Treatment-specific online companies have exploded since the pandemic. But the ethics are… complicated. What happens when you can order a little understood treatments in the mail? What happens when those treatments are habit forming? Abdul explores the explosion of treatment-specific online companies and talks to Chris Hamby, a reporter at the New York Times, about his recent reporting on online ketamine therapy.

TRANSCRIPT

[sponsor note] [music break] 

Dr. Abdul El-Sayed, narrating: The FDA finally rolls back a 38 year old policy that limited blood transfusions from gay and bisexual men. The U.S. Preventive Services Task Force recommends that women start getting regular mammograms at 40 rather than the previously recommended 50. A new study shows that Black Americans are far less likely to be treated for opioid use disorder. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] If you’ve listened to a podcast in the last three years, which of course you have, or if you’ve even just watched anything on television, you’ve probably seen a lot of ads that sound like this. 

[clip of unidentified ad number 1] Because it’s delivered at home, it costs a lot less and is a lot more convenient for people to receive. 

[clip of unidentified ad number 2] And if treatment is right for you, we’ll ship genuine medication right to your door. 

[clip of unidentified ad number 3] If it’s right for you, Hers will ship to your door for free. 

Dr. Abdul El-Sayed, narrating: These new companies that promise to treat your male pattern baldness, erectile dysfunction or depression through an online diagnosis and then popping your prescription in the mail. That simple. And over the past three years during the pandemic, they’ve ballooned. That trend? It’s the result of a couple of complex dynamics that could have only arisen during the pandemic. Since 2020, depression, anxiety and ADHD have risen sharply. That jump in illness has happened way faster than our ability to treat it. And that’s where today’s story sits. At that intersection between skyrocketing mental illness rates and telemedicine. One of the ways that we’re trying to expand treatment for mental illness is through telemedicine. Rather than having to travel miles and meet someone face to face, we can use the magic of the Internet to facilitate a visit that would otherwise not have happened. And there’s no doubt that telemedicine has been critical to getting treatment out to folks who otherwise would not get it. And if you’re a regular listener on the show, you know that one of my biggest concerns with the sunsetting of the COVID public health emergency that took place last week is that it might curtail access to the type of telemedicine that so many people rely on. But just like every cloud has a silver lining, every rose has its thorns, and that’s that it created the space for companies offering, we’ll just say, less than safe treatments in less than regulated ways. See, male pattern baldness or erectile dysfunction, their treatments are well characterized and relatively safe. But what about when the treatments still aren’t all that well understood? What if those treatments are habit forming? The ethics of these online treatment companies are complicated. Think about it. Medicine is built around a model where the outcome isn’t supposed to be predestined. You come in with a set of symptoms. Your provider is supposed to do a history and physical exam, come up with a differential diagnosis, pursue their diagnosis with a set of tests, and then if a treatment is necessary, write a script for it. The clinician isn’t usually paid to write you a specific script for a specific medicine right up front. They go where the diagnosis leads them rather than starting with the medicine they’re supposed to prescribe and then working backwards. These treatment specific online models do the exact opposite. They put the physicians who work there in a tough ethical position or worse those doctors put themselves in that position. And honestly, treatments for baldness or PE, they’re not that dangerous. Doctors know exactly how to prescribe them. And you’ve never really heard of a Viagra addiction. Well, at least not to the medication anyway. But when it comes to online mental health treatment, the explosion in telemedicine treatment has led to a phenomenon that well beyond all of the others sparked a bit of my concern and that one? That’s mail order ketamine. See, while there is strong evidence demonstrating that ketamine can be effective in treating serious treatment resistant depression, the evidence based treatment protocols are focused on larger, more limited doses under serious clinical observation. And you can’t do that through an online model. So instead, these online providers are prescribing smaller, more frequent doses, which just isn’t what the data has shown is effective, never mind safe. And when it comes to side effects, ketamine is decidedly not Viagra or baldness treatment. Ketamine is habit forming, meaning you can get addicted to it. It also has some serious side effects like incontinence. The FDA hasn’t approved either the form nor the treatment course because there’s another piece here. The FDA oversees manufactured drugs. But mail order ketamine is synthesized in small batches by a class of smaller outfits called compounding pharmacies, which, you guessed it, the FDA doesn’t regulate. There are definitely people who have benefited from expanded access to ketamine, and I think it’s critical that we have more treatment available, not less. But I also think we owe it to patients to address the ways that people who seek to profit off of them can exploit them when they’re in a place of desperate need because, well, capitalism. So just in case you lost me here, let me summarize. You’ve got a mind altering, chemically addictive medication with a serious risk of side effects being pushed by physicians who are employed specifically to write scripts for it and being mixed in compounding pharmacies out of view of the FDA. What could go wrong? And that’s the question our guest today set out to ask in his reporting in The New York Times. He interviewed over 40 patients, two dozen doctors and medical professionals to understand the promise and perils of online ketamine. Chris Hamby joined me to talk about his findings. Here’s my conversation with Chris Hamby. 

