Over the past decade, Fentanyl, a cheap, hyper-potent, and synthetic opiate has accelerated the opioid pandemic already ravaging the country. Abdul reflects on the way that our atomized, lonely communities left us vulnerable to opioid addiction and fentanyl and sits down with Dr. Rahul Gupta, director of National Drug Control Policy to talk through the history of the opioid epidemic, fentanyl, and how the federal government is working with local communities to solve it.

TRANSCRIPT

Dr. Abdul El-Sayed, narrating: [AD BREAK] [music break] Covid continues to spike across the country, suggesting we may be headed into a serious wave as winter progresses. A new study found that 60% of the authors of the DSM, the Bible of Psychiatry had taken industry funding. Americans set records for Affordable Care Act insurance enrollment in 2023. This is America Dissected. I’m your host, Doctor Abdul El-Sayed. [music break] I got to be honest with you. One of the hardest parts of this job is trying to talk about really difficult things. Things most people never want to have to experience, like disease, disorder, and death in optimistic and uplifting ways. I try my best to offer a bright side at the end of each conversation. But today’s subject, even compared to some of our most difficult subjects we’ve covered here, is particularly challenging. That’s because of all the terrible things that can happen to people, Fentanyl overdose is among the worst. And at this moment, Fentanyl is killing tens of thousands of people a year and the number keeps going up. See, it’s not just that Fentanyl kills, it’s that Fentanyl takes lives in their prime. Just before the holidays a good friend of mine lost his younger brother, in his late 20s. He had two kids. And even those it doesn’t kill, it doesn’t really spare. Death, in fact, is just the tip of an iceberg. Those Fentanyl doesn’t kill it slowly dismembers. Chopping out pieces of their lives as they give more and more and more to the chemical imbalance that has afflicted them. Lost are the things that make us human. Small joys, the nurturing relationships. Love itself. And then there are all the people who have never touched the drug, but whose lives have certainly been touched by it. People like my friend who will never hug his brother again. His niece and nephew will grow up from here on out without any more fatherly hugs. Substance use disorder is a terrible disease, one that Fentanyl makes much more deadly than traditional opioids owing to three critical barbs. First, Fentanyl is incredibly potent. Potency is a measure of how much of a substance you need to achieve biological activity. Potent drugs don’t take much. And because it’s so potent, that distance between an active dose and a lethal dose is extremely small. Miss that window and it’s over. Second, Fentanyl is synthetic. You don’t need poppy farms, just chemicals and a bit of time and space. And that leads to the third barb. Fentanyl is dirt cheap to make, cooked in huge batches both in the US and abroad. And because it’s so cheap. Dealers can and do cut it into other drugs. That means that people don’t even know they’re taking it. And because a tiny dose can be lethal, you can come to understand why the advent of Fentanyl over the last decade has led to a skyrocketing number of overdose deaths. Nearly 74,000 people died of verified Fentanyl overdose in 2022. That’s 13 times as many as in 2014, when Fentanyl deaths started to hockey stick. That number continues to grow. As you know, if you’re a regular listener, no disease is about a single vector, in this case a specific drug. It’s also about the context for that drug. And in this case, that’s the broader opioid epidemic that gave rise to it. Fentanyl is just the end game of a now decades long opioid epidemic that kicked off because of the greed of the Sacklers and other prescription drug manufacturers. But what started as a prescription opioid epidemic then quickly morphed into a heroin epidemic. And Fentanyl is, as we discussed, easier to make, more potent and cheaper. So here we are. But it’s not just the Sacklers that created the space for this. It’s the way their product hit a society that already been drained of economic and civic resources. Poverty in a community is one of the biggest predictors of opioid overdose deaths. So is social isolation, and it’s hard to ignore the way that those intermixed in long forgotten boomtowns across our country, places made vulnerable to OxyContin and its spawn. Even in the darkness though, there are solutions, folks in communities big and small are working on it. This week here in Wayne County, our county commission will vote on a project we’ve been building to create the single biggest municipal investment in access to lifesaving, overdose stopping naloxone in U.S. history. We plan to deploy 100 vending machines, well stocked with naloxone, as well as fentanyl test strips across our county. These kinds of solutions are exactly what our guest today has been focused on promoting. Doctor Rahul Gupta is the director for national Drug control policy, and in that job, he’s the country’s Fentanyl czar. He’s not new to this challenge. He served as the state health commissioner for West Virginia at the height of its prescription opioid epidemic. And he joined me to talk about Fentanyl, the broader opioid crisis, and what we as a nation can do to take it on. Here’s my conversation with Dr. Rahul Gupta. 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

Dr. Rahul Gupta: Sure, my name is Doctor Rahul Gupta. I’m the director of drug control policy here at the White House. 

