Jeffrey A. Singer joins us this week to talk about the ongoing opioid overdose epidemic in the United States. Why are there so many opioid users in the US?
Specifically, what kinds of drugs are we talking about, fentanyl? Oxycontin? Is the overdose death problem a direct result of doctors over-prescribing opiates to patients for pain management?
Show Notes and Further Reading
Here’s a Cato briefing event that features Singer: “A ‘Modern Plague’? How the Federal Government Should Address the Opioid Crisis.”
”Misdiagnosing the Opioid Crisis”; this article appeared in Inside Sources on September 27, 2017.
Trevor mentions Jacob Sullum’s book Saying Yes: In Defense of Drug Use (2004).
Listeners may also be interested in our Free Thoughts episode with Johann Hari, “Chasing the Scream: The First and Last Days of the War on Drugs.”
Trevor Burrus: Welcome to Free Thoughts. I’m Trevor Burrus. Joining me today is Dr. Jeffrey A. Singer, a general surgeon in private practice in metropolitan Phoenix, Arizona, and principal and founder of Valley Surgical Clinics, Limited. He’s also a Senior Fellow at the Cato Institute. Welcome to Free Thoughts, Jeff.
Jeffrey A. Singer: Happy to be here.
Trevor Burrus: Is there an opioid crisis?
Jeffrey A. Singer: I don’t like to use the word “crisis” because [00:00:30] it creates this whole atmosphere of panic. There’s a problem with too many people dying from opioid overdoses. And there’s also been a change in the mix of the type of opioids that are causing these deaths. Of course, it’s always worrisome to see that year after year there’s an increase in the number of people dying from overdose deaths, so it’s a problem. But, I don’t like to use the word “crisis” because [00:01:00] every time our policy-makers react to a crisis they usually overreact and they don’t think things through, and all of their reactions tend to create a whole new set of unintended consequences that eventually, make it into a crisis.
Trevor Burrus: Maybe that’s how we are. But, when we talk about opioids. Opiates? Opioids. Is there a, we use both of those, sometimes.
Jeffrey A. Singer: Yeah.
Trevor Burrus: I’ve heard that, I think, opioids include synthetics.
Jeffrey A. Singer: That’s right. Yeah.
Trevor Burrus: Yes. But we’re talking about [00:01:30] pills that doctors like you prescribe, like OxyContin, for example, and also heroin, and everything in between. I don’t know if those are the two, fentanyl, I guess would be maybe, the outlier.
Jeffrey A. Singer: Well, fentanyl is used medically. Most of the time the type that is used on pain patients is actually, a patch. Fentanyl’s about 50 times the strength of morphine, and so it’s made in these [00:02:00] patches that allow it to be slowly absorbed over about 72 hours. A brand name for that, people may have heard of is called Duragesic. So, you prescribe, let’s say, a 25 microgram patch of fentanyl, and it’ll last somebody for a couple of days.
It’s also used by anesthesiologists in the operating room intravenously because it gets the person anesthetized. It’s that powerful. It’s not prescribed in the outpatient [00:02:30] setting in any form other than the skin patch. So when you hear about reports in the news about people who are dying from fentanyl overdoses, they’re not taking these skin patches and somehow figuring out a way to scrape the fentanyl off of the surface of it and convert that into something suitable for injection. This is fentanyl making its way into the country in the illegal market.
Trevor Burrus: What about OxyContin? What [00:03:00] is that?
Jeffrey A. Singer: Well, OxyContin is long-acting, controlled-release oxycodone. Oxycodone actually, has been around for many years. It’s an oral opiod that was invented in 1916. And then in the mid 90s a long-acting form was developed so that you could take it, and it could last, let’s say, 12 hours as controlled-release. In order to do that, the capsule is made in such as to have actually, [00:03:30] more oxycodone in it, so it could release more of it slowly over a period of time. That’s what made it very popular for people who wanted to recreationally use opioids, because if you can get a hold of an oxycodone tablet and get the ingredients out of it, you can get a lot more oxycodone out of it than if you just got an oxycodone capsule. So, when OxyContin came on the scene, [00:04:00] that became probably one of the most popular opioids for people who are recreationally using opioids to try and get a hold of, because you got more bang for your buck.
Trevor Burrus: But, you would prescribe that for people with chronic pain?
Jeffrey A. Singer: Usually. It’s for people who you know are gonna be needing a strong opioid for a long period of time. For a short duration, such as a patient who just had, let’s say, an outpatient surgery, oxycodone or hydrocodone, also popularly [00:04:30] known as Vicodin, is usually what you need, because a person’s not gonna need it for more than maybe, 5 to 10 days, whereas-
Trevor Burrus: Is that like getting your wisdom teeth out or something like that?
Jeffrey A. Singer: Yeah, yeah. Whereas, if you’re gonna give it to somebody who you know is gonna be on pain long-term chronically, then if you could give them something that lasts longer so they don’t have to take it as frequently, and you know they’re gonna be taking it long-term, that’s more practical, OxyContin is more practical for something [00:05:00] like that.
So, what happened was, because, first of all the narrative that everyone has bought into, and this is very frustrating to us practitioners, is that the opioid overdose death problem is a direct result of doctors prescribing pain medicine for patients. So, the popular notion is that I’d write a prescription for an opioid for my patient for pain, my patient becomes [00:05:30] a drug addict, and then starts resorting to all sorts of illegal behavior in search of the drug. He becomes a dope fiend, and then he eventually overdoses and dies.