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

Chris Hamby: Yeah, I’m Chris Hamby. I’m a reporter at The New York Times. 

Dr. Abdul El-Sayed: Chris, I really appreciate you uh reporting about ketamine sort of at the edge between changing telehealth rules. This uh new substance um that we found some additional uses for beyond um the street use and therapeutic uses that are really quite profound for folks who take it and the um incessant uh impact of consumerism and health care. Um. So just to sort of step us back, what what drew your eye to the explosion of online ketamine? 

Chris Hamby: Yeah, I mean, I think it’s um well, the advertising has certainly gotten um more aggressive. I think, you know, during the pandemic, there was an increase in telemedicine use um across a you know a range of types of medicine. And uh, you know, a lot of it arguably has been good um or it has increased, you know, access and affordability to some types of care. Um. But I was not aware that this was a substance that you could obtain um online and take it home. Um. I was you know, I think, well, first, a lot of people may not be aware of ketamine as a treatment for mental health disorders in the first place, but um I had you know read a few articles about that. You know, it’s um, you know, along with some other sort of psychedelic like drugs gaining in popularity. But I assume that this was something you had to receive in the clinic. And um thanks to some uh pandemic era rule waivers, um it is actually was possible. Um. It is still possible to do it uh at home. And so uh, you know, I saw some of these, uh you know, their advertising on social media, um some of the companies that have sort of sprung up or or grown substantially uh since the pandemic advertising this. 

Dr. Abdul El-Sayed: Yeah, it’s almost like you can’t really miss these advertisements. And the thing about this is it’s a perfect storm. Uh. There’s no doubt that ketamine can be an important therapeutic for people with um certain uh illnesses, including treatment resistant depression. And um at the same time, uh it is a uh a medication that is ripe for abuse. Right. This is a drug that has been um available on the street for some time and certainly has high abuse potential. All in this moment where um you’ve got uh a changing regulation for purposes that are well beyond the circumstances of this particular medication. You’re in the midst of the pandemic and people need uh their treatment. And telemedicine made that possible. Um. And then in the circumstance uh where the the common use um has sort of gotten well beyond um what we’d normally expect in terms of a new therapy. Right. And uh and so this perfect storm really does highlight a number of of dynamics um in this this moment in health care. And it’s, I think, a really, really important window into how those uh forces can can come to bear um and some of the consequences on that. So can you tell us a little bit about ketamine? Uh. What are its origins? What’s um what’s it used for therapeutically? And then um what is the more common usage on the street? 

