--:-- Charlie: I guess I should probably kind of tell my story a little bit. My name is Charlie. I am from South Burlington, Vermont. My mother was an alcoholic and whatever, but it wasn't too bad. I played hockey and won a national championship in prep school and then went on to play Division II. Freshman year, I got injured. I got prescribed this medication, and obviously as one progresses, you think, you're the man, you're an athlete. You're never going to be a drug addict. Next thing you know, you're doing heroin because you started experiencing withdrawals. That ended up sending me down a deep, dark path that led to an even deeper problem. I left, I ended up dropping out of college. I lost everything that I'd ever worked for, literally was homeless, ended up going to prison. My whole time was consumed by getting the next fix. Towards the end of last year, the CDC confirmed that the opioid crisis in America is getting worse. More and more Americans are dying from opioid overdoses, tens of thousands a year. It's a crisis that doesn't seem to have a whole lot of solutions. But yesterday may have been a turning point.
--:-- Jeff Berman: Good afternoon. I'm Jeff Berman, the U.S. Attorney for the Southern District of New York. Today, we announced the first ever drug trafficking charges against a pharmaceutical company and two of its executives for illegally distributing prescription drugs that help fuel the opioid epidemic. We've talked about lawsuits against Purdue Pharma on the show before, but now federal prosecutors for the very first time have criminally charged a major drug distributor for its role in perpetuating the opioid epidemic in America. Rochester Drug Cooperative, or RDC, is one of the nation's largest drug distributors. From 2012 to 2017, it shipped tens of millions of highly addictive oxycodone pills and fentanyl products to pharmacies that it knew were illegally dispensing narcotics.
--:-- Jeff Berman: Prosecutors decided to treat the executives of a major American drug company the same way they treat street dealers and cartels. They perp-walked the CEO. Our office will do everything in its power to bring to justice anyone responsible for unlawfully fueling this opioid epidemic, and that includes executives who illegally distribute drugs from their boardrooms. This is one solution, calling out distributors who knowingly supply opioids to people who don't need them. But this crisis needs many solutions, and Vox's German Lopez has been reporting on another critical part of this picture, how to treat addicts. Before we got into that, I asked him to explain how this crisis began.
--:-- German Lopez: So there's really three waves to this opioid crisis. The first wave is the mid-1990s when Oxycontin came out. The marketing for Oxycontin and the campaign that Purdue Pharma, the maker of Oxycontin, really fueled this idea that opioid painkillers are the safe and effective drug. There's no question that our best, strongest pain medicines are the opioids. These are the same drugs that have a reputation for causing addiction and other terrible things. In fact, the rate of addiction amongst pain patients who are treated by doctors is much less than 1%. And doctors bought it. They started prescribing a lot more of these opioid painkillers. And that led to this problem, not just where patients were getting these drugs and misusing it, but it also made it easier for their kids to pick up an opioid from the medicine cabinet and start misusing it or take it to a party and that kind of thing.
--:-- German Lopez: Death of a four-year-old boy is now being investigated as a drug overdose. The child's toxicology results are still pending, but they believe they will prove the child overdosed on either heroin or prescription painkillers. It also made it so patients had excess pills and they would sell them to the black market or to their friends. All in all, that led to this proliferation of these opioids. Then there's the second wave. During the aughts, early 2010s, people who got addicted to opioids eventually transitioned to heroin. People were caught off from their painkillers. A lot of people were like, well, I'm still going to suffer withdrawal. I still want these opioids. And they went to heroin for that. The drug cartels took advantage of the situation. They saw this giant opioid problem, so they just flooded the market with heroin. And then the last wave is the one we're in right now, the one that started taking off around 2014, I would say.
--:-- German Lopez: A lot of this heroin is no longer really heroin. It's fentanyl and it's analogs, essentially synthetic opioids. They like opioids you make in a lab. These are super potent. Some of them like carfentanil is used as an elephant tranquilizer. It's called carfentanil and in the U.S., people are dying and overdosing from the toxic opioid. It was just like you went from being coherent and then you just live like a blackout. You can look up federal agencies warning that this can be used in chemical attacks and that sort of thing.