That is not what’s going on. In fact, the data shows, even, I’m talking government data, the National Survey on Drug Use and Health, showed that a non-medical opioid use, so that’s recreational, peaked in the year 2012. [00:06:00] And total opioid use actually peaked in 2014. And according to the National Survey on Drug Use, only about a quarter of people who are overdose victims, even have obtained any sort of prescription for an opioid. And of course, that doesn’t necessarily mean they actually got it directly from the doctor. They could have, could have been a stolen a prescription, it could’ve been that they were doctor shopping and malingering in order to get pain medicine.
But the point is, that at least 75% [00:06:30] of the people who are overdose patients are people who are using opioids for non-medical purposes in the illicit market. So, I’ve been trying to point out that the source of the opioid overdose death problem is drug prohibition. Because when I go into the supermarket or liquor store to buy a bottle of liquor and I see on the label it says, let’s say, ” [00:07:00] 80 proof,” or “15% alcohol,” the thought never crosses my mind that it may not be that, that it could be adulterated with all sorts of impurities or laced with something that could kill me. I believe what it says on the label, because it’s legal, and in the legal market.
Number one, they have competitors and number two, I have recourse if I’ve been defrauded and injured. [00:07:30] But, when were dealing with the illegal market, you go to somebody in a subterranean way who says, “Yeah, I have what you want.” And you don’t know if it’s the dose, you don’t know if it’s pure, that’s what’s happening. In fact, what we’ve learned, because of the narrative that it’s a doctor’s prescribing, since about 2010, 2011, all of the policies of both the federal government and the state governments have been aimed at curtailing the amounts of opioids prescribed.
So, [00:08:00] we just heard this past July, the CDC reported that for the seventh consecutive year, prescriptions of opioids by healthcare practitioners have come down. And in the meantime, the DEA, Drug Enforcement Administration, actually controls the amount of opioids that can be manufactured. So, in 2016, they ordered a 25% reduction in opioids manufactured. And they’ve asked for another 20% reduction for this year.
So, we got the amount of opioids [00:08:30] being prescribed is down, the amount of opioids being manufactured is down. In addition, now all 50 states have what they call prescription drug monitoring programs, where they’re surveilling patients and doctors, doctors prescribing and patients using, opioids. And the idea is, and it’s successful in doing this, is it casts a chilling effect. It makes doctors feel like when they’re being watched, that they really, it makes them cut back on their prescribing, even if they have [00:09:00] no doubts that they were doing the right thing by prescribing it, just because they feel like they’re being watched and they don’t want to get into trouble.
So, they don’t want to be outliers, as they say. So, all of these things have teamed up to cut back on the supply. And what’s happening? The death rate’s going up. Isn’t that interesting? So, that would make most people, I would think, wonder, “Gee, maybe it’s not a matter of doctors prescribing opioids, because we’re stopping that and deaths are going up.”
The other thing that has been happening is, [00:09:30] the mix of the opioid deaths has changed, whereas it used to be the majority were from prescription-type opioids, now the majority is from heroin. And in the last year, the amount in 2015 numbers, over 4,000 Of the 32,000 opioid overdose deaths were from fentanyl. The year before it was 2,000. So, that doubled. They’re projecting that the 2016 numbers, which come out in December, are gonna be even [00:10:00] worse, even more heroin, which is now the predominant cause of death, and fentanyl. Now, like I say, fentanyl is bad news, [crosstalk 00:10:08]
Trevor Burrus: From a recreational standpoint.
Jeffrey A. Singer: Fentanyl is super-powerful. And here’s another irony, a lot of people, they have this, there’s this myth out there that heroin is so dangerous and so evil that, take one hit of heroin and you’re hooked for life.
Trevor Burrus: I grew up believing that. I was taught that in D.A.R.E.
Jeffrey A. Singer: I was taught that, too. But the fact is, heroin is [00:10:30] nothing other than diacetyl morphine. That’s the chemical name. It’s just a modified morphine. The generic name is diamorphine. It was invented by the Bayer company in Germany in the 1890s. And they named the brand heroin, which I understand comes from the German word “heroisch,” which has something, I don’t speak German. It has to do with meaning that it’s more powerful, stronger, than morphine, which it was. It’s about 2 1/2 times the strength of morphine. [00:11:00] Dilaudid, which is perfectly legal in this country, and in fact, routinely in patients for whom morphine is not doing the job of controlling the pain, then we step it up and go to Dilaudid. Dilaudid’s about 5 to 7 times more powerful than morphine. So, it’s twice as powerful as heroin. That’s legal. And of course, fentanyl’s, I guess, 50 times more, 5-0, 50 times more powerful.
Trevor Burrus: So, you think that doctors, you’re talking about [00:11:30] Dilaudid as mostly used in hospitals, correct? [crosstalk 00:11:34]
Jeffrey A. Singer: It’s available in oral form and we’ll prescribe it for patients too, as well.
Trevor Burrus: Do you think that there would be people using heroin in the hospitals and prescribing maybe, a pill form if it were invented, if heroin were not prohibited? Heroin would be available to doctors as one of those things-
Jeffrey A. Singer: It is, in the rest of the developed world.
Trevor Burrus: Oh, okay. So it’s not even just fantasy land, it is the real world?