Chris Hamby: Well, it was first approved more than 50 years ago by the FDA as an anesthetic. So uh, you know, it would be used to sedate patients during surgery. Um. It still is sometimes uh it’s used more in in children. It’s it’s on the WHO’s list of essential medicines and is frequently you know used, especially in the developing world. Um. And so it has been you know used in that context for quite a long time. Um. And but that is at significantly higher doses. Uh. And obviously just, you know, once given under the care of a medical professional during uh a surgery. Um. More recently, there has been interest in it as a mental health treatment um and at lower doses, it is um no it’s called a it’s not technically a psychedelic according to whom you ask um, but it is a dissociative anesthetic and uh it can [?] a state uh you know visualization, sort of an out of body experience. Some people describe it, um you know, at these lower doses, and it is um showing quite a bit of benefit in some, albeit early research, indicating that it can sort of be sort of a mental reset for for some patients, um it’s most of the research has focused on patients with pretty um severe and complicated um situations. Uh. Most of the research has been on treatment resistant depression, as you said. Um. So people um with significant depression that has not responded to other more traditional therapies over time uh and it it the research tends to focus on um infusions given in a clinic. And it’s usually a time limited series of maybe half a dozen over a few weeks. Uh. And most of the research really is looking at that. There’s been some research on how do you extend those antidepressant effects beyond that, sometimes with um periodic booster doses. Um. But what we’ve seen with the at home use is really sort of a different treatment paradigm um that is beyond what there has really been a lot of research on, which is um taking either a tablet or a lozenge um that dissolves in the mouth over a period of time uh and taking it uh more frequently and for a longer period of time. And there’s just really not a lot of research to indicate whether that is um, you know, on really the safety and efficacy of that long term. And there are some um indications that it could be problematic in various ways. 

Dr. Abdul El-Sayed: And then uh tell us a little bit about the street use. Um. The non-therapeutic use of uh ketamine. 

Chris Hamby: Yeah, I mean, it has over you know at times this sort of waxed and waned, the popularity of it as a street drug in some other countries, um UK, Hong Kong, um it has been much more popular as a recreational drug. Um. It has also been um, you know, pretty popular. It’s sometimes you know known as a club drug. Um. Electronic dance music scene um in this country. It uh yeah, I mean, some people do abuse it uh and it is it is a schedule three controlled substance uh by the Drug Enforcement Administration because of its potential for dependance uh and abuse. And um yeah, it causes you know, as I said, some people find the dissociative sort of experience um it’s almost like a psychedelic in some ways um to be pleasant. Um. Some people I’ve talked to find that horrifying, um you know, so it just depends um really on the person. But it it does sort of have a um a history of at least amongst some subset of users um causing addiction and abuse. 

Dr. Abdul El-Sayed: Yeah. And I want to be clear about this, which is we have this mesh point here that we’re circling around, which is the capacity for a substance to be used for non-therapeutic purposes that is then made widely available for therapeutic purposes that are off of the evidence for which that use was was tested. And that’s where you start to have the incessant power of corporate capitalism and health care, where there’s a lot of money to be made off of this substance, which for many users will be used for the purpose of treating uh treatment resistant depression. For some users could um lead to really quite debilitating um side effects that they may not be fully aware of. And then for some users still um could potentially lead to dependance, which is also really quite debilitating. And the fact that that that spectrum is so fuzzy is really what makes this a moral and ethical question, because at the end of the day, you’re right, a lot of the evidence about ketamine use for therapeutic purposes is based on a very particular kind of regimen involving infusions under very direct supervision by professionals who know what to look out for. And you have this change in regulation that then uh opens up Pandora’s box in terms of all of these new pseudo experimental uses, but are hitting the market as if this is how ketamine ought to be used uh out in the community. And that’s the place where I think there should be a lot of discomfort about what this story tells us. Can you tell us a little bit about what was that regulatory change, what was it intending to target? Um. And then how did it how did it get monetized, in effect, by you know I hate to say the ketamine industrial complex uh to turn into this um this this this far bigger uh phenomenon? 