--:-- German Lopez: The dangerous thing with fentanyl is that sometimes it's still advertised or sold as if it's heroin. But because fentanyl is so much more potent than heroin, if you're a drug user and you're like, I'm going to use the same dose I did last time. If you're using fentanyl, that's going to be way more potent. So your risk of overdose is just going to be way higher. And that's what we've really seen in the past few years is like a tremendous spike in overdose deaths because fentanyl has come in and really just completely shaken up these street markets.
--:-- German Lopez: And who's dying? Who is this affecting? Is it spanning communities and socioeconomic groups in America or is it sort of more focused? For most of the opioid epidemic, it has by and large hit white Americans the hardest. That's starting to change. There are like rising overdose deaths in black communities as well now. But for the most part, it has hit white communities the hardest.
--:-- German Lopez: How has that changed the conversation around opioid addiction? I mean, comparing it to crack, which mostly affected black Americans and led to mass incarceration. In the 1980s and 1990s, crack was all over the news. It was once the rich man's drug. But as crack, cocaine is cheap and abundant. And perhaps most tragically, it now threatens the future of the poor and the young. It's typically framed that Nixon started the war on drugs, but Reagan is really the one who transformed the federal system into this massive war on drugs machine.
--:-- German Lopez: Drugs are menacing our society. They're threatening our values and undercutting our institutions. They're killing our children. And that was all in response to crack. Our most serious problem today is cocaine, and in particular, crack. Reagan and Bush, they were not just going against drug traffickers and drug dealers. They were going against drug users, and they were very explicit about that in their drug plans. Who's responsible? Let me tell you straight out. Everyone who uses drugs, everyone who sells drugs, and everyone who looks the other way.
--:-- German Lopez: This tough-on-crime push included even Democratic politicians. So the Clinton administration passed this 1994 bill that was really focused on treating drugs and crime in a harsher, more punitive way. Gangs and drugs have taken over our streets and undermined our schools. Every day we read about somebody else who has literally gotten away with murder. But the American people haven't forgotten the difference between right and wrong.
--:-- German Lopez: Hillary Clinton, who supported the bill, at one point made this remark calling people super predators. They are often connected to big drug cartels. They are not just gangs of kids anymore. They are often the kinds of kids that are called super predators. No conscience, no empathy. We can talk about why they ended up that way, but first we have to bring them to heel.
--:-- German Lopez: I'm guessing the tone has changed for this opioid epidemic. Obama and Trump have really taken a more public health approach towards this issue in that most of the money that they've actually put towards this has generally gone to treatment and generally gone to harm reduction strategies like providing naloxone, which reverses opioid overdoses to police officers, fire departments, that kind of thing.
--:-- German Lopez: There are some quirks with Trump. Sometimes what his administration and Congress are doing doesn't match what he is saying. Earlier this year, he talked a lot about giving the death penalty to drug dealers. And that's definitely concerning, but it's much more public health oriented than it used to be. It's now basically a cliche to say we can't arrest and incarcerate addiction out of people. That's something that you've heard the drug star's office under Obama repeatedly say.
--:-- German Lopez: Not only do I think it's really inhumane, but it's ineffective and it costs us billions upon billions of dollars to keep doing this. If you compare that to like the 80s and 90s, if somebody said we can't arrest our way out of the problem back then, they would be laughed out of the room. It would just be taken as like that's inconceivable. Of course, the criminal justice system is not only going to play a role here. They're going to take the frontline main role.
--:-- Sean Rameswaram: How much do these very different approaches, I mean, it's literally black and white. It's really hard to ignore that when we have a drug overdose crisis involving black Americans, we take this punitive approach. When we have a drug overdose crisis involving white Americans, we tend to take this more public health view. And there are studies that show that at least in terms of how people like the general public and lawmakers view black people, they tend to have like really discriminatory thoughts like they are more likely to be criminals or less innocent and so on and so forth.
--:-- Sean Rameswaram: If you're a policymaker, you are more likely to know someone who died of a drug overdose or struggled with addiction now because a lot of these politicians tend to be white and segregated white communities and that kind of thing. If you've never seen it firsthand, it's really easy to draw a caricature in your head of what that's like. But if you see that your brother or your best friend or your dad or mom or whatever now is struggling with addiction that makes it personal.