Jeffrey A. Singer: Yeah, it’s called diamorphine. [00:12:00] That’s the generic name. So, they don’t use the word “heroin.” In 1924, that equivalent of the drug czar, the head of the Bureau of Narcotics at the time, became persuaded that heroin corrupted morals, unlike morphine. It was morally corrosive. So, he asked for Congress to completely ban it. And within about 10 years, the number one opioid [00:12:30] to which people were addicted became heroin. And economists would have predicted that because, what would you rather push, something that is totally banned or something that you can find another way to get it?
So, meanwhile, that didn’t happen to other countries. So, since the 1920s, in the UK, diamorphine as they call it, that’s available. It’s very controlled, but it’s used for controlled pain patients, terminal cancer patients. And in fact, since the 1920s, [00:13:00] they have been, they’ve had heroin maintenance therapy programs for heroin addicts in the UK. It really formally developed as a project in Switzerland in 1994, but on a small level, heroin maintenance therapy had been underway in the UK since 1920. So, there are many countries, in fact one of my colleagues in my medical practice is an immigrant from Singapore. He trained in Singapore. And he was telling me how very strict [00:13:30] the drug laws are there. I think he said you could go [crosstalk 00:13:33]
Trevor Burrus: Oh, they’re really, really-
Jeffrey A. Singer: … to jail for life if you’re found in possession of marijuana.
Trevor Burrus: Yeah, marijuana. You can’t chew gum there, you definitely can’t smoke weed.
Jeffrey A. Singer: Yeah, so I said to him, “Yet, you guys prescribe heroin for your patients in the hospital.” And he, I was teasing him. He didn’t know that, so he looked at me like, “What, are you crazy?” And he said, “Heroin? What are you talking about?” And I said, ‘Oh, maybe I was wrong. I thought you used diamorphine on your severe [00:14:00] pain patients in the hospital?” And he said, “Oh, yeah, we use diamorphine. That’s heroin?” “Yeah, heroin’s just a brand name.”
So, that’s the point. The point is that, we just arbitrarily decided because of the totally unsubstantiated suspicion that it corrupts moral character, to ban heroin. There’s no reason why if one hit of morphine for your post-surgical pain, or one hit of Dilaudid doesn’t cause you, or a fentanyl patch doesn’t cause you to immediately become a [00:14:30] drug addict, why would something that’s basically, the same [crosstalk 00:14:33]
Trevor Burrus: There on the same spectrum.
Jeffrey A. Singer: Why would it be any different? And of course, there’s evidence going back decades of people who are true recreational heroin users, lead a perfectly normal, happy, productive life, and occasionally engage in heroin use for their own, because they want to-
Trevor Burrus: Recreational.
Jeffrey A. Singer: … for recreational uses. And they don’t become addicts. And that’s been well documented in the medical literature. But these [00:15:00] are the myths. And unfortunately, these myths are influencing the policymakers.
Trevor Burrus: In terms of recreational use, you don’t actually, I hadn’t thought about it that way, but you don’t hear much about recreational use of morphine or Dilaudid, even though they give you many of the same effects, if not more, of heroin. Fentanyl has been coming in, but mostly in adulterating heroin supplies. But, because morphine and Dilaudid are controlled and legal, [00:15:30] it seems that, that’s the reason why heroin is easier to get, would you agree, because it’s not, it’s illegal.
Jeffrey A. Singer: Yeah, according to the CDC, Thomas Frieden, back a few years ago, he said that the street price of heroin was about a fifth of the street price of prescription opioids. So what’s happened is, I mean, I’m aware of people, I even know people on the personal level, who tell me and have shown me actually, that they keep a [00:16:00] little stash of Vicodin. And every once in a while, they, just like, I like to have a cocktail at the end of a long stressful day before dinner just to relax, they like to take a Vicodin. I even have told them, “I don’t think that’s an ideal thing, if you want to relax.” Well, they like it. They take a Vicodin, maybe once every week or so. And then they keep it hidden in their drawer because they didn’t get that by getting a prescription from a doctor. They got it somewhere. But in any case, [00:16:30] that’s the way these things are, that’s what we see.
Trevor Burrus: When we go back to the doctor prescriptions, people might be thinking, “Oh, Dr. Singer is definitely downplaying this, but the numbers are shocking and the maps are shocking. And you look at states like New Hampshire, or you have some counties with addiction rates that are unbelievable, never seen the level of overdose deaths.” And it definitely was true that starting in the 90s with drugs like OxyContin, [00:17:00] doctors were prescribing more opiates than before, correct?
Jeffrey A. Singer: Yeah. Well, first of all, I remember, because I’m old enough to remember, when I graduated medical school, that was at the height of the war on drugs. So, it was actually drilled into us as medical students that, “Drugs are evil, drugs are bad, narcotics.” So, most of the prescribing habits of me and my peer group were very restrictive. So, we were really [00:17:30] stingy with the pain medicine. Then around the end of the 80s, early 90s, a lot of articles started appearing in the medical literature and a lot of people started speaking out about what was then be called, came to be called “opiophobia,” where we were afraid to prescribe opioids irrationally.