Dr. Abdul El-Sayed: Can you tell us a little bit more about what the Office of National Drug Control Policy does? What are the various moving parts that you’re involved in day to day? 

Dr. Rahul Gupta: Yeah. The office really has has a very interesting, uh, sort of portfolio it on one hand develops, uh, the president’s national drug control strategy. That cuts across 19 agencies of the federal government. Uh, that can range from public health, like health and human services, including its components to the Department of Education. But then there’s also crossover to national security that involves agencies such as the Department of Justice, DEA, um, Department of Defense, Homeland Security, and so many others. So, uh, it’s an opportunity for us to work across the United States government. But then also it, uh, takes the it’s budget of $44 billion dollars on drug control across these agencies and utilizes the president’s strategy to implement the budget in a way that, um, is appropriate and accountable. 

Dr. Abdul El-Sayed: All right. So your job is basically to make sure that the trains run on time, uh, on every aspect of, um, of, of of drug control. I wanted to talk to you today, uh, because of, obviously your, um, your oversight and and responsibilities vis-a-vis the the, uh, national response to the opioid epidemic. But then also, um, you’ve held a number of public health roles, uh, before this. Uh, I want to ask you, just how bad is the current state, uh, when it comes to the opioid epidemic? 

Dr. Rahul Gupta: Yeah and you know, right now we have seen a significant escalation, a double digit increase in opioid overdose deaths, which has now flattened for the last year, year and a half. Uh, but it comes on the heels of, uh, an American dying every five minutes around the clock. Um, even if that was bad enough, it’s only the tip of the iceberg. Because for every, uh, individual that passes away, there often can be up to 15 or so individuals that may have a non-fatal drug overdose. Um, and I’ve seen this as a, my role as a physician in practice, I’ve seen this in my role in uh, at a local public health and state public health levels managing this. But certainly in the last two decades in America, we’ve lost about a million Americans to drug overdose. We have about 47 million Americans today who suffer from substance use disorder. And we have another 23 plus million people who are in recovery. So this certainly impacts a large swath of the American population. But at a time when, uh, not only is it a public health crisis, which it is clearly so, it also is impacting our economic opportunity and national security. The reason for that is we have some of the lowest birth rates on the record. Uh, we know from some of the studies that it’s costing, this alone is costing us about $1.5 trillion dollars a year in the economy. And, of course, so this becomes one of the most, uh, challenging but also important domestic policy problems that have its tentacles across the globe. 

Dr. Abdul El-Sayed: So that is really helpful to understand in terms of the present state. And you talked about this, this massive increase in opioid overdoses and and deaths. The nature of the epidemic has changed itself. It’s not just, uh, a matter of scale. It’s also a matter of the substance itself. Can you kind of walk us back in history about the various phases of this? How did it start, and then how has it evolved to where we are today? 

Dr. Rahul Gupta: Yes, I think it’s one of the most fascinating things to understand, uh, for us, which is, you know, there for maybe a thousand years or more has existed a almost like a balance between humans and plant based drugs in so many ways. When I say plant based drugs, I mean drugs like heroin, cocaine and others. Um, what has happened? Um, obviously in the United States, we saw the pill, um, uh, pill mills and others that started with a prescribing overprescribing back in the early 2000s. Um, and and that evolved into when we started to get control over the prescribing piece, that, uh, issue being transitioned off to one that is much more cheaper, alternative and readily available in streets called heroin. And then heroin we saw get mixed in with fentanyl about a ten years ago or so. We started seeing fentanyl pop up, which is, you know, obviously 50 to 100 times more potent than morphine, much more deadly and lethal. And now we’re seeing a predominance of this drug fentanyl and other synthetics. And what I mean by all this, uh, if you look at the chronology. We have entered and not just the United States, but the world has entered a phase moving from plant based drugs where there were crops and farmers and fertilizers to chemical based drugs, which can be created in the closet with just simple as a chemistry set and and web access. And you could create some of the most lethal, dangerous substances on the face of the planet, just by simple compounds. So for the last eight years or so, we’ve begun a new phase for the first time in human history, literally, where these drugs are going to stay, they are much more lethal and dangerous. And people often aren’t aware that it’s in their backgrounds and in their, their neighborhoods. 

Dr. Abdul El-Sayed: So I want to I want to ask, you know, we’ll talk about fentanyl as sort of the 2.0 version of, of opioids. But can you tell us a little bit about the chemistry of opioids? Why are they so devastating as a as a drug class?