--:-- Sean Rameswaram: And you do not think wow my brother is suffering I want to send him to prison. You're going to start thinking of this in a more empathetic and sympathetic way. Like, okay, how would I save my brother's life here? That's essentially happened on a mass scale here. Like these lawmakers who predominantly live in white communities have seen this up close and personal. And it's made them think of the issue in a more empathetic and sympathetic way.
--:-- Sean Rameswaram: We've got a crisis. How to treat it. German's been traveling the country looking for solutions. What he's found comes after a quick break.
--:-- Sean Rameswaram: I'm Sean Rameswaram for him. This is Today Explained. Are you bad with money? There's a podcast for that too. It's called Bad With Money. It's a podcast where New York Times bestselling author and comedian and bisexual icon Gabby Dunn breaks down everything about money and our complicated relationship with it.
--:-- Sean Rameswaram: Gabby talks to comedians and journalists and activists and more about everything from universal basic income to weed. She reveals all her own most embarrassing financial woes. She's gotten friends to open up about their embarrassing financial woes. And she talks to experts about the state of the American financial system and all the things wrong with it.
--:-- Sean Rameswaram: The first episode of Bad With Money's new season features a conversation with personal finance expert Susie Orman about her journey from being the only female stockbroker at Merrill Lynch in 1980 to becoming a legendary queer finance guru. There's an all-new season of Bad With Money, and it's playing in podcast apps now. Subscribe so you never miss an episode.
--:-- German Lopez: The main solution for opioid addiction are these medications. There's buprenorphine, which is also known by its brand name Suboxone. There's methadone, and then there's naltrexone. Okay. The first two in particular, buprenorphine and methadone, are the most common ways to treat opioid addiction. These are essentially medications that make you no longer have cravings and withdrawal. And that's because they themselves are actually opioids. But the idea is that they're safer opioids and taking on this medically supervised regimen.
--:-- German Lopez: And they're supported by all sorts of health organizations, the CDC, the World Health Organization, and the American Medical Association. So there's a lot of support for these medications, and they're really backed by the research. But to be clear, that is sort of just like treating addiction with another lesser addiction. It is often framed that way as if it's replacing one drug with another.
--:-- German Lopez: Yeah. But that's not the right way to look at this. The problem with addiction is not drug use. People use alcohol all the time. They drink caffeine all the time. The thing that makes addiction a problem is when that drug use becomes compulsive and so expansive that that's all your life is about. Like it starts hurting other aspects of your life. So maybe you stop showing up to work and that kind of thing.
--:-- German Lopez: So we can take these medications, which are opioids, but they're not using these in a way that's leading to all these other problems. How does this work state to state? Are there places that have figured out how to give people these other drugs, methadone, buprenorphine, in ways that are better than others?
--:-- German Lopez: In Vermont, they have something called a hub and spoke system. Generally, what this means is that it's integrated addiction treatment into the rest of the health care system. So the hub is the intensive care unit, essentially. That's where people who are, they might have just overdosed or really at a bad point with their addiction and they do not have a handle of their condition at all. That's where they'll go, and they'll be seen there daily.
--:-- German Lopez: The spoke are actually just doctor's offices that do this more long-term care. Well, they'll make sure this person is on buprenorphine. Some patients go there every week, monthly, even longer time stands just to get their buprenorphine. And that's essentially their long-term care. Okay, Vermont has this hub and spoke system, which is essentially normalizing addiction treatment, integrating it into everything else. That doesn't seem that crazy.
--:-- German Lopez: How did they come up with it? So in the 2010s, Vermont started seeing what's happening with the opioid crisis. John Brooklyn was really the architect of this program. John Brooklyn, architect of the program, but also a doctor, Dr. John Brooklyn. Yeah, John Brooklyn.
--:-- German Lopez: So the original idea for the Hub and Spoke, I presented to the state of Vermont saying, let's create these centers of excellence, addiction excellence. I mean, he really described it plainly. It's like, yeah, this is just like how we would treat any other health care problem. And I thought, OK, let's make sure we're doing this, but for addiction.
--:-- German Lopez: If someone just had a coronary bypass and they were seen at the local french fry shop eating a double bacon cheeseburger and smoking a pack of cigarettes, the doctor would say, hey, man, I'm not taking care of you anymore. They'd be like, you have to go back to the hospital and see the cardiologist. There should have been some kind of a network that you could refer that person to to help them get stable.