And patients were voicing, patients were afraid to take it when I’d prescribe it. They tell me they’re in pain, I give them a prescription for an opioid, and they won’t take it because they’re afraid to become an addict, because of [00:18:00] what we’ve all been indoctrinated into believing. So, anyway, in the early 90s, we were basically exhorted to loosen up, be more compassionate, don’t be so afraid of the opioid, take care, your patients are in pain needlessly. And so, we changed our prescribing habits. So, as we changed our prescribing habits, obviously, more opioids got into circulation. And if more opioids are in circulation, there are also [00:18:30] more opioids that can get what they call in the narcotics, in the drug enforcement business, diverted. Prescription pads could be stolen.
Trevor Burrus: Or just sold by the person who got the prescription.
Jeffrey A. Singer: Right, medicine cabinets can be raided, whatever. So, the fact that more opioids were being prescribed would lead you to think that more opioids are available for whatever purposes you want, including recreational purposes. [00:19:00] Then, when we started to see this increase in the number of people dying from opioid overdoses, the government responded by getting restrictive. There’s a lot of other ways, for example, in 2010, Purdue, which is the manufacturer of OxyContin, came out with what they call an abuse-deterrent formulation, because the people who would use OxyContin recreationally, like I said, has a higher concentration of oxycodone, so they’d either [00:19:30] crush it and snort it, which was popular, or they’d dissolve it and inject it.
They came out with a formulation that couldn’t be crushed. And if you tried to liquefy it, it became this gel that was not suitable for injection. And within, and of course, they patented that, and then within about six months, they replaced all OxyContin that was out there with this abuse-deterrent formulation. The FDA encouraged that, and they have guidelines [00:20:00] where they’re, and policies where they’re encouraging pharmaceutical manufacturers to come up with abuse-deterrent formulations.
Now, a couple of things to keep in mind. Number one, the pharmaceutical companies love this, because this provides an opportunity for them to evergreen their patents. Because the abuse-deterrent formulation gets a new patent and comes sometimes, very conveniently at the time when generics are starting to cut into their profits, because their patent on the original OxyContin wore off. Well, now, [00:20:30] all of the competitors making generics, they can’t make the abuse-deterrent formulation until that patent wears off.
So, that’s why the pharmaceutical companies are very happy to comply and try to come up with new abuse-deterrent formulations. I can’t blame them. But, we’ve seen other things occur, which is, if you’re trying to access this on the recreational, first of all, when I prescribe oxycodone or OxyContin for my patient, I know that they take [00:21:00] it with a glass of water. I don’t have to say to them, “By the way, don’t crush this and snort this.” They never intended to. It never even crossed their mind, because that’s the setting that we doctors prescribe it in. So, we’re talking about people trying to use recreationally.
So, what happens is, when they find that they can’t use it that way, they just go on to something else. And that’s exactly what’s been happening. Moving on to more cheaply available and easier to use heroin, or heroin laced with fentanyl. [00:21:30] In fact, a study came out in June of this year, economists at Notre Dame University, it’s a national economic research working paper, and they studied the substitution of heroin for OxyContin, starting with the appearance on the scene of the abuse-deterrent formulation in 2010. And interestingly, they found a one-to-one substitution.
Trevor Burrus: Really?
Jeffrey A. Singer: [00:22:00] Yeah, so, as OxyContin became abuse-deterrent, then everybody moves over to heroin and that’s all. Meanwhile, some state legislators unwisely are encouraging, or actually passing laws requiring insurance companies to cover the abuse-deterrent form. And what they’re trying to do also is encourage to replace all of the generics that are out there, and all of the non- [00:22:30] abuse-deterrent forms with abuse-deterrent forms.
Well, like I said, getting back to the evergreening of patents, that means that people who are paying out of their pocket for pain medication, because they’re in pain, suddenly are paying more than they have to, because the only product available is this newly-patented abuse-deterrent form, they can’t buy the cheaper generic. In addition, by requiring the health insurance companies to cover it, because in many states, the health insurance companies will only cover the generic, not the abuse-deterrent form. But by passing laws [00:23:00] requiring them to, you’re raising the cost to the insurance company, which, of course, makes the premiums go up.
Trevor Burrus: I’m unclear. Are you against the abuse-deterrent form? Do you think that that was, you said the numbers and it might have pushed people into heroin, but, so you think overall it was bad that they had the abuse deterrent forms?
Jeffrey A. Singer: Well, let me put it this way. There are several studies besides this Notre Dame study showing that it tends to make people just substitute. It’s sort of like, you push in a balloon on one end and the air comes out [00:23:30] another. I just think that, I’m sort of, ambivalent about abuse-deterrent forms. If you want to manufacture an abuse-deterrent form, make it available on the market, fine. I don’t think that the FDA should be promoting it, encouraging it. I think they should take a neutral position. Go ahead and do it if you want. Keep that, maybe let the consumer and the prescribing doctor decide on a case-by-case basis.
If he wants [00:24:00] to prescribe the abuse-deterrent form, maybe the practitioner’s got a little concerns about a patient that he’s wondering if this patient’s really in pain, maybe the patient’s trying to doctor shop to get some drugs for recreational use, so the doctor decides, “I think I’m gonna prescribe the only abuse-deterrent form for this guy.” That should be on a case-by-case basis. I just don’t think that we, as a matter of policy, should be encouraging that abuse-deterrent forms replace [00:24:30] the regular forms. And also, we shouldn’t be forcing insurance companies to cover it, because it’s just adding to the cost of health insurance.
Trevor Burrus: Let’s talk about the doctors, here. Is there a fear now amongst doctors about prescribing opiates because the DEA might come after you?