Dr. Rahul Gupta: Yeah. So what has happened is and I would say that the, uh, the people in the supply side, the bad actors that figure this out, oftentimes at almost the same speed as public health and scientists have, which is, um, just like any other addiction. Uh, what happens is basically when you’re taking these medications for pain or otherwise, it creates a tremendous amount of dopamine release in the brain, which basically makes you feel good. Um, you can get very similar patterns, whether, um, you’re doing the same thing with gambling or some of the other addictions. Uh, at the end of the day, that need for more dopamine or continued dopamine, um, is so critical for individuals that it causes insatiable appetite for these drugs, but also one that turns into a brain disease of addiction. And then as a result of that, people obviously are not really suffering from a disease. That we often didn’t know when I went to medical school it was often taught as a moral failing as opposed to the diesease of addiction. But at the same time, the more potent these substances are, obviously the the more efficacy they will have in the brain. Um. So it that’s the reason that if you see the cartels and other traffickers, they’re moving towards much more potent drugs. Obviously, the side effect is people will overdose and die, but they continue to use these opioids one brand or another. Licit or illicit oftentimes to get people in the throes of addiction. 

Dr. Abdul El-Sayed: So what I’m hearing is that you’ve got an extremely addictive chemical that is also really deadly. And the thing about that combination is that when someone’s chasing a high in an addiction, they require more and more of the substance to get that high. And when you’re balancing between that and then the edge of deadliness, right. That’s where um this becomes so profoundly devastating. So if it’s not killing you quickly, um, it is sapping you of your energy, your resources, your time slowly. And and that creates a really monstrous, um, type of chemical. I want to now shift, having talked about that to Fentanyl. What what makes fentanyl so much worse than the kind of plant based, uh, opioids that you talked about earlier? 

Dr. Rahul Gupta: Yeah. And let me just add one more thing to what you’ve mentioned very correctly, which is oftentimes when people are used to these substances, then oftentimes the goal is not only, you know, it’s not about high it’s actually about preventing withdrawal. So if people continue to use and they’re afraid literally in fear, when you talk to people about going into the withdrawal the next time and they want that substance. Now, obviously fentanyl is on the literally the top of the list of those substances. What makes it deadly is a couple of things. First, the potency. It is about 50 to 100 times more potent than morphine, meaning that small amounts of drugs, uh, enough to be on the tip of the pencil, could be potentially lethal for someone. The second thing that makes it much more deadly is that there’s a market of counterfeit pills now available. So I talked about a transitional [?] eight years or so. One of the things that has also happened is, um, that the bad guys have figured our appetite for pills. So what is now happening is when, let’s say, a teenager will go on to websites to purchase because they’re having trouble with exams for Adderall, or they’re having anxiety, maybe Xanax. Um, there’s a six out of ten likelihood that the pills that they’re buying online through the social media app on their phone is going to have instead, it would be a counterfeit pill having potentially lethal doses of Fentanyl in it. So, uh, oftentimes people aren’t even aware that this drug is in their drug supply. And, uh, I mean think about that six out of ten. The odds of doing that is worse than playing Russian roulette with your life. 

Dr. Abdul El-Sayed: Hmm. 

Dr. Rahul Gupta: Yet, um, this counterfeit pills have pervasive, uh, have prevaded the market in a way that it is no longer safe. I mean, it’s life threatening to go out and purchase these drugs online. Uh, and it’s a very important message, because if people are having trouble with either a mental health issue or otherwise, the important part is to go seek help with a provider and go to a pharmacy, not go online and try to purchase drugs yourself. 

Dr. Abdul El-Sayed: And so it’s the potency of fentanyl makes the probability of overdosing that much higher, simply because you run into the problem of of almost not being able to differentiate between a lethal dose and a sublethal dose, and then the fact that it can be manufactured and spiked into a drug supply, which makes it that much more pervasive. Where is where is the the fentanyl supply coming from in the U.S.? You hear a lot you know, a lot of folks are fearmongering about, uh, the border being a fentanyl issue, etc.. But I want to understand, like, where is it actually coming from here? How easy is it to manufacture? How much of it is being domestically manufactured versus, uh, brought in from abroad? 