Chris Hamby: Yeah. So previously before the pandemic you would have had to have, go to your doctor for an in-person evaluation um before receiving a prescription for this. Um. The big change was really that with the pandemic, you could see someone by telehealth and uh they could prescribe it for you, you could um receive it, get your prescriptions renewed. Um. And so that really um sort of opened up this this whole new space. Another area that uh, you know, I didn’t really realize until I got into this a little bit further is that a lot of this is actually it’s sort of opened up a business for a new uh industry of sorts um or a new sort of product for an existing industry, uh the compounding pharmacy industry, um which you konw so when you have these in-clinic infusions, uh those are you know the clinics are usually purchasing the FDA approved version of ketamine, which is usually a vial of liquid. Like a medical professional would give uh in an operating room and you know the medical professional at a mental health clinic will administer this um by I.V. or injection. Um. But the at home use um doctors either cannot or are not willing to prescribe, you know, send someone home with a vial of ketamine, which obviously could be quite dangerous um, in addition to the difficulty of administering it via that route. But so you have like this whole industry really that um can take uh it is exempted from a lot of um regulatory requirements that normal drug manufacturers are required to meet. Because um the idea initially was that they would, you know, make small amounts of sort of specialized medicines for patients who, for one reason or another, couldn’t take an FDA approved version of a drug. Maybe they had an allergy to um one of its ingredients or they couldn’t swallow a pill or something like that. Um. But the compounding pharmacy, really uh the industry has really um has seized on this and um is able to compound tablets and lozenges, which there is no FDA approved tablet or lozenge of ketamine that you can get. But um so it sort of gives these these compounding pharmacies sort of a lot of rein to do this and to to ship across the United States, really. And so they’ve sort of filled this space um you know a lot of telehealth companies advertising in this area. Um. You have a lot of uh well, maybe not a lot of, but at least some even just smaller practitioners um who have sort of come up in this space and realized that you know with telehealth, um you can see a significant number of patients fairly quickly. And so even just individual providers in areas like family medicine have started doing this and seeing patients across the country. Um. And they are, you know, significant uh providers in this space. [music break]

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Dr. Abdul El-Sayed: You know, the the context I want folks to understand about compounding pharmacies is that the assumption is that these are pharmacies that are uh mixing um a particular formulation of a medication for patients with a far closer level of supervision of a particular physician who is ordering uh medications compounded this way. And this isn’t like your usual uh CVS. This is a uh meant to be a local kind of shop that does a very boutique kind of medication for people who are needing a very unique kind of formulation. And what’s happened now is that with the advent of the Internet and the the easing of regulations, you’ve got this situation where a compounding pharmacy can say, you know what, like we can sell huge amounts of this stuff, right? Because we we’ve lined up a bunch of loopholes and we found a physician who uh is willing to peddle huge amounts of this stuff with very, very little oversight. You in your piece in the Times, you talk about one Doctor Smith. Um. Can you tell us a little bit about uh about that practice um and you know what they are doing uh in terms of um being able to take this this these loopholes, line them up and then put a significant amount of ketamine out in the world? 