Jeffrey A. Singer: Oh, absolutely, yeah. Especially-
Trevor Burrus: Do you know, is this so common that everyone knows someone? Are they really going after doctors? Because this idea of doctors as pushers [00:25:00] is quite prominent. And it’s gotta be true though, that some doctors probably are some bad apples, right? Some doctors are pushers, right?
Jeffrey A. Singer: Yeah, I don’t think everybody knows someone. I don’t know any. We’ve all read stories, There are certain places that were hotbeds of this, like in Florida. And we see these news reports. So, we are all aware of it. I can tell you the overwhelming majority of doctors, just like in every other field, are ethical people who want to do the right thing. There’s always going to be [00:25:30] some bad apples in every field. You can’t have a perfect world. And you shouldn’t design policy based upon the exceptions to the rule.
Trevor Burrus: We had pill mills. That was a real thing. Maybe it still is, I’m not sure.
Jeffrey A. Singer: They’ve kind of, they’re disappearing, because of these guys being arrested for pushing basically, without, there were some dishonest doctors who are always writing prescriptions, and clearly, [00:26:00] basically, with drug dealers using their medical licenses drug dealers. But that’s the exception. What concerns doctors is for example, in my state of Arizona, we have a prescription and drug monitoring program that’s been in effect since 2011. And every quarter, I get a report from the State Board of Pharmacy telling me how many prescriptions I wrote for various categories of narcotics in the last quarter and [00:26:30] placing me on a graph with respect to my colleagues in my specialty. And then it labels me either “normal, outlier,” or “extreme outlier.” Now, interestingly, and we’ve all noticed this, all my colleagues, it tells you the number of prescriptions written, but it doesn’t have it broken down by the number of patients. So, if you happen to have a busy practice, you’re going to write more prescriptions. That doesn’t necessarily mean-
Trevor Burrus: Per capita.
Jeffrey A. Singer: [00:27:00] Yeah. It doesn’t have it down that way, it just has my number of prescriptions.
Trevor Burrus: Well, that’s weird.
Jeffrey A. Singer: Yeah, it is. So, meanwhile, one thing for sure is, you don’t want to be an outlier, because even though technically, it says in the report, “This is just for your informational use, so you can see where your practicing pattern is with respect to your peers in your specialty, and use it wisely.” That sort of thing. But you’re always in the back of your mind, “They’re watching me.” One thing I don’t want to be [00:27:30] is on a list of outliers. So, everybody who’s, we talk at the coffee machine, the water cooler in the doctor’s lounge. Everybody’s saying that they’re very nervous about this [crosstalk 00:27:42].
Trevor Burrus: Outlier, yeah. Let’s take a step back to the bigger issues on this, because we were talking before we started recording about Jacob Sullum saying “Yes.” And then the sort of, positive aspects of drug use. I think that in order to really look at this crisis, I’m putting [00:28:00] that in scare quotes, and think about it the right way, we have to first understand in a way that it seems a lot of people attacking the opiate thing and saying, “We have to stop this,” first understand that these drugs do a lot of good for people.
Jeffrey A. Singer: Right.
Trevor Burrus: We have to look at the other side that yes, there might be addiction on a higher level, because suddenly people who are in pain, they have access to things that take them, take the pain away or at least mitigate it to some extent, [00:28:30] which is the most of the use of this. It’s doing a lot of good, correct?
Jeffrey A. Singer: Right. And this is not obviously, gonna be the official party line of the medical profession, but now speaking as a Libertarian physician, it’s important to bear in mind number one, addiction is actually on a molecular level, a particular behavioral health disease. Not everybody becomes addicted. There’s a difference, first of all, between becoming chemically [00:29:00] dependent on a drug and addicted to a drug. If you become chemically dependent, obviously, you experience withdrawal symptoms when the drug’s taken away, but once you overcome that, you’re done.
Example is when you have a hangover after having a lot of alcohol the night before. That hangover is actually a form of withdrawal from the alcohol. And that’s why a lot of people will tell you, if you have the hair of the dog that bit you, you have a Bloody Mary, it gets rid of the hangover. Sure, because you just gave yourself some more of the chemical. [00:29:30] So, that’s one thing, whereas addiction is different. Addiction, you’re thinking about the next dose while you’re receiving this one. You’re craving the substance, even when you’re withdrawing in detox you go back to it. That’s why you see a high recidivism rate among narcotics addicts or alcoholics who have been detoxed from their substance.
Trevor Burrus: So, [00:30:00] you wouldn’t call diabetics on insulin addicts?
Jeffrey A. Singer: No.
Trevor Burrus: They would be chemically dependent?
Jeffrey A. Singer: They’re chemically dependent, though, because they’ll get-
Trevor Burrus: Yes, but they’re not addicts, because [crosstalk 00:30:12]
Jeffrey A. Singer: They’re not addicts.
Trevor Burrus: Because they don’t have the, they don’t, I mean they have, if you took it away they might rob a convenience store to go get it, right?
Jeffrey A. Singer: If you took it away, they’ll probably go into-
Trevor Burrus: Insulin shock.
Jeffrey A. Singer: Yeah, diabetic [crosstalk 00:30:23].
Trevor Burrus: But you know what I’m saying, if you took it away. Or, here’s one, benzodiazepines are very addictive, from what I understand.
Jeffrey A. Singer: You can get addicted to [00:30:30] that, yeah, for sure.