Dr. Rahul Gupta: Yeah. So one of the first things, you know, what we did, uh, in this administration is figure out the global supply chain. It’s a very important question. And also the drivers of that global supply chain and the choke points. So what it turns out that the majority of the chemicals, that’s basically precursor chemicals that need to make fentanyl are coming from China. And as they are shipped directly or indirectly into Mexico, that’s where the fentanyl is being produced, and then the powder is pressed into pills or other forms, and it’s trafficked northward across the border through legitimate ports of entry. So over 90% of the fentanyl that comes from our southern border comes through legitimate ports of entry through passenger vehicles, cargo vehicles and individuals carrying them. Um, so as opposed to, you know what often is talked about, that someone with a, uh, you know, a migrant with a backpack coming across. Um, that’s the picture oftentimes that’s tried to be painted across a unforgiving terrain. Um, but the reverse is true so much, which is the normal chain is exploited. The reason that they do that is very clear, because they want to get, like any other commerce, their product, to the market as quickly as possible and be able to retail it off. And that’s the reason why they do it that way. 

Dr. Abdul El-Sayed: There’s another drug that we’re hearing, uh, even beyond fentanyl. Uh, xylazine, can you tell us a little bit about xylazine vis-a-vis, uh, fentanyl and then, you know, traditional opioids? 

Dr. Rahul Gupta: Yes. So xylazine, what we’ve found recently more in the last few years, is that it is an obviously, it’s an animal tranquilizer, and it’s being mixed more and more into fentanyl. So we have something called fentanyl associated xylazine. So now you’re getting it mixed in. Why is that happening? Well because predominantly as a sedative uh, fentanyl is short acting. And this allows the actions to be worthwhile longer so people don’t have to purchase a drug repeatedly. Um, but we’ve seen significant increases in, uh, overdose deaths from a combination of fentanyl and xylazine. That’s one aspect why earlier in 2023, we called xylazine mixed with fentanyl as an emerging threat. Now, the difference between the xylazine combo, as opposed to just fentanyl is the xylazine also causes a tremendous amount of its own addiction, but it also leads to a significant amount of other complications, such as wound problems. There are some of the most, uh, terrible wounds I’ve seen in my career are the ones of people who are using xylazine because it can cause a lot of tissue ischemia or tissue death. Um, the reversal, uh, drug naloxone, while it works with the fentantyl component, it doesn’t work for the xylazine component. So the drug reversal becomes way more complicated, basically. So, um, you know, it’s important for providers, physicians and others to be aware that fentanyl mixed with xylazine is out there in literally all communities. And, uh, it is a larger challenge and it’s important to recognize it and address it. [music break]

[AD BREAK]

Dr. Abdul El-Sayed: So I want to ask you, you know, thinking through this, you talked about, um, you know, for example, somebody trying to get Xanax and that Xanax is spiked with fentanyl. Obviously there’s a risk that that person overdoses right then and there. But if they don’t overdose and they presumably took Xanax, how does that yield a fentanyl addiction? And you’d have to figure out that what you had was fentanyl, how does that work in the real world? 

Dr. Rahul Gupta: So the goal for people who are peddling counterfeit drugs is that individual will take, uh, that counterfeit pill or fake pill, and it’ll have fentanyl in it, and they will take fentanyl so many times before they begin to develop a substance use disorder or addiction. And then then they will start to seek out that drug themselves. Uh, because of those brain pathways that continue to long for dopamine release and want that drug further. So they’ll try to get the same brand from the same supplier, uh, and same amount. And that’s how that works in the real world, because there’s this, uh, ability for people if you’re repeatedly using opioids, whatever they might be, then addiction sets in. And if you look at the CDC, it normally says, you know, the timeline is about 3 to 5 days, after which the likelihood of substance use disorder goes up from opioids if you’re continuously using it. So, uh, the notion from people who are trying to get more people into addiction and make profit off of that is exactly that. 

Dr. Abdul El-Sayed: I want to talk a bit more about the policy response, but how has the street responded? I mean, in my work, um, in our local health department, we’re hearing a lot about, uh, the notion that, uh, users have gotten a lot smarter about the risks of this. Um, how has that shown up in in the data that you’ve seen? 

Dr. Rahul Gupta: Yeah. So, you know, one of the important pieces for us has been that to make people aware of this. So if someone is doing, let’s say, cocaine for a long time and now the drug supply is being spiked with fentanyl, they need to be aware of that. Uh, for a couple of reasons. First, they can make the best decisions for themselves that they’re aware of. They have the ability to be, check in with a drug testing strip for fentanyl. And secondly, they’ll be able to have at least naloxone available, an antidote for opioids in the vicinity in the area. So if something bad was to happen to them, at least they could be revived right away. Um, these are important pieces because I think the community is really responding to this. They’re realizing that, uh, drugs like naloxone or Narcan are critical life saving tools and the ability to check, uh, your drug supply with test strips for drugs like fentanyl like xylazine is oftentimes lifesaving. So it’s this type of work that’s important to empower people in order to save lives. And that’s part of that policy change that we have enacted. 