Chris Hamby: So, Dr. Smith, um is a longtime um emergency medicine/family medicine practitioner, he had until recently a family medicine practice in South Carolina. His wife had uh some struggles for which ketamine was quite helpful, and um he became interested uh in in prescribing it. Uh and I think in his view is is actually thinks that it is a very beneficial thing to a lot of patients. Um. He’s been pretty outspoken about um, you know, feeling like this should be um a more broadly accessible therapy for a lot of patients. And he has really sort of starting relatively early on in the pandemic, kind of stuck his neck out there to provide this service to patients. Actually, there’s a thriving Reddit uh community on this for therapeutic ketamine use that has just exploded in the last few years. And he has really he frequently posts on there. He um uh you know interacts with patients. Um. A lot of people recommend him on there. Um. And so basically, out of a small office in South Carolina, he has been seeing um in the last few years, by his count, more than 3000 patients, I believe, uh in 44 states. Um. And, uh you know, a lot of the times he does end up prescribing them ketamine to be taken at home. Uh. And so it will be shipped to their home. And some services um like Mindbloom. Um. It’s one of the big sort of Silicon Valley startup type companies that that uh is in this space will have um more spaced out doses. And they typically require you to interact with um some sort of guide or um, you know, you have to be a little bit monitored and have a blood pressure cuff when you’re taking it. But um a lot of other sort of smaller practices like Dr. Smith don’t really require that. They will just check in with you once a month for what patients told me was anywhere from a 15 to 30 to 45 minute appointment. And it may or may not be Dr. Smith himself. And they will um just sort of check in how you’re doing and in many cases renew the prescription. Um. And so, you know, you have a significant number of people who are taking ketamine um every three days at pretty substantial doses for a pretty long period of time. And um, you know, I think I spoke with Dr. Smith a couple of times, and he was very um forthcoming uh and is, you know, I think feels like he is really helping a lot of people. And um I did speak with some of his patients who recounted to me that they have had some of the side effects um that are associated with this, but that are often minimized, which are bladder damage, um often temporary, but sometimes permanent, and then um experiencing addiction or issues with abuse. And, um you know, I think Dr. Smith um obviously said that that was unacceptable and that if he found out about that, he would take action. But that his feeling is that we should not allow questionable decisions by a few people to limit access to something that could really help a lot of people. So that’s that’s where he’s coming from. 

Dr. Abdul El-Sayed: I want to dig in a little bit more on the side effects, but just for context for listeners. The hard part for me is not that we should be keeping a really important treatment away from people. It’s that we’re talking about the wildest of the Wild West when it comes to the formulations that are truly therapeutic because we just don’t have evidence around the efficacy in terms of what regimen you should use. And if you have a vested interest in billing patients for the prescriptions that you write, then you also have a vested interest in making sure that you’re not listening for the other side of safety and efficacy, which is the safety part. And then what’s even worse is that when we’re talking about a medication which we know to have a high addiction profile, once one of your patients gets addicted, they now have an incentive not to share with you that they’re having potentially debilitating side effects, including that addiction itself. And so the thing becomes a self uh driving outcome. The physician makes money by willingly um being less attentive to side effects. The patient gets a medication that they initially jumped on to try and treat uh um what might have been a very debilitating mental illness but may develop an addiction. And so they have an incentive to keep the thing going. And on net, what has created is a lot of money flow from someone suffering a debilitating depression to a doctor selling a treatment and somebody who now has an addiction on top of their mental illness. Like that that is uh at the at the worst case scenario, the circumstance, not to mention um a lot of the bladder damage, which is really, truly debilitating for folks. I know you interviewed many, many patients um for your piece. Can you tell us a little bit about what their experiences were? Um. What was it that you found in terms of both the good in terms of people who felt like their depression was treated, but also potentially the bad in terms of the side effects that you found? 