Trevor Burrus: And people take those consistently. And there’s that distinction, really, so you seem to be describing addiction as like-
Jeffrey A. Singer: No, because one is a behavioral disorder and one is more of a physical condition.
Trevor Burrus: But you could have that physical condition and then behavior disorder with it.
Jeffrey A. Singer: Absolutely. You could be addicted and dependent. But there’s an addictive behavior. So, that’s why some people, regardless of what substance they’re taking, they can have a tendency, and it’s kind of, built into the genetics, they could have a tendency to become addicted to the substance. Whereas the [00:31:00] majority of the population doesn’t, which is why you’ll see documented episodes of people using substances like heroin, cocaine, other substances that have a record of getting people addicted, and they use them regularly, recreationally, without any addiction problems, because they don’t have that biological condition that gives them this behavioral disorder.
Trevor Burrus: Going back to what I was, on the question, so some [00:31:30] of these long-term pain sufferers, they have benefits from this.
Jeffrey A. Singer: Right.
Trevor Burrus: Do they become at least chemically, dependent? [crosstalk 00:31:42] But it seems like if they’re really in pain, it could be worth it.
Jeffrey A. Singer: Right, and that’s the whole idea. That’s why we see commonly, people are maintained for years on things like OxyContin, or long-acting control release morphine pills, for their pain. So they are chemically dependent. [00:32:00] If they don’t get their pill within a certain period of time, they start getting withdrawal symptoms. And also, their pain gets severe. But, that’s the trade-off. [crosstalk 00:32:11]
Trevor Burrus: That’s not necessarily a bad thing.
Jeffrey A. Singer: Right. In fact, opioids, as opposed to a lot of other chemicals, are relatively safe. Alcohol, long-term use can kill the liver, the pancreas, the brain. It’s related to certain cancers. Opioids, aside from causing constipation, because it slows down the gut, [00:32:30] there’s been really no-
Trevor Burrus: Demonstrated long-term effect?
Jeffrey A. Singer: Demonstrated, yeah, organic damage that it can cause. Which is why we are comfortable having people on methadone maintenance indefinitely. Methadone is about the same strength as heroin. It was invented during-
Trevor Burrus: It is?
Jeffrey A. Singer: Yeah, it was invented during World War II.
Trevor Burrus: Why is it supposed to be a substitute for heroin? What’s better about it?
Jeffrey A. Singer: Well, because when you take it orally, it gets absorbed from the gut. It levels that bind with your opioid receptors enough so you won’t experience withdrawal [00:33:00] symptoms [crosstalk 00:33:02]. Because, the whole idea here, is you’re not allowed to enjoy it.
Trevor Burrus: Okay, yes, of course.
Jeffrey A. Singer: So, that’s-
Trevor Burrus: That’s the problem. It corrupts the morals. Isn’t that what they said in 1924?
Jeffrey A. Singer: Yeah.
Trevor Burrus: Yeah, exactly.
Jeffrey A. Singer: And the idea behind methadone maintenance is that you get used to not, it’s sort of, behavior modification. You’re blunting withdrawal symptoms, but you’re getting used to not feeling the high. And [00:33:30] then it’s hoped that over time, you can be tapered off the methadone. And now you don’t crave the high anymore, and you’re over your addiction problem. That’s the idea behind medical-assisted treatment, whether it’s methadone or Suboxone or others. But, getting back to your earlier point, I would argue as a libertarian, if a person is getting pleasure out of the mind-altering characteristics of a particular drug, whether it’s [00:34:00] opioid or mushrooms, or LSD-
Trevor Burrus: Or Xanax?
Jeffrey A. Singer: Or Xanax, yeah. I mean, or marijuana, or Jim Beam, as long as they’re not in any way directly threatening my rights or safety, to each his own. Who am I to say that, that person is wrong? That person has a right to, they are [00:34:30] obviously deriving a pleasure, so there’s a value in it for them. If they have a relationship with a substance that is self-destructive and has become irrational, well then, they’re probably suffering from the addictive behavioral disorder. That’s a different story.
Trevor Burrus: Can you, as a doctor, prescribe an opiate to someone merely to satiate their addiction problems? If you know they’re an addict and they don’t have pain, are you allowed [00:35:00] to prescribe an opiate to them so they don’t go through withdrawal symptoms?
Jeffrey A. Singer: That’s where I get into, I could get into trouble, because I’m being watched by my prescription drug monitoring program. First of all, when I write a prescription for an opioid, there has to be a reason why I’m writing the prescription in my medical records. I have to have a diagnosis. And the diagnosis can’t be that he doesn’t want to go into withdrawal.
Trevor Burrus: But, that’s an interesting distinction, right? And I’m actually doing work on it right now, because this has been a fight [00:35:30] for a very long time, since the Harrison Narcotics Act of 1914, that we are to make a distinction, first of all, the distinction between medicine and dope, an illicit drug, is not exactly clear, obviously, as we talked about with heroin. But also, this question of, “Why isn’t withdrawal a sort of, disease, a medical problem that you can alleviate as a doctor?”
Jeffrey A. Singer: I’ve said that. In fact, when [00:36:00] I gave that hill briefing for the Cato Institute back in June, I remarked to the group, “It’s okay for me to have a person on methadone maintenance. Why can’t I have them on OxyContin maintenance?” In fact, pain specialists do have people on OxyContin maintenance, but they’re doing it-
Trevor Burrus: With special permission?
