Generational Learning

[Jaunty Guitar Music]

Mike: Welcome, everybody. This is Avoiding the Addiction Affliction brought to you by Westwords Consulting and the Kenosha County Substance Abuse Coalition. I'm Mike McGowan.

Mike: Numerous times over the past 200 plus episodes of this podcast, we've talked about the ongoing opiate epidemic. We've come at it from a variety of directions, and today we'll discuss some of the ongoing research designed to lower the catastrophic mortality rate.

Mike: My guest is Dr. Daniel Ciccarone. Dr. Ciccarone is a professor of family community medicine in the School of Medicine at the University of California, San Francisco. He is a recipient of numerous awards and honors for his work with addiction medicine, street drugs, particularly heroin and its many derivatives, and also for his work with the treatment and prevention of HIV, AIDS, and related diseases in socially marginalized populations.

Mike: Welcome, Dan, or Dr. Ciccarone, if you'd prefer.

Dan: Oh, Dan is fine. Thanks for having me on, Mike.

Mike: Well, thanks for doing this. We've talked about this a lot. It would be great if I could ever do a podcast and say, we're over the hump. But part of that is, is today I was listening to an NPR Morning Edition report that you were on.

Mike: The headline of the story is that overdose deaths are down for the first time in five years and that the fentanyl supply may actually be drying up. However, I think you would say it's not as simple as that, is it?

Dan: No, it's not. I mean, you know, at first blush, it's possible that we're over the hump. It's possible that overdoses are on a durable downward direction.

Dan: It's just not clear, you know, it's like the polls that we're going through today, you know, you don't know until enough time has passed to be certain that the decline in overdoses in 2023 is a durable event or not, or just a temporary event. It is certainly not simple. You put 10 experts like me in a room and we would have a grand conversation about the 10 different reasons why overdoses might be going down.

Mike: Well, okay. Let's do that.

Dan: (laugh) Let's call up all my friends and we'll get on a conference call.

Mike: Well, I don't want to be cynical, but when I've told people that we may be there, that overdose deaths are down, some of my colleagues have cynically suggested, well, maybe that's because everybody using it is no longer with us.

Mike: Ah, that's a little bit cynical, but that's certainly one of the possibilities.

Dan: You know it is a cynical notion and it's probably, if I had to choose one, it's probably the, unfortunately, the leading notion. And that is that if we think about the opioid overdose phenomena as a 24 year triple wave epidemic where pill overdoses led to heroin overdoses led to fentanyl overdoses.

Dan: And my research, both qualitative and quantitative, has really tied those three together. Those waves are not independent, those waves are connected to each other. So if we think of this as a triple wave epidemic, one notion that comes to the fore is that we can see this population as a cohort. That is a group of people moving through time, and the cohort is big.

Dan: It's hard to give an exact number, but some people will say anywhere from, you know, two to four million serious level opiate users or dependent, folks dependent on opiates of various sorts. That is a very big population. That's a historically large population. And there's a little bit of good news to this notion of a cohort.

Dan: The cohort is not growing, right? There's no, there's very little evidence that young people are coming into fentanyl at this late date. That's good news. But that also means that the cohort is dying at 70 to 100,000 people a year. And people are going into treatment, people are going into recovery, people are going down their own path to a recovery. So cohort is actually going down. And if the cohort is going down, and the drug supply, as risky as it is, hasn't changed in its risk then we're going to see less deaths. Now, I'll just remind everyone of a technical point here, and that is when the CDC, Centers for Disease Control, report overdose deaths, they're not reporting a rate.

Dan: Rate is where you say the number of problem over the number of population. The CDC doesn't want to admit to the size of the population of hardcore, let's just say, opiate users, and therefore only gives us counts. If your denominator, if your population is shrinking, then your counts are going to shrink, assuming that risk remains the same.

Dan: So that is the number one factor. There is another one that's sort of closely related and that is the effect of COVID. COVID accelerated a lot of harmful things in American society, including overdose, suicides and the like. And that we noticed, for example, with suicides, that that has reverted back to a normal lower level.

Dan: So 2023 could be a COVID mirage, what we call a regression to the mean phenomenon. I would say those are the two sort of leading ones. We could get into, you know, supply effects. We could get into some of the other the more positive notions of increased treatment, increased naloxone if you'd like.

Mike: Well, yeah, the supply effects, I think, are interesting since we're talking about on election day, and that's a huge issue everywhere. But it's really, if we're ever going to beat stuff like this, it's the demand side that's going to beat it.

Dan: Unfortunately, you know, there are a few people who understand drug supply from a public healthy notion, you know, how drug supply affects public health than myself.