--:-- German Lopez: And to Vermont's credit, it actually saw, based on early data, drug overdose deaths drop in 2017, which is very different from the rest of the U.S. where drug overdose deaths spiked. Vermont's not the only state with an opioid addiction problem. Why aren't more places doing this?
--:-- German Lopez: I went into Vermont expecting to ask this question of like, okay, so what was the hardest thing about setting up this hub and spoke system? And I would expect this response of, oh, well, it costs money to set up these hubs, these spokes and get doctors prescribing these drugs. Yeah. But that wasn't the biggest problem. The biggest problem by far was stigma.
--:-- German Lopez: So after like decades of seeing this as a criminal justice issue, lawmakers and the public still have stigmatizing to attitude sore addiction. They don't see it as a health problem. They still see it as like a moral failure on the person's part. You don't have the understanding of the science that's universally accepted. There's still a lot of debate about whether you should or shouldn't be on medication.
--:-- German Lopez: And so when you have that kind of debate, you're going to have a lot of people just going to fall back and say, ah, you know, it's their choice to do this kind of thing. If you look at like major medical organizations like the American Medical Association, they will tell you that this is a health issue and you need to treat it as like a public health issue as a result.
--:-- German Lopez: But when you're trying to tell lawmakers that after these years of like thinking, yeah, we'll respond to drug problems with prison, it can take some time to like really walk them through why that's actually not the right approach, why you should set up this healthcare system to take care of addiction. That's apparently what was the biggest hurdle in Vermont is just walking policymakers through why this is important. And clearly it worked.
--:-- German Lopez: So how is Vermont paying for all this now? Most of the funding for this actually comes through Medicaid because Vermont, first of all, got a waiver through the federal Medicaid program to actually help set up these hubs and spokes and that kind of thing. And then most of its patients are on Medicaid.
--:-- German Lopez: A direct comparison is New Hampshire, which is directly neighboring Vermont. It's consistently been one of the worst states in terms of drug overdose deaths. And part of the problem there is there are just large swaths of the state that do not have accessible treatment at all. If there is a treatment clinic, it might be weeks or months of wait times before you get care.
--:-- German Lopez: And this is really important for addiction because the time when somebody says, I want to get treatment, it's a really sensitive period. I mean, first of all, somebody has had to admit that they have a problem, which is not easy. And then second of all, they're starting to go through withdrawal and that kind of thing. Withdrawal is really terrible. It's like imagine the worst flu, mix it with like horrible anxiety.
--:-- German Lopez: These people, if they say, I'm going to get treatment, and they face these weeks or months long waiting periods, and they have to go through this full withdrawal process, there's a really high chance they'll relapse. And once somebody relapses, there's also a chance that they will just say, okay, I'm not going to treatment anymore.
--:-- German Lopez: Is there a way that fixing this could make financial sense? The White House actually put out this report where they said that the opiate epidemic cost $500 billion in terms of economic output. If we're talking about like tens of billions of dollars in federal funding to take care of this issue, if we avert another $500 billion from going away, that's a massive return on investment.
--:-- German Lopez: We have these solutions in like treatment and medications and so forth, and it's just we're not using them. We're talking about hundreds of thousands of people dying over the next decade due to opioid overdoses and if federal lawmakers don't do something if state lawmakers don't do something about that that's a lot of people dying on their watch.
--:-- Charlie: What ended up happening was after my like third attempt at rehab I had decided that okay you know I'm gonna try this Suboxone thing. I took it illegally off the street for a while and I came in. I finally got my name called on the list. It was a very long list. It absolutely changed my life. I'm still very lucky. I put in a lot of work.
--:-- Charlie: I went from literally dying, overdosing, homeless, sleeping in the airport. Now I am lead account executive for a financial merchant services firm. And I have a condo, two dogs. I take care of my mother and, you know, I pay my bills. It's crazy, man. It's absolutely crazy. You know, and I tried multiple times.
--:-- Charlie: At first I thought, oh, you know, I'm never going to be on Suboxone. I'm never going to be on it. Obviously, it's not just the Suboxone. But it gives you a crutch and it gives you some hope. Now you're able to not be sick and have a normal, stable, emotional sense, physical sense.
--:-- Charlie: I think that if I did not have the Suboxone, I certainly wouldn't be here today. Thank you.