Jeffrey A. Singer: Well, they’re treating pain. They’re pre-treating a diagnosis of pain. They’re not treating the chemical dependency. It’s a fine line, right? Obviously, the patient who’s a [00:36:30] chronic pain patient, when he starts to withdraw from the OxyContin, he develops worsening pain and withdrawal symptoms. But, he’s being treated for his pain condition, not for his chemical dependency, officially. Officially, I’m talking about here. Listeners can’t see the sarcastic look in my face while I’m talking.
But, I would argue, if it’s okay, if the government gives permission to doctors to prescribe Suboxone for people who [00:37:00] are addicted and don’t want to go into withdrawal, or gives permission for methadone maintenance clinics to be established, and there is a rigorous application process and all that, that you have to go through. But let’s say, it does give permission for that. So, it’s kind of arbitrary. The only difference between methadone and OxyContin is a couple of molecules. That’s it. They’re all in the same category of drug. They all have the same long- [00:37:30] term lack of deleterious effects on the organs.
Now, some are more beneficial than others, if you’re trying to do a substitution, just because of their nature. For example, studies suggest, the jury’s still out on this, but a lot of studies suggest that methadone is more effective than Suboxone because it binds to more of the opioid receptors [00:38:00] than Suboxone does. So, it gives a more complete satiation, sense of satiation than does Suboxone. A lot of studies have suggested that more people stay on methadone maintenance than stay on Suboxone programs. They tend to, has more of a, a smaller retention rate than does methadone. So, each of these opioids has different characteristics that make one be more advantageous than another, but they’re all [00:38:30] basically, the same kind of chemical.
Trevor Burrus: And that’s why the word is super-interesting, when you hear people talk about, “We have to stop these addicts,” or something like that. They’re using “addicts.” And so, that’s a word that makes people think of bad people.
Jeffrey A. Singer: Yeah, addict’s a vice.
Trevor Burrus: Addict addiction is a vice. And it seems to me that we can’t ever really deal with this “opioid crisis” until we accept the fact that it’s okay for some people to be addicted to opiates. I mean, in general, [00:39:00] we accept that for nicotine, to some extent. We accept that for, I get headaches if I don’t have coffee.
Jeffrey A. Singer: Yeah, we jokingly say, “I’m addicted to coffee,” or, “I’m addicted to chocolate.”
Trevor Burrus: Exactly.
Jeffrey A. Singer: These things are actually true things.
Trevor Burrus: Can people be contributing members of society, which is, I’m rolling my eyes when I say that, because I find that to be a very loaded phrase, but can people be contributing members of society and be opiate addicts?
Jeffrey A. Singer: We see it all the time. First of all, we see it with alcohol, [00:39:30] very commonly in the workplace. I’m sure we all know of people that we suspect might have a drinking problem. Maybe they show up for work and they smell from the alcohol, or when we do get together socially, they tend to drink a lot. But they show up for work, we don’t ask questions. They perform well. And we don’t see them drinking on the job. So, we just mind our own business. We see that all the time.
But even with opiates, in fact, my specialty’s iconic figure, [00:40:00] William Halsted, he was considered the Father of American Surgery. He was professor of surgery at Johns Hopkins, and created the residency program as we know it today. He invented a concept, many of the earliest major operations were designed by him. To this day, there’s the Halsted Technique of this, the Halsted Technique of that. I mean, he’s a historic figure. He was a morphine addict. Originally, he was [00:40:30] a cocaine addict, actually.
I jokingly say, “Oh, that explains why we have to start our first surgery of the day at 7:30 in the morning, and we have to show up at 5 a.m. for rounds.” Now I get it.” Because he started this long ago. He was a cocaine addict. And there are books written about this. A number of his colleagues had an intervention. They took them on an ocean cruise, because they were worried about him. And it was popular in the 19- teens and 20s, to treat cocaine addiction by substituting your addiction [00:41:00] with morphine.
Trevor Burrus: Okay. I’m not sure what the [crosstalk 00:41:03]
Jeffrey A. Singer: It doesn’t make sense to me, but that was what they thought back then. So they ended up getting him addicted to morphine. And that was kind of, a well-kept secret among just his closest associates until he retired. He used to come home from a long day at work and take enough morphine to prevent his withdrawal symptoms, and take enough in the morning to again, prevent it. And he was a great professor and academic and surgeon. And nobody really knew about [00:41:30] that until afterwards.
Trevor Burrus: So, if we accept that addicts, I think I’m going to stop using that word. I want to use a different word, because dependents, that’s an okay thing. If we can accept that and we can say that maybe just the raw number of opiates being used is not a good indicator of only badness, the people are getting pain treated, or getting pleasure from it, and they’re contributing to society, that we can accept that. Then we have to still deal with this death problem.
Jeffrey A. Singer: Right.
Trevor Burrus: And we talked before [00:42:00] we started recording, that that really should be the focus, is how to stop people from dying. And that’s going to, what you think that ultimately, that’s going to take?
Jeffrey A. Singer: That, I wish that all of the people in the public policy arena who are passing laws, to switch their focus to that. Instead of saying we can’t allow people to have, underlying their approaches, we can’t allow people to engage in these vices. But if instead, they said, “We need to have less people dying.” Well, what is the source of people dying? [00:42:30] It’s drug prohibition. Just like [crosstalk 00:42:33]
Trevor Burrus: The adulteration of heroin.