Dr. Abdul El-Sayed: I want to talk a little bit about the the policy response here, because, uh, obviously we’ve been we’ve been fighting this epidemic now for, uh, almost two decades, as you talked about. And I want to ask you, you know, as as you think about this, in a perfect world, what would we be doing, uh, across levels of government, uh, to take this, uh, epidemic head on and and finally defeat it? 

Dr. Rahul Gupta: Well, I think, you know, we that’s exactly what we’re doing right now, which is we have to look at both the demand and supply as two sides of the same coin. That’s the first aspect. We have to change the way we think about it, because often people tend to think about it exclusively [?] reduction or exclusively as supply reduction. Either those are a mistake, and those policy mistakes were made for plenty of years in the past. Uh, and we can’t afford to because we have so many Americans dying. Now, when you approach that on the demand side, uh, things that we have to do is to encourage, uh, making sure that we are enacting harm reduction policies. That means the availability of naloxone becomes critical in communities. Um, the fact is that more naloxone equals more lives saved. We made naloxone now available over the counter. We like to see it, um, be available, just like a fire extinguisher or an automatic, uh, defibrillator, devices that are in public spaces. Then we have to expand treatment and that’s what we’ve done. We’ve passed legislation to remove the X waiver, which has now made from 128,000 providers that can provide treatment for opioid addiction to almost 2 million now. And we’ve got to make sure that people understand and get rid of stigma, even providers, to start treating people with addiction, screening people with addiction. And then prevention is critical because one of the pieces of the prevention, evidence based prevention works. We have to invest in prevention to ensure that, uh, drug use is either prevented or delayed. And and lastly, on the demand side, I would say recovery. Uh, you know, recovery isn’t about just treatment. It’s important to get people into treatment, but recovery is about everything else around them, like transportation, housing, jobs, education, all of those things. So we are working right now with businesses like Google to make them recovery friendly workplaces, small businesses and larger recognizing and realizing that it is much easier and better for business to have committed employees, as those are in recovery, uh, you know, millions of them, uh, as opposed to be firing and hiring systems. So we are encouraging more businesses to become recovery friendly. Now, on the supply side, I will say, uh, we have to recognize this as a business, as ecommerce. And that’s exactly what we’re doing. And why do we do that? We, uh, sort of go away from, you know, locking people up approach to going after the profits, both the operating capital and the profits and finding the choke points of that supply chain and really disrupting in a way that we can hold people and countries accountable for the actions. Because today, the fact is that this, uh, scourge is not only limited to the United States. We have now a global coalition that consists of 130 countries and international organizations that are working to defeat, uh, the scourge of synthetic drugs, whether it’s methamphetamine, fentanyl, uh, whether it’s, uh, you know, ketamine or, uh, other drugs. It’s really critical across the globe that we’re working together as countries and partners and allies to defeat this. 

Dr. Abdul El-Sayed: We’ve seen, uh, spikes in opioid deaths in other countries, but none of them have been as bad as the United States. What do you think makes this the epicenter of the crisis? Vis-a-vis the some of the policy solutions that you talked about? 

Dr. Rahul Gupta: Well, I think for one, we are the canary in the coal mine. You know, we have a population that is inherently had to take the, uh, disproportionate brunt of the pandemic. We have overall an unhealthy population. But at the same time, we have some challenges, like, obviously child poverty, trauma uh, you know, income inequality and those type of social determinants that make it much more difficult in some ways to put together and ensure that, uh, people have the ability, the tools that they need. But what that means is that we have to put resources behind it. And this is exactly why, uh, the president has put, uh, forth [?] resources into communities way more than has been ever in the history. Right now. We are, um, you know, asking Congress for even more resources to make sure that people when and where they need help are getting it. But for other countries, I will say this. Today, you can divide up the world into three types of countries. Those who have a synthetic drug problem like fentanyl and know about it like the United States. Second category is those countries that have a synthetic drug problem but aren’t aware of it. We’re trying to make them aware. And there’s a lot of countries in that category. And the last is those countries that are going to have a synthetic drug problem. We’re cautioning them to be aware. So the entire world unfortunately today is can be split up into those three categories. But there is no country that is going to be immune from the challenges of synthetic drugs unless we act proactively. And this is exactly why the president has been leaning forward on this, he has met with the Chinese premier, uh, President Xi on this just a few weeks ago, and he’s making sure that, uh, we’re doing everything possible in the administration and across government and across people because this is not a red state, blue state issue. Uh, this affects everybody. And so it’s an important part of President Biden’s unity agenda for the nation to come together to address it. 