Chris Hamby: Yeah. I mean, I will say um and I spoke with, I think more than 40 uh patients um taking this at home uh for the story. And I mean, I think the majority of them felt that it has been helpful, um uh you know, that it has improved um their depression or anxiety, some PTSD. Um. You know, many of them, obviously, because this is they only had this expanded access because of COVID. It’s still fairly early on really to say whether um any, you know, sort of the magnitude of those benefits or whether they’re sustainable. Um. But I think definitely a lot of people feel like, at least in the short term, that it has helped them. Um. But a significant number of people also experienced um some of these side effects that have been associated with um abuse of ketamine in the past, but that people who are proponents of its broader therapeutic use now generally minimize, which are principally the bladder issues and the risk of addiction and abuse. And uh it it is you do um have situations like the one you described in which patients um, you know, if you do find that you have become you feel like you are addicted to this, you are not likely to tell your doctor that you are abusing the drug or if you’re experiencing bladder symptoms, you may not tell your doctor. And in fact, I spoke with a number of people who said that, who said that they, you know, did not want their prescription to be cut off. Um. And even people who were experiencing pretty significant bladder problems um said that they had not told their doctors because they felt like the ketamine was working and they were afraid if they were getting cut off, they would go back to, you know, the severe suicidality, even in some cases that they were experiencing before. And, you know, it really is a complicated risk benefit tradeoff in some of these cases. But I think there’s just what this really highlights is that when you’re when you’re doing it at home um via telehealth, there’s just there was already it was this was a difficult situation and there’s just such little support for a lot of these patients right now. Uh. And these are some of the patients suffering from some of the most severe and complicated mental health issues. And they’re really um sort of taking a very powerful drug that is not an approved first line therapy for this. And they’re really doing it without a lot of supervision. So, um you know, I think it’s just a very difficult situation to know from their perspective what the right thing to do is. And then you combine that with sort of a number of regulatory gaps. And it really is um I mean, the phrase that you used, Wild West is one that I heard again and again and again. 

Dr. Abdul El-Sayed: And one of my frustrations, too, is just the role in marketing in all of this. Right. A lot of the ways that these uh providers are marketing is as if ketamine is the front line therapy for depression. And it’s a general problem with pharmaceutical marketing in general, which is that you are inducing a demand for something that we put behind a physicians pen pad for a reason, because it’s has considerable safety concerns that come with it. And we require people to be certified as practitioners of medicine after years and years and years of training and years and years and years of experience. And when you go right to them and say, we are going to finally get you past your challenge, it’s a form of manipulation of people who are suffering and especially when you have a treatment that you are positioning as if it’s front line that has very little evidence behind the particular use that you’re offering. And you know that it has the risk for abuse and that is that poses a number of ethical, frankly, moral uh questions. And there are going to be people who are hurt on the back end. It’s also, you know, it’s important that we get these medications out the right way. And that’s that’s the other side of it, which is to say ketamine uh has evidence behind it for the for the treatment of treatment resistant depression. It is an important uh medication. I worry, right, that sometimes the blunt tool of policy um is just that it’s blunt. And so you’ve got wild swings one way or the other. And um the risk is that now the response is that we wildly restrict um ketamine access even beyond the the direction where you’ve addressed some of these um misalignments of incentives um that have led to this. What is the regulatory situation like? Uh. You know, my my um partner, Sara, my spouse, she’s a she’s a uh psychiatrist and she treats patients via telemedicine all the time and has fundamentally opened up an avenue for treatment. Um. But there’s also a number of restrictions around, you know, the way that that um that treatments are given and how they’re um set up. And, you know, and so in some respects, the answer is not to shut down telemedicine. The answer seems to me to be more about how you address uh these misaligned incentives in the ways that, uh you know, how a medication with with high abuse potential um uh should be formulated and can be formulated. And the assessments that need to happen to watch for um these big side effect risks. Where is the conversation about regulation now and where does it look to be headed? 

