AI transcript
0:00:00 (dramatic music)
0:00:02 When I say the opioid crisis or the opioid epidemic,
0:00:08 you probably say enough already.
0:00:12 I understand, you are sick of hearing about it.
0:00:15 We are more than 25 years in
0:00:17 if you use the introduction of OxyContin
0:00:20 as the onset of this crisis,
0:00:21 which most smart people in the field do.
0:00:24 OxyContin is a powerful medical pain reliever
0:00:27 that its manufacturer, Purdue Pharma,
0:00:30 promised would not addict its users
0:00:32 away other opioids can.
0:00:33 This was a big deal
0:00:35 since many millions of people seek out pain relief,
0:00:38 whether intermittently or regularly.
0:00:41 But that non-addictive promise, it turned out to be wrong.
0:00:46 Addiction to OxyContin,
0:00:47 and then similar drugs from other pharma firms,
0:00:51 spiraled into a public health catastrophe.
0:00:54 In 2023, 81,000 people in the US died from an opioid overdose,
0:00:59 more than 10 times the number in 1999.
0:01:03 So the problem has continued to worsen.
0:01:06 Many of the current overdoses
0:01:08 aren’t from prescription drugs like OxyContin,
0:01:10 but from black market versions
0:01:12 or from other drugs that contain fentanyl.
0:01:15 That’s another synthetic opioid
0:01:17 that began as a medical drug,
0:01:20 and which is far more powerful than most opioids.
0:01:23 Fentanyl has now worked its way into the supply
0:01:26 of street drugs in the US,
0:01:28 most of it smuggled across the Mexican border
0:01:31 by American citizens.
0:01:34 A great many people,
0:01:35 policymakers, medical professionals and regulators,
0:01:38 parents, law enforcement,
0:01:40 they’ve all spent the past few decades
0:01:42 trying to end the opioid crisis,
0:01:44 but without much success.
0:01:46 So as sick as you may be of hearing about it,
0:01:50 imagine being the parent of someone who died from fentanyl
0:01:53 or the husband or the child.
0:01:56 Although you might not have to imagine,
0:01:59 you probably know someone
0:02:01 who’s experienced this kind of tragedy.
0:02:03 It’s that common.
0:02:05 Last week in part one of this two-part series,
0:02:08 we asked a simple question, why?
0:02:10 Why is the opioid crisis still raging after all these years?
0:02:15 There are actually a lot of correct answers to that question.
0:02:19 Here’s one.
0:02:20 So it looks like it’s spreading through social networks,
0:02:24 areas of the country that have more Facebook friends.
0:02:26 Those areas also have more deaths.
0:02:28 Sometimes the physical product will spread through networks
0:02:32 and sometimes just the idea,
0:02:34 oh, when I was in pain, I got this opioid
0:02:37 and maybe you should try this opioid.
0:02:39 That was David Cutler, a health economist at Harvard.
0:02:42 We also heard last week from Keith Humphries,
0:02:44 a drug researcher and policy advisor at Stanford.
0:02:48 Humphries thinks that part of the blame goes to advocates
0:02:50 who want to make drugs easier to get
0:02:52 and want to remove the stigma of drug use.
0:02:56 The faith that the advocates had
0:02:58 that if you removed all pressure
0:03:00 and you removed all shame from, you know,
0:03:04 sitting on a park bench using fentanyl,
0:03:06 then people would seek out care,
0:03:09 proved to be completely incorrect.
0:03:11 Today on Freakonomics Radio, a dissenting voice
0:03:15 who thinks that shame is a big part of the problem.
0:03:18 Sometimes I feel like I’m working
0:03:20 in the days of the Salem Witch trials.
0:03:22 Also, billions of settlement dollars
0:03:25 have started to flow from the pharmaceutical firms,
0:03:29 although not Purdue Pharma,
0:03:30 yet they are still fighting over a bankruptcy plan.
0:03:33 How the states are spending that money
0:03:36 is not always transparent.
0:03:39 Observers say this is not only a moral travesty.
0:03:42 It’s also a travesty from a data perspective
0:03:45 because we’re just going to have no sense
0:03:47 of how these monies were actually spent.
0:03:50 Why is the opioid epidemic still raging?
0:03:53 Part two begins now.
0:03:55 This is Freakonomics Radio,
0:04:10 the podcast that explores the hidden side of everything
0:04:13 with your host, Stephen Dubner.
0:04:16 Stephen Lloyd is a physician in Nashville, Tennessee.
0:04:29 The U.S. has more fatal drug overdoses per capita
0:04:32 than any other country in the world,
0:04:34 and within the U.S., Tennessee is right near the top,
0:04:37 along with West Virginia, the District of Columbia,
0:04:40 Delaware, and Louisiana.
0:04:42 Lloyd works as an addiction recovery specialist,
0:04:45 and he is chair of the Opioid Abatement Council of Tennessee,
0:04:49 which helps direct the settlement money
0:04:51 that is being dispersed to states.
0:04:53 We first spoke with Lloyd several years ago
0:04:55 for an earlier series we did on the opioid crisis.
0:04:59 Here’s what Lloyd was advocating for back then.
0:05:03 I think anytime you lessen the stigma
0:05:05 associated with addiction,
0:05:07 you increase people’s opportunity
0:05:08 to step out of the shadows and ask for help.
0:05:10 So when we got back in touch with Lloyd now,
0:05:13 I asked if the stigma has declined.
0:05:16 He says no.
0:05:18 The opioid crisis has affected everybody
0:05:20 from politicians’ sons to people who are unhoused.
0:05:24 And so you would think that the stigma
0:05:26 would be easier to break here, but it just hasn’t.