Dan: And I can say both of this in the same breath that supply matters in terms of use patterns and dangerous patterns. And it is hard to control supply. And we've seen it time and time again. We have two generations of evidence that says that supply control works. It just doesn't work as well as we want it to.

Dan: And the best evidence in the negative is that the prices of drugs on an inflation controlled level have never been cheaper. Drugs have never been purer. The supply, no matter what drug you're looking at, whether it's the cannabis world or the stimulant world or the opiate world, the drugs are cheap, which means that our supply interventions are simply not working as well as we want them to.

Dan: So we have to reduce demand. We have to think about what it is about this triple wave epidemic that could have been prevented so that we can prevent it in the future.

Mike: Right.

Dan: And we have to think about durable systems of resilience that is getting young people to say no or to choose lighter drugs or lighter habits than more serious ones and we have to think about giving people escape routes into treatment and recovery and doing that in a very forthright and robust way.

Dan: Easy pathways that people can enter. Because right now there's still a lot of barriers and hurdles to go through and shame to go through and the like.

Mike: Well, let's talk about your cohort, your colleagues. I was reading a September 19th article in the New England Journal of Medicine that you wrote. You talk about the findings from the Healing Community Study.

Mike: Well, tell us about that research and the findings.

Dan: So, the Healing Community Study is one of the largest randomized controlled trials the government, you know, through the National Institutes of Health, NIH, has ever run. And long story short the findings of this randomized controlled trial, where they didn't randomize individuals, they randomized communities, they took 67 communities.

Dan: Pretty much like in the northeast quadrant of the United States, if you will. Randomized them to, we're going to promote more treatment, we're going to promote more naloxone, and we're going to look at things like prescription patterns to make them safer. And randomized with communities that they just observed, you know, and didn't intervene on.

Dan: And the final result was, no benefit, right? So despite millions upon millions of dollars. A very good idea. These are all evidence based ideas. Naloxone has a good evidence base. Treatment has a good evidence base. We saw no effect. The problem is that the trial happened during COVID. They lost a lot of time.

Dan: They only had nine months of follow up. That is just not enough time. They were overly ambitious in their statistics. And one thing I firmly criticized them on was being overly ambitious. And that's because it would have actually cost more money to do a randomized control trial where it should have been more like, I don't know, 120 communities instead of 67.

Dan: It's just a statistical phenomenon. And I think the NIH simply wasn't willing to do it to that level. So they had overly optimistic expectations. And then finally they gave the communities a lot of choice. And I think some of the communities maybe because of political affiliation, maybe because of their own sort of values they chose some of the weaker interventions.

Dan: They didn't say they were going to expand treatment by 20%. They didn't say they were going to expand naloxone by 30%. They chose some of the easier interventions. And then that's always a problem when you're dealing with communities and that you can't impose your will upon them and say, you're going to do this and you're not going to do this.

Dan: So those are the reasons why I think it failed and ironically, the communities that they looked at many of those states have had declines in overdoses in 2023. And so we're back to the original question of this conversation, and that is, what is causing overdoses to go down?

Dan: If this huge trial didn't cause them to go down what are the factors? And you know, it's probably going to take us a year or two to figure it out, to figure out what's working. And let's hope that 2024 doesn't go back up. The early signs of 2024 says it's on the same trajectory downward.

Dan: So let's hope that that remains true.

Mike: I'll come back to that in a second, because you and I have been around the block a couple of times, right? So we've seen cycles before.

Dan: Sure.

Mike: You talked about variables, COVID being one of them. You know, all of a sudden, other variables, like xylosine comes out of left field.

Mike: So it seems like there's always a new something coming around the corner.

Dan: Sure. We do know the drug cycle and we're probably seeing a grand cycle as it speaks. So as I mentioned earlier, there's new people are avoiding fentanyl and I don't have firm evidence for that. All I can tell you is circumstantial evidence that says that this cohort as we observe it, whether it's through emergency department visits or through deaths is getting older, which means there are substantial numbers of young people coming down to lower the average age, if you will. We do see an unfortunate uptick in adolescent and 20 something deaths, but it's nowhere near the level of use and problem that would keep this cohort alive and well for a while.

Dan: So fentanyl, believe it or not, does come to an end. I'll say here for the first time, fentanyl epidemic comes to an end. There's nothing about it that says this is a forever drug. And even if it is a forever drug, it won't be a forever drug at these levels. And that's because new people coming in are going to reject it.

Dan: It's too strong. It's too dangerous. It's not as much fun as some alternatives are. Even if that's all you're looking for is fun, fentanyl is not your fun drug. It's too dangerous. It's too harsh on the body. And people have learned that and they're telling their friends who are telling their younger cousins and nephews and nieces, you know, think of a different drug.