Dr. Abdul El-Sayed: Yeah. I really appreciate your point. And I appreciate your insistence on, um, a lot of the social circumstances. I mean, you don’t have to look much further than, uh, the pandemic and the implications it had for people’s lives to appreciate the impact on the demand side of of mental health. And right now, you know, it’s not just that we’re facing a substance use epidemic. We’re also facing a suicide epidemic, particularly among young people. And unfortunately, one of the principal drivers of substance use is is mental illness as people uh turn to substances for self-medication. And so much of that is is is kind of driven by loneliness and the struggle of being able to make it every single day. But it’s also accentuated by a certain inability to have broader societal conversations. And I think one of the frustrations that I often have is that we’ve seen, uh, among, you know, all swaths of society, a focus on the challenges of, uh, this epidemic and the scourge of, of of opioids and fentanyl. On one side of the conversation, you have a broad based engagement with a lot of the drivers of of this issue. And on the other, we sort of name opioids and fentanyl. And then there is this unwillingness to engage with the churn, the challenge of daily life when it comes to being able to afford, um, what it is that you need to afford to support yourself and your family. And then, you know, an insistence upon some of that stigma. And I want to ask you like why do you think it is it is so difficult to connect the dots for folks around how tough it is, uh, particularly for, uh, lower income Americans to eke out a life and the implications it has for this opioid epidemic? Like, on the one hand, you can’t talk about fentanyl and on the other, not talk about all of the drivers that lead people to self-medicate with opioids. Why do you think there’s a disconnect there? And how do we get past it? 

Dr. Rahul Gupta: So I think, uh, one important piece of this is I’m going to give an example afterwards as well, is that we have to look at this as a societal issue. We have to look at this as a much more comprehensive issue than just one with a drug use problem issue. Um, because people who are suffering from substance use disorder are, you know, it’s not about this only treatment or only staying alive. Those are very important pieces, don’t get me wrong. But it’s also about the rest of it. So it’s about their home. It’s about the connectivity with their family and their community. It’s about having transportation and a job, uh, to feel, um, that you are in control and you are in control over your destiny and you have hope of all the things. So, um, this is more about just surviving. It’s about thriving. I’ll provide you an example. We very seriously have looked at what are the biggest things we can do to bring that number down? 110,000 Americans a year die. And we see this, if we, in addition, distribute about 7 million doses of naloxone, we’re going to be able to bring this down number by 26,500. Those are predictive, uh, data. Um, so we’re focused on that. We’re focusing on getting naloxone out there and connecting people to treatment. The second thing, the big thing out of this is, um, it’s so unbelievable to think every single day in the United States, 2 million Americans are incarcerated on an average daily basis. And two thirds of them are in there because of a substance use disorder. So what do we do with them? When when they are released into the community because they’ve not been consistently treated, uh, when they’re when they’re in, uh, in custody, uh, they overdose or die in the first few days right after release, or they have reasons to be reincarcerated because the mental health piece [?] originally was not treated. So one of the things we’re doing is and and believe me, there’s over 20,000 people like that that are dying each year because of that. So what we’re doing is now we’re encouraging states and making it available, cutting the red tape. And that’s exactly what the president is focused on. To make sure that there’s treatment available in jails, in prisons, including the federal system. And when we do that, we predict that we could save almost 20,000 lives from dying. But more importantly, also in addition to that, uh, that we will have economic opportunities for those individuals that are reentering society. So when you treat mental health conditions, when you treat substance use disorders, not only are we saving lives, but we’re actually contributing to the economy, because today, the number one killer of people, working age people between 25 and 49 is drug overdoses. And we’ve got to get ahead of that. 

Dr. Abdul El-Sayed: The other piece of this is is the stigma. You know, you think about implements that, um, really can reduce the harm, whether you’re talking about naloxone, which I think at this point is far less stigmatized, but also things like syringe exchange programs and, um, you know, you’ll have communities that are resistant to these kinds of syringe exchange programs and then are passing laws that, in effect, criminalize use. If you if you’re with somebody and you both use and and when one of you dies that you can be charged with with manslaughter and the implications of this, uh, around stigmatizing what we know to be a disease are really quite profound. I want to ask you, what what will it take for us to to take on that stigma in a real way? I mean, you talked about your medical training and mine where we treated, uh, drug use not as a disease and a malfunctioning of neuronal pathways, uh, that are gamed by a substance that we treated instead as a moral failure and all of the concomitant consequences of that. Uh, you know, we moralized against and in trying to take that on, it seems like that habit is really dying hard. And it also seems that in some of the hardest hit communities, it’s where those those habits are the worst. What does it mean to take on the stigma head on? How are you all, uh, in the administration thinking about that? And then what are the kinds of messages that we need to see echoed, uh, in local communities to be able to, to destigmatize this, uh, and start making way for some of the really, really critical harm reduction interventions that we need. 