0:05:28 I went back and looked to find the first doctor
0:05:30 in the United States that described addiction
0:05:33 as a disease and not a moral failure.
0:05:34 It was actually Benjamin Rush.
0:05:36 And he did it before 1776.
0:05:39 So we’ve known for a really long time
0:05:41 that this is not a moral failure,
0:05:43 but it’s still the predominant thought out there right now.
0:05:46 I don’t know how to break through that.
0:05:47 – Lloyd is the chief medical officer
0:05:49 for a chain of clinics called Cedar Recovery.
0:05:52 Most of their funding comes from the federal government.
0:05:55 – We do outpatient treatment of people
0:05:57 with opioid use disorder.
0:05:58 – I realize this is gonna sound flip,
0:06:00 but I would guess business is booming, unfortunately, yes?
0:06:03 – Yeah, sadly, and I’m with you.
0:06:05 I hope one of these days to be out of business,
0:06:07 but yes, unfortunately,
0:06:08 it’s growing faster than any of us would like.
0:06:10 If I make it till July 8th of this year,
0:06:12 I’ll be 20 years in recovery myself.
0:06:14 – Congratulations.
0:06:15 – You know, a unique spin with not only being a doctor,
0:06:18 but a doctor who was addicted earlier in his career
0:06:21 to the very drugs that started all this
0:06:23 with pain pills and really the drug OxyContin.
0:06:25 – Does that give you an advantage
0:06:27 as a physician in this kind of treatment mode?
0:06:29 – I sure think so because I’ve been there.
0:06:31 I’ve stolen pills out of people’s medicine cabinets.
0:06:34 I’ve been dope sick more times than I can shake a stick at.
0:06:36 So when somebody comes in to me
0:06:38 and I can see that they’re in withdrawals,
0:06:40 it’s not something I blow off.
0:06:42 – Do you tell them about your background
0:06:44 and how does that affect your treatment of them?
0:06:46 – Most of the time, they know coming in,
0:06:48 but I always lead off with it
0:06:50 because one of the hardest things to do
0:06:51 is overcome the shame and the stigma.
0:06:53 So I just let them know that their doctor’s been there
0:06:55 and I had to overcome the same things.
0:06:57 – When you look at what’s been happening
0:07:00 with opioid abuse and opioid overdose death
0:07:03 in the last several years since we first spoke,
0:07:07 I never would have predicted
0:07:08 it would have continued to rise like it has.
0:07:11 What’s your best assessment,
0:07:14 whether it’s opinion or informed by data
0:07:17 of why there’s still so much opioid overdose and abuse?
0:07:21 – I think the last time we talked was four or five years ago
0:07:24 and I’m with you,
0:07:25 but I don’t think either one of us saw COVID-19
0:07:28 and COVID really changed the landscape
0:07:31 because if you think about addiction
0:07:32 and realizing that the solution is community
0:07:35 and relationship, it’s about connection.
0:07:37 And then look at how we treated COVID
0:07:39 and I’m not saying things were done wrong.
0:07:41 We were all isolated, right?
0:07:42 We were in our homes, we were working from home,
0:07:43 we weren’t interconnecting.
0:07:45 I knew that it was gonna kill our folks and it did.
0:07:48 Overdose rates in the South were up between 40 and 50%.
0:07:51 Any state you looked at.
0:07:52 So when you and I first talked, I never saw this,
0:07:54 but of course I didn’t see COVID-19.
0:07:56 – Do you feel it’s plateaued?
0:07:58 – I’m hoping, you know, I work in a lot of states
0:08:00 and so I’m starting to see some evidence of some plateauing.
0:08:03 I know that here in Tennessee, it does look like that,
0:08:06 but even if we spend our open abatement dollars
0:08:08 very, very wisely, it’ll take at least until the year 2046
0:08:12 to get back to pre-1996 numbers,
0:08:15 which is a pretty daunting thought.
0:08:16 – Those numbers that Lloyd just cited
0:08:21 that overdose death rates in the South
0:08:23 were up 40 or 50% during COVID, I was skeptical.
0:08:27 So I went and looked up the numbers.
0:08:29 Turns out he was actually understating the COVID spike.
0:08:33 Overdose deaths in Alabama, Louisiana and Tennessee
0:08:36 were up more like 100% from 2018 to 2021,
0:08:41 a doubling during COVID.
0:08:43 So this gets me to wanting to ask you about fentanyl.
0:08:49 When you were addicted, it was a different scenario really.
0:08:54 Can you talk about the substances now
0:08:57 and how that’s changed the game?
0:08:59 – It’s so weird you ask me this
0:09:00 ’cause I’ve actually struggled a little bit
0:09:02 over the past couple of weeks
0:09:03 because my sobriety date’s coming up July 8th
0:09:06 and between May and July are usually fairly tough times for me
0:09:09 because I go back 20 years and remember where I was.
0:09:12 And the thing I realized was that when I was using back
0:09:14 in early 2000s, fentanyl was not a thing.
0:09:17 I mean, it was a drug and it was in the hospital
0:09:19 and they were using it in surgeries
0:09:20 and for cancer patients with patches and sprays,
0:09:23 but it wasn’t illicit powder fentanyl
0:09:25 that’s in absolutely everything now.
0:09:27 And it dawned on me that it’s very likely
0:09:30 towards the end of my using when I had to go to the street
0:09:32 to get my supply that I would have run across fentanyl.
0:09:34 So the landscape is night and day compared to 2004.
0:09:38 – It sounds like what you’re saying is
0:09:41 that if you’d been born 20 years later
0:09:42 and lived the same life, you’d have been dead by now.
0:09:44 – I’d have died, yeah, and that was the struggle
0:09:46 because I recently become a grandparent.
0:09:49 I can’t help myself, but to go there sometimes
0:