interventions have we ignored? Right? We need to be creative, We need to be bold, We need new sources of funding, and we need new understandings in order to handle this historic

crisis we do. The other thing, of course, we don't know right now is the latest reports say show on the one hand, that fentanyl is pervasively connected to the overdose fatality epidemic, but they also show that stimulants cocaine, methamphetamine, and other things like that are showing up more and more and more, and it appears that some of these overdoses involved just the use of stimulants like cocaine and meth amphetami without fentanyl. Other cases they're mixing it with fentanyl.

But we don't know why they're mixing it, right, I mean, you know, one of the theories has been it's like the old heroin cocaine speedball that was popular back in the eighties, where people like the mixture of the drugs. Another is that the sellers don't even know what they're mixing. It's just you know, a little bit of stuff getting mixed accidentally or whatever. But what more can you tell us about why this stimulant thing is showing up more

and more and more, both with and without fentanyl. Yeah, this is a great question. It's such a great question that I've spent most of COVID pondering it and written two papers. My most recent papers discussed the fourth wave of the opioid epidemic, which is the stimulant use and polly substance use that includes the mixture of an opioid and a stimulant. The goofball, which is historically what we called methan fetamine and heroin mixed together, was historically unusual.

You had to be an expert to do it, you had to know what you were doing. You had a feather in the methanphetamine in just the right amounts, and so you didn't see a lot of it. You had to. There was only a few very fussy people who knew how to mix them the right way, and that's because the methan and fetamy would simply bowl over the heroine

and you've wasted your money on the heroine. Now, fentanyl is a very powerful opoid, so now they're meeting manoamano powerful synthetic stimulant like meth and fhetamine, which is coming in historic levels of potency and purity potent percent pure. We've never seen methan and fetamine like this before. You got this powerful opioid and you get this powerful stimulant that are coming together, and half of us stimulant deaths

are related to that combination. Now, where fentanyl is being detected along with meth and fetamine in the bloodstream of people who have died, it needs to be explained. We have this vague notion in drug policy that uppers and downers kind of undulate through history, that we have the sort of upper wave and then the next generation chooses downers like heroin, and the next generation uses uppers like crack. This vague notion of of undulation throughout the decades. Here

they're colliding together. So not only is stimulus coming at the end of a twenty year opioid triple wave, but it's coming in as a as a combined use, and that needs to be explored. There's two forces that are driving the latest numbers. One is the breaching of the East West divide in terms of fentel. Fentinel has now moved westward. And the second is the methophetamine epidemic. We've always had an endemic problem in the United States in

the West coast. For the opposite phenomenous happening, and that is meth and fetamine is now going all the way to the northeast United States where it didn't hit before and they're not used to it. The size of the at risk population has increased for methan fhetamine on the East coast and for fentinel on the West coast, and

that's raising the numbers as well. So the question about what to do, I mean, obviously there's a bigger socioeconomic factor here and about jobs, an opportunity and people having a sense of hope. That is probably the most important contextual answer to this problem of the opioid epidemic. But then there's the specifics. We know that making the lock zone more widely available the antidote has you know, saved tens of thousands of lives, if not, if not hundreds

of thousands of lives. We know that more drug treatment smart drug treatment. We know that more needle exchange programs are hopefully allowing safe injection sites. So what are now called over those prevention centers that those things could be beneficial. We know that drug testing slips where people get fentel and have it tested. But when you think, are there other key things apart from the ones that I've reeled off that you think are really important to have out there? Yeah, yeah,

that's a great list. You know, that's a historic opportunity. And people ask me, am, I that's a mr an optimists, and I'm I'm always an optimist because here we have a historic crisis. But in crisis, there's opportunity, right, And what's the opportunity there? The opportunity is to take a deeper understanding of where we are as Americans, right to look at those false zones in America, to look at what we can do to lift cities up, to make

communities healthier. So I agree with what I would call primary prevention and not just educating don't do drugs right, but making communities more resilient, making them healthier, making them happier. The other historic opportunity here is to move away from what's been an unfortunately unbalanced drug policy where we focus too much on supply, too much on catching the quote bad guys end quote, or or stopping the flows of drugs or locking people Upright, Remember, the war and drugs

has also been a warm black and brown people. It's been heavy incarceration rates, right, we need to end that has been an utter failure. It's broken families apart. It isn't actually led to the disenfranchisement of communities. Um, to change how we view drug use is the most important opportunity here. Right, We're not gonna put the genie back on the bottle. We're not going to stop recreational drug use. It's a human phenomena that's been going on for thousands

of years. That's an American phenomena. People like to alter their consciousness. But can we make it less risky, and the answer is yes. And that's where harm reduction comes in. That's where regulation and taxation comes in, and we have to stop making it punitive to use, stop locking people up for it. That's where diversion programs come in. That's where creating an opportunity comes in. That's where I would

expand my list that I love harm reduction. We need more in the locks than we need more needle exchange. I love the idea of demand reduction, including treatment low barrier treatment, including upreneurs the methodone. But I also think we need to change the conversation about drugs and accept that it's a normal human behavior that we can redirect from problematic use to less problematic use. And that's our cultural opportunity. Okay, well listen, Dan, you've been a spectacular guest.

I have learned a lot. I'm sure our listeners have learned to use amounts. So thank you ever so much for joining me today, and I welcome any comments from our Psychoactive listeners, which I'll be happy to share with you. Thanks so much, then, thanks for inviting me. It's been a pleasure. Psychoactive is a production of I Heart Radio and Protozoa Pictures. It's hosted by me Ethan Naedelman. It's

produced by Kacha Kumkova and Ben Cabrick. The executive producers are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren Aronovski for Protozoa Pictures, Alex Williams and Matt Frederick for I Heart Radio, and me Ethan Naedelman. Our music is by Ari Belusian and Especial thanks to Avivit Brio, Sef Bianca Grimshaw and Robert Beatty. If you'd like to share your own stories, comments, or ideas, please leave us a message at eight three three seven seven nine sixty. That's one

eight three three Psycho zero. You can also email us as psychoactive at protozoa dot com or find me on Twitter at Ethan Natalman. And if you couldn't keep track of all this, find the information in the show notes. Tune in next time for one of America's leading writers, Michael Pollen, whose recent book This Is Your Mind on Plans is breaking new ground. There are insights. I had an influence of mushrooms years ago. They still have validity in my life today. You had I think the same experience.

Oh yeah, I know I did. There are insights I had and you could. You know. You can also call them banal insights around love and connectedness, but they're real. Um. But also, think of the people using psychedelics to quit smoking and they come to the profound conclusion that smoking is stupid and it's killing them. They knew that at one level. But there is a sturdiness to the insight on psychedelics. It's it's what James called the no edic quality, right that this is not just an opinion, this is

a revealed truth. Subscribe to Cycoactive now see it, don't miss it. M