Dr. Rahul Gupta: Well thank you. That’s a really important question. And let me say first of all, that, um, stigma is not only alive and well, but in our own profession in health care it’s doing pretty well. Why? Because one of the things is that we often don’t look at stigma as something that we need to actually work against. You know, we have the same situation with cancer about a century ago, highly stigmatized disease. And then we turn it around. And today it’s one of the most researched, invested, uh, conditions. We have a lot of compassion and sympathy with people, and we do a lot of prevention around it. Um, I see, uh, you know, substance use disorder as one of those situations. But we don’t need to take 100 years to get there. Uh, so it starts at home. What I mean is, uh, one of the things we’re trying to do is have a curriculum for health and health related professions that get students interested early on into, um, the disease of addiction, and then they will hopefully have career paths that will be rewarding in that sense, but also destigmatizing. In addition to this, uh, from a policy standpoint, you know, one of the things we’ve done is this the first time in the history of this nation we’ve introduced harm reduction as a policy of the federal government that includes naloxone [?] service programs and drug checking fentanyl test strips as an example. The reason for that is not only are these evidence based programs that are shown to reduce mortality and improve outcomes, but also that they’re critical to saving lives. And we take an oath in in health uh and medicine to not do harm. Part of that oath is to ensure that we’re saving lives, uh, without passing judgment. Uh, so harm reduction is an approach where we go and, uh, meet people where they are and carry them along for the ride. Uh, we’ve now began to fund that, actually for the last couple of years, significantly. But to make sure that communities have the resources to have naloxone, have [?]  programs and drug checking, uh, test strips. The reason these things are important because all no matter who you are, rich or poor, Black, Brown or white, uh, urban or rural, uh, red or blue, everybody is impacted today by this. And if if, you know, I call my kids regularly to check on them because even though they’re adults, uh, you just never know. Anyone could be impacted. So it’s important to make sure that we are looking at this from a community standpoint. We’re looking at this from individuals and human beings that understand that every life is precious and worth saving and do everything you possibly can. And in that realm, stigma has no role because we cannot treat dead people. Uh, so it becomes really important that we work as yourself, physician leaders, to ensure that we’re doing everything possible to eliminate stigma. 

Dr. Abdul El-Sayed: I mean this is I mean, for a lot of listeners, I think this can be a really, um, demotivating conversation. It’s hard to look at these numbers and feel like we’re we’re moving. What gives you hope? Uh, as you think about this moment, as you reflect on the the conversations you get to have, as you as you travel the country, uh, what uplifts you? 

Dr. Rahul Gupta: Well, the biggest thing that, uh, you know, uplifts me, first of all, is the challenge, right? So it’s it’s it’s an easy thing when, uh, you can almost see the light at the end of the tunnel. But what gets me most hope is when I travel across the country and I meet oftentimes parents of teenagers who passed away, and they look at me in the eye and say, only if I had naloxone available. And then they’re working as a mission in their life to ensure no other child or individual dies and has access to naloxone. The courage, the strength when I look in their eyes, uh, is probably more than I would have, being very honest. When I see that, that tells me that no, um, this is something we can all accomplish coming together. This is one area where everybody wants to make a difference. And in fact, when you put the right policies together, you can see light at the end of the tunnel. So to give an example, as I mentioned, we’ve had double digit rises in overdose deaths. And now we’re starting to see the flattening of the curve. And epidemiologically, just like a large ship, you know, one of the first things you start to see, it’s slowing down of the rate of increase and then have it come to zero and then start to decrease. So we’re seeing that in real time happening right now across America. And the time to do now, um, you know, in 2024 is often to double and triple down on the efforts to ensure as many lives can be saved as possible. The fact is that I keep a tab every single day we lose almost 300 Americans, and every five minutes we lose an American to overdose. And that’s what keeps me going every single day. To know that there are people whom we do not know, who we may not ever come across. But as a provider, as a physician, as a director, I have the opportunity to have an impact, a positive impact on their life and on their family. 