Chris Hamby: So that is um really the concern that even a lot of patients and physicians practicing in this space who support the use of ketamine for uh mental health treatment, that is their concern, is that there will be an overcorrection because we do have sort of a wild west and that they will limit access to people who legitimately need it. Um. You know, there are I spoke with some doctors who um you know are becoming more conservative in their practices because of the sort of early information that is coming in uh there are different groups um on, you know, Facebook or other other places where um they’re not uh publicly open groups, but they are for providers of this sort of therapy. And there are, I’m told um, you know, an increasing number of accounts of patients having problems like bladder issues or abuse addiction issues. And so I think there are some providers uh who are seeking uh you know to arrive at some sort of voluntary consensus standards um to sort of self-regulate part of this field, to try and impose um at least, you know, something that responsible actors could draw on. Because, I mean, there are probably and I think I’ve spoken with a number of them, you know, well-intentioned practitioners who just legitimately don’t know what the best practices are because they aren’t well defined. And so um, you know, really, in the absence of any sort of, um you know, FDA requirements on uh prescribing guidelines or, um you know, uh it really is sort of left up to the physicians at this point to develop best practices. Um. In terms of the DEA restricting um use by telemedicine, they have proposed a rule going forward because what what was set to happen was that when the public health emergency ends May 11th, um the ability to prescribe this uh without seeing a patient in person would go away. It would revert back to the pre-pandemic roles. Um. What the DEA has proposed is, is to um have sort of a a little bit of a middle ground where in general patients would have to have um one in-person visit or a referral, um but uh they could continue to to do it at home for the most part. And so I’ve spoken with various providers who are sort of trying to figure out how to navigate that space without totally blowing up um their practices. But ultimately, this is an off label drug um that’s going to probably continue coming from compounding pharmacies. So, you know, the FDA, I have asked them repeatedly on this, and there’s just not a lot of clarity on what exactly their role is in all of this. 

Dr. Abdul El-Sayed: Hmm. This is not the only medication that has these risks and these misaligned incentives around it. Um. You can think about other psychoactive medications with with with similar challenges. And I want to ask you, as you think about stepping back from ketamine specifically, what do you think after your reporting and from the insights of the providers and the patients that you talked to, what should be the system moving forward around uh tele– tele-psychiatry uh and tele-mental health. Right. Because it’s clear it’s opened up a whole lot more access. And that really is fundamentally critical considering the challenge that we have to getting care. And at the same time, it has opened up you know, it’s like we are trying to claim the Wild West now and it opens up a lot of opportunity for actors who simply want to make money at all costs to practice in, at best irresponsible ways, at worst, in truly predatory ways. Um. What would you like to see this this world look like um once this moment of turbulence is over? 

Chris Hamby: Well, it’s really difficult to see how this is going to shake out neatly. I mean, I think one reason why there was sort of this ketamine boom during the pandemic was because there were a lot of shortcomings before. I mean, there were, you know, one reason that people were so hungry for and a new a novel antidepressant that actually had a different mode of action than traditional antidepressants was because a lot of the traditional antidepressants just don’t work that well for a lot of people, or they have significant side effects. Um. So there’s really a lot of issues of drug development there. Um. And, you know, we can sort of go um down the line about the incentives for certain types of drug development um and the way that the FDA approves um drugs. Uh. And then, you know, in terms of the telemedicine piece from this, I mean, it would be difficult to argue that broader access to telemedicine can be beneficial for some people. But I think we’re really trying to figure out what that balance is right now. And I think that that’s what the DEA is really grappling with um in this rulemaking that’s ongoing right now. And um they have gotten a lot of comments from the public on that. And it’s it’s still open. Um. And that was really sort of the fundamental issue that I I ask pretty much every patient and provider that I spoke with. You know, how do you, you know, how do you strike that balance between access, uh affordability and safety and efficacy? Um. And, you know, no one really had the perfect solution. And I think that that’s kind of the place that we’re in right now um is is, you know, hopefully. Yeah. You know, like I said, I think there are a lot of um physicians groups that are trying to be responsible and establish voluntary standards, but that will only get so far and there will still be bad actors. Um. There are there are just a ton of regulatory gaps. And um and I think you’re always you’re always going to see this tension there. So um and it kind of swings back and forth. And I think during the pandemic, it swung pretty far in the permissive end of the spectrum. Uh. And you know I think we may be starting to see a swing back to some degree, but there’s always just going to be this this tough balance um that can’t be completely addressed by regulatory action. 

Dr. Abdul El-Sayed: Mmmm. Well, we really appreciate you shining a light on it and um in covering this. Our guest today was Chris Hamby. He is a reporter with The New York Times. Chris, thank you so much for making the time. 