Dan: And so you do see cycles and what we're seeing now is this uptick, particularly in stimulants. Right, so methamphetamines taking off, cocaine is taking off again, both of which are widely available and relatively cheap and that is going to be the phenomena for 24, 25, maybe even going into 26.

Dan: Xylosine is a weird one It's a downer, like fentanyl, and so why that one's coming in, why is it adulterating the fentanyl supply, are still open questions. Some people like it, a lot of people don't like it. We're doing research on xylosine now, so you just have to call me in a year and I'll give you more answers. (laugh)

Mike: I'll do that. (laugh) Well, you know, I read another article on NPR and they were interviewing people, and I know you've worked with this population who were, looking for housing and living on the street and using. And I thought it was interesting. One of the gentlemen quoted said, well, we're just more careful.

Mike: You know, we all carry Naloxone. And that was a gentleman who was admitted to using fentanyl, not even as an, I mean looking for fentanyl. In other words, not looking for anything else. And xylosine at the same time. That's a little scary proposition though. It's not as easy as just carrying naloxone with you.

Dan: But I do think there is a learning curve, you know, so for example, we're seeing overdose declines that are happening more rapid and more robustly in the eastern states that had fentanyl four years later than the west coast states. So west coast states are more or less flat, maybe slight declines in 2023.

Dan: So I think there's a learning curve, you know, the people on the east coast are learning to deal with fentanyl. They know how strong it is. They have respect for it. Now, doesn't mean it's terribly less dangerous, but it's perhaps a little. People have adapted to it. We certainly have talked to lots of people in our ethnographic work who have been using fentanyl for years now, and they have a serious respect for the drug and know how to use it in a way that they don't overdose or they overdose in just to be blunt, you know, non fatal ways.

Dan: You know, they might have a small overdose, but not the big one. And people are carrying naloxone. You know, one of the theories is that by 2023 we finally have enough street level saturation of this life saving drug and that's because enormous efforts have been put into rolling out naloxone in many places.

Mike: What do you think is, you know, this is my third professional go around with opiates, right? We went through the, for lack of a better term, the "French Connection" heroin thing in the 70s and 80s, and then we went through the "China White" after that, and then it dips down. Now we're at the fentanyl, xylosine, whatever.

Mike: What do you think is, as it dips, you said cocaine and the stimulants, but what's the next thing on the horizon that you're worried about, concerned about?

Dan: Well, many of these drugs are coming in as adaptations, right? You know, we don't have a grand theory about cycles, but one of the theories has already been stated, and that is that the new people reject the drug and they just simply choose something else.

Dan: But one could look at xylosine as an extender of fentanyl, it makes it last a little longer. One could look at stimulants as a way as an adaptive response, and we've written a couple of papers on this showing that people are using it to actually protect themselves from the seriousness of fentanyl.

Dan: It kind of blunts some of the more serious downside of fentanyl. So it's not terribly surprising. We do know that cocaine comes in as a kind of booster laden opiate cycles. You know, the people start off with heroin and then they say the heroin is not good enough anymore. So they start adding cocaine and the speedball cycle.

Dan: So this speedball cycle that we're in, whether it's cocaine or methamphetamine, makes a lot of sense to me. Xylosine is a little bit of still of a head scratcher. But I think what's really be interesting is what are the young people using? And I don't, I don't have an answer for you today. I know people are looking into it, but and you know, some of the early suggestions are ketamine and other hallucinogenic like drugs, psilocybin, et cetera.

Dan: MDMA remains forever popular among young people. There's also a bit of good news and that if you look at the national survey data, the young people simply aren't using substances as much as we think they are. And whether that's a survey error or whether it's the truth is an interesting question, but, young people paying attention to this idea that substances are not necessarily the best way to have fun and not necessarily the best way to move through life. And so there is generational learning. And the opioid crisis is a, you know, a generational apparition. You know, people got addicted to opioid pills.

Dan: And there was a lot of diversion to the street where people had a grand party with them. And then the pills started to dry up and people segue over to heroin because it was cheaper and more available. Not everybody, but you know, it was a meaningful, but a small, but meaningful percentage of the population.

Dan: And then heroin became contaminated with fentanyl. So the lessons learned from that are. You know, don't allow legitimate supply of drugs to hit the streets, and you know, don't replicate that phenomenon of excessive prescribing and excessive diversion of legitimate products.

Dan: Legitimate products have a lot of cachet on the street because they're seen as safe, believe it or not. And then if you do that anyway, and that happens anyway, don't rapidly pull the supply back, right? That's sort of the, one of the more controversial conclusions that can come up with.

Dan: And that is that we pull the supply of pills back way too rapidly without protections in place to handle the consequences of that. And the consequences of that were more deaths from heroin and way more deaths from fentanyl.

Mike: Well, you've touched on it several times in several of your answers and your article certainly touched on funding, education, treatment, harm reduction.

Mike: Where do we spend our time, efforts and dollars? Like what's needed to stem the tide for good?

Dan: It's a good question. There has been a movement over the last generation or so to spend more money on demand reduction that would be treatment, recovery, resilience efforts for children to not go down this pathway.

Dan: But we still spend a lot of time on supply reduction, a lot of money on supply reduction. We still spend a lot of time criminalizing drug use and having a criminal justice system as an approach to the drug problem. The criminal justice approach to the drug problem definitely does not work.

Dan: It incarcerates a lot of black and brown people. It's incredibly prejudicial in the way it is acted out and it has nothing to show for it. It has no deterrence effect that'd be shown for it. It has no grand reduction in costs. It costs a lot of money. And so again, we go back to honest demand reduction, which says, you know kids here's ways to have a healthy nervous system that doesn't include drugs.

Dan: Or if you do use drugs, then here's a harm reduction approach that says, use them more safely. We need to have harm reduction for the people who are already caught up in cycles of drug use so that they don't acquire hepatitis C and HIV, that they get naloxone to help treat an overdose that they get their abscesses and other complications treated in an honest and compassionate way so that they don't distrust the healthcare system.

Dan: And they're willing to come in and say, okay, now I'm ready for treatment. And the only person I trust is you because you treated me like a human being last week, right? We need more of that. Right. And we just need open, open, open pathways to treatment and recovery. Recovery systems are relatively open but they need to be diverse enough so that they don't exclude people who don't like a certain religion or want a different kind of spirituality in their recovery program, so there needs to be robust diversity in the recovery movement.

Dan: And treatment just needs to be, I criticize my colleagues all the time for being so restricted. Oh, I'm only going to take this person under those conditions and they have to jump through these hoops and I'm like, stop it.

Mike: This many times, right?

Dan: We don't put barriers down for people with diabetes treatment.

Dan: We don't put barriers down. It's like, oh, this is your third heart attack. I'm not going to treat you anymore. Like, we don't do that in medicine. So why addiction does that? And again, this is all at margin. Most addiction doctors are wonderful, compassionate human beings and systems are improving year by year, generation by generation.

Dan: We just need more of it. And then finally, I'll just put a plug in that we need a bigger workforce. You know, we do need to convince medical students and other students to entering the health professions to be part of this program of making addiction medicine a big, robust, legitimate, you know, equal partner in the healthcare sphere.

Mike: Oh, that's a great place to leave it. And that sounds good to me, you're hired. So we'll put you in charge and then we'll just, let's follow the edicts. You know, I will comment on one thing you said there, which is when we criminalize it, it also, it doesn't just do something to the people who are then put in that situation, it stigmatizes the disease for everybody. Because you don't, yeah, you don't want to be one of those people, "those" people, right? And so then people don't go for help.

Dan: And there have been calls among some big names in my field to re-stigmatize drugs that we've gone too far in the opposite direction.

Dan: And I utterly, 100 percent disagree. Stigma does not help. It's actually the biggest problem we have in addiction. We need to be treating this like an ordinary disease. This is no different than diabetes. This is no different than high blood pressure. It's a mixture of genetics and environment. And in the environment, there's some elements of choice, but it's not like choice is the only thing.

Dan: One doesn't choose to get diabetes. One doesn't choose to get heart disease. One doesn't choose to get an addiction. Right? There are some choices that are made. Maybe those choices are regrettable. Maybe they can be turned around. But we have to have respect for the disease process, environment, and genetics.

Dan: And with that, we'd have a more compassionate approach. We would stop being like, you know, Marcus Welby in the 1950s TV show that said, you brought this on yourself. And he was talking about, you know, heart disease, you know we don't do that anymore. We welcome people in, we say, and if they've left treatment for a while and they come back, we don't badger them.

Dan: We say, welcome back. We're happy to see you again. How can I help you?

Mike: Right.

Dan: And that's because that like diabetes. It's a difficult thing for people to wrap their heads around, right? You don't just say, Oh, I'm so ready for insulin! Thank you so much! I'm, you know, most people are like, Oh, why did I get here?

Dan: I don't want this. I don't want the disease. I don't want insulin. I don't, it's not much different in addiction. People have to get adjusted to the diagnosis. They have to get adjusted to the treatment plan. And if it takes a third attempt or sixth attempt, so be it.

Mike: Right. Great place to leave it.

Mike: Dan, not only thank you for the podcast, but thanks for your work. It's so important. Really appreciate it.

Dan: I really appreciate that, Mike. Thank you so much, and thanks for having me.

Mike: Yeah, and for those of you listening, you're always welcome to listen at any time you're able. Until you're able to listen again, stay safe and live well.