Dr. Abdul El-Sayed: Well, Dr. Gupta, we really appreciate you being, uh, one of those folks who is who’s making that impact. And, uh, joining us today to talk to us about it, uh, share your perspective on on what yet needs to be done and what is being done. Uh, and we appreciate your leadership. Our guest today was Dr. Rahul Gupta. He is the director of national drug control policy. And, um, and thank you so much for your time, Dr. Gupta. 

Dr. Rahul Gupta: Thank you for having me Abdul El-Sayed. I appreciate it. Thank you. [music break]

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. Daily Covid hospital admissions are up 20% over the past two weeks. ICU admissions and deaths are up 18%, and those numbers show no sign of letting up in the coming weeks. As we’ve discussed, the numbers are a combination of three key things. First, the new JN.1 variant, though it’s not more transmissible, deadly or immune evasive than its Omicron predecessors. It’s yet another variant that’s exploiting the nooks and crannies in our immune system. Second, those immune systems haven’t gotten the update they need. Remember, only 20% of the population 18 and up have gotten their updated Covid vaccine. That means that 4 in 5 of us are out here extra vulnerable to this thing. The third is that it’s just that season. Covid, as we well know by now, is a seasonal virus. It’s driven in large part by human behavior. When it’s cold, we spend more time indoors and we congregate and it spreads. What to do? Get vaxed if you haven’t and invest in some good indoor air purifiers. It’s not just Covid they’ll protect you against, but those vicious cold bugs that everyone seems to be getting right now. In other news, let’s talk about money in medicine. The Diagnostic and Statistical Manual is the gold standard of psychiatry. Let me explain why it’s so important. For most physical diseases, we have what we call a pathophysiologic model of how the disease happens. We can literally explain down to the level of cells, even inside of cells, what’s going on. A heart attack, a plaque formation on the inside of the arteries that feed the heart, that leads to blood clotting and the occlusion of those arteries. Cancer, cells lose the internal capacity to regulate their ability to divide, leading them to do exactly that in ways that infest other tissues. The flu, influenza virus attacking our cells, triggering an overwhelming immune response. PTSD, well, that’s that’s a little bit harder. See, we don’t really understand at the cellular or subcellular level what causes most mental illnesses. Instead, we categorize them according to patterns of symptomatology, life experiences that come before or after them, and the treatments those symptoms respond to. Which means that definitions of diseases really matter as you clump them together, offer diagnoses, and then treat them. And for that, we turn to experts. Except that experts are people too. And it turns out that 60% of those people that wrote the last DSM, DSM five, had received funding from industry, mainly pharma, to the tune of $14 million dollars collectively. Now, there’s no clear proof that the funding shaped the definitions that they codified in the DSM. But it’s probably not great to have experts who took industry financing defining what it is and is not to have a mental illness. Particularly one that shapes the way that diagnostic decisions get made and treatments get prescribed. It’s another example of just how pernicious the influence of pharma money can be. Finally, during last year’s open insurance enrollment period, this happened. 

[clip of unspecified news reporter] The landmark legislation has surpassed projections and broken the all time enrollments record for the third consecutive year. 

Dr. Abdul El-Sayed: 20 million Americans enrolled in health insurance on the Affordable Care Act marketplaces, nearly 14 years after the passing of the ACA. That’s a record. In fact, this is the third straight year of record enrollment. The story is a complicated one, though. First, the good part. It reflects the fact that plans on the ACA exchanges are getting better, and that more Americans see them as a strong alternative to traditional employer based programs. But then there’s the other part. More Americans are turning to them because they’ve recently lost Medicaid coverage after the administration rolled back pandemic era Medicaid extensions. Well, I think it’s awesome that people have an alternative. I think it’s less awesome that we’re trading a strong government option that was heavily subsidized for a less strong private one that is less subsidized. Either way, it should remind us how critical health insurance is for millions of people and how devastating losing it would be, especially considering this. 

[clip of Donald Trump] And we’re going to fight for much better health care than Obamacare. Obamacare is a catastrophe. Nobody talks about it. You know, without John McCain, we would have had it done. But John McCain, for some reason, couldn’t get his arm up that day. Remember, he goes [pause] that like that. That was the end of that. 

Dr. Abdul El-Sayed: Yeah. As much as I wish more people had free government insurance, repealing the ACA is not the play. That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. Also, if you love the show and want to rep us, drop by the Crooked store for some American Dissected merch. Don’t forget to follow us at @CrookedMedia and me @AbdulElSayed no dash, on Instagram, TikTok and that website that was formerly called Twitter. [music break America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Charlotte Landes mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice, and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests, and do not necessarily represent the views and opinions of Wayne County, Michigan or it’s Department of Health, Human and Veteran Services. [music break]