Jeffrey A. Singer: Yeah, you don’t know what’s in it. You by a Percocet pill or an oxycodone pill on the black market, and we see more and more cases of these pills are being imported from, let’s say, China, and then are being also, laced with fentanyl. You think you’re taking an oxycodone. You’re taking a fentanyl. You stop breathing, because it’s so powerful.
Trevor Burrus: Actually, just to stop you for a sec. Do you know actually, if we, when we may qualify that as an overdose death, [00:43:00] do we do enough toxicology to say, “Okay, it was fentanyl-laced OxyContin?” Or do we just look at the jar and say, “Oh, there’s an OxyContin jar. He overdosed with OxyContin”?
Jeffrey A. Singer: Late in the last several years actually, this is about 2006 or so, they’ve been getting more specific. There have been a lot of articles written about how, depending on who the medical examiner is, some are more conscientious than others in trying to distinguish, but since the attention has focused on [00:43:30] this, efforts have been made to get more uniform toxicology when autopsies are performed.
So, we are starting to be able to differentiate. But that’s, the cause of the deaths is drug prohibition. And we know from experience in countries that have decriminalized drugs, like Portugal, the death rate has gone down dramatically. In fact, in 2015, the overdose death rate from [00:44:00] opioids in Portugal was six per 100,000. In the United States the same year, it’s 312 per 100,000. So, these were all opioids.
So, and apparently, the Portuguese equivalent of the drug czar says they estimate there are 25,000 heroin addicts in Portugal today. There were 100,000 and they started, when they decriminalized drugs there. So, obviously, that would be [00:44:30] the smartest thing to do. In this political environment, that’s probably what they would say is a bridge too far. So, then okay, at least let’s stop killing people.
So, why don’t we focus all of these efforts that right now are focused on restricting doctors from helping their patients in pain, and restricting the production of legal pharmaceutical grade opioids. Instead of putting those efforts into that, why don’t we put them into harm reduction programs, [00:45:00] so that people will be less likely to kill themselves. Harm reduction programs such as, in addition to medical assisted treatment programs like methadone maintenance or Suboxone, there’s needle exchange programs, so people aren’t spreading hepatitis and HIV.
Even better, there’s safe injection rooms. They’ve been around for 25+ years. They’re in every country but the United States, in the developed world. The idea there is with a [00:45:30] clean needle exchange program, which is very prominent in this country, you go in, you’re given a clean needle and syringe. But then, once you get out on the street, if you’re a minority in the inner-city, you’re arrested for possession of paraphernalia. If you’re white in the suburbs, you just, maybe you sell it, or after you use it you give it to somebody else. So, it’s not perfect.
But whereas, with the safe injection room, you go into the room, you inject there, and then you leave. The needle is then discarded by the people who run the place. And not only [00:46:00] that, but you have the bonus of somebody being around there with Narcan so if you overdose, because again, you’re using an illegally obtained substance, so you don’t know really what’s in it. So, let’s say you overdose. Well, there’s somebody there to detox, to give you the antidote of Narcan, which doesn’t happen with needle exchange programs.
Actually, the CDC is okay with that. They encourage what they call “safe syringe programs.” It’s kind of, a generic term, whether you do clean needle exchange or safe injection room, [00:46:30] it comes under the safe syringe program. They think that’s a good idea, because it stops the spread of disease and death. But, in this country, for example, when the City Council of Seattle at the beginning of this year, voted to have a pilot program for safe injection, a whole bunch of the state legislatures, state legislators tried to stop it, because it “sends the wrong message.”
So, there’s a resistance on that kind of, cultural level here in this country. That’s a good harm reduction [00:47:00] program. Several countries, about a half-dozen, have heroin-assisted treatment programs, started in Switzerland in 1994. It’s still going, 23 years later. And it’s in Germany, the Netherlands, the UK, Canada. Belgium is about to start a program. Spain has that program.
And in this case, what they find is, people have not been able to be retained in methadone maintenance programs, because like I say, it’s hard to keep people, [00:47:30] there’s a lot of dropouts. What they did in Switzerland, they say, “If you have failed a methadone maintenance program and you’re an addict for at least two years, you’re 18 or older, and you’re willing to surrender your driver’s license, we’ll let you come in here up to three times a day and inject diamorphine, which is not on the illegal market. This is the pure stuff. Because it’s made there, it’s available. And we’ll give you clean needles where you inject yourself. You sign in, you sign out.”
[00:48:00] 23 years later, 20% of the people who signed up in 1994 are still in the program. It has a very successful retention rate. Average rate is three years. And what they found is a 62% reduction in street crime. The sale of heroin on the streets has pretty much disappeared, because a lot of these people were selling heroin to support their habit. Well, now they don’t have to.
And interestingly, in Switzerland, they reported that teen heroin [00:48:30] use has come down, because when the kids see these people going in and out of the clinic to get their injection, it doesn’t look cool. So, it’s kind of, lost its appeal. Also, a lot of these people have gotten to work. In Germany, they started a program shortly after Switzerland, and they reported 40% of their clients have full-time jobs. So, these are things that we can think of. If we can’t bring ourselves to end drug prohibition, at least, [00:49:00] let’s stop making people die. Because the drug prohibition, that’s what’s making people die.
Trevor Burrus: Thanks for listening. This episode of Free Thoughts was produced by Tess Terrible and Evan Banks. To learn more, visit us on the web at www.libertarianism.org.