Chris Hamby: Yeah, thanks so much for having me on. [music break]

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. In case you didn’t know it, there is and has been a severe shortage in blood for blood transfusions for some time now. You’d think that to address it, you’d want all the possible donors you could get. And up until last week, the FDA had banned blood transfusions from certain groups of people, specifically gay and bisexual men. The ban harkens back to the early AIDS crisis, when our lack of knowledge about HIV transmission mixed with homophobia and led to the policy. Instead following the lead of the UK and Canada. The FDA is scrapping that ban for a questionnaire it will require of all donors. Banning instead people who’ve had anal sex with a new partner in the past three months, or those who are taking prep for HIV prevention. This policy has a very clear advantage. It doesn’t openly discriminate against a whole class of people. Instead, it more narrowly targets preclusions around behaviors associated with higher risk of HIV transmission. And while Prep does exactly the opposite, meaning it reduces transmission, it can also mask an HIV infection, which could lead to false negative screening tests for blood. This is the right move and it’s about damn time. And this also might be a good time to remind you that if you haven’t given blood lately, I really hope you’ll consider it. The U.S. Preventive Services Task Force, which sets policy on disease prevention around the country, has revised its recommendations for mammograms, recommending that mammograms begin at age 40. Again, that’s because this is the first revision since 2009 when the task force delayed the age of first recommendation from 40 to 50. They also recommended mammograms every other year instead of every year. That every other year recommendation, it still stands. Why the change? Screening is critical to catching early disease. To find it before it’s too late. But screening can also come with costs in terms of overtreatment. Positive mammograms require a biopsy, literally a needle into the breast. Not only are these painful, but it’s really scary to be told that you could have breast cancer. And the high probability of negative biopsies was why the task force had pushed the recommendations back last time. But what’s happened is that the rate of breast cancer is generally increasing. That’s right. And that’s largely because people are having fewer kids and having them later. And that’s largely because pregnancy before 35 reduces the probability of breast cancer, as does breast feeding. And well people are having kids later, if at all. Finally, a new study in the New England Journal showed that Black Americans are far less likely to be treated for opioid use disorder than white folks. The study followed nearly 25,000 people who had been treated for opioid overdoses and found that Black patients were less than half as likely to receive treatment for opioid use disorder in the form of buprenorphine or methadone. While the study looked at filled prescriptions not necessarily written ones, it paints a dire picture of the way our society deals with drug use differently by race. There’s a whole sordid history, you have to understand. Before the opioid crisis, there was another drug crisis in the eighties and nineties. The drug was crack cocaine, which hit Black communities hardest. Rather than empathy, though, we got this:

[clip of unspecifized speaker] This. This is crack cocaine seized a few days ago by drug enforcement agents in a park just across the street from the White House. 

Dr. Abdul El-Sayed, narrating: Drug use was criminalized, blamed on a lack of morals and harsh sentencing for things like possession and three strikes laws turned the crack epidemic into a mass incarceration epidemic. But when the opioid crisis hit us, it landed first in low income rural white communities, and the response was, to say the least totally different. Rather than criminalization, communities rushed to recognize drug use for what it always has been, a disease. And that’s a good thing. It’s just that it was such a contrast to the way that the drug crisis affecting mainly Black folks was treated. But as we discussed recently, it was only a matter of time until this crisis hit the Black community too. And what this data tells us is something many of us have already known. Our society still treats drug use differently when it’s among Black folks. How else do we explain the fact that Black folks with opioid use disorder are less likely to get medical treatment for their disease? It also speaks to the fundamentally broken way we provide health care in this country. The fact that Black folks are way less likely to have consistent health care throughout their lives and the ways that the health care system has earned the mistrust of Black folks both historically and continues to do so today. Drug use is a disease. People deserve treatment, not blame, no matter the color of their skin. 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 and pick up some America Dissected merch. [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. Vasilis Fotopolous 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, Michael Martinez and me, Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It is 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 hosts and his guests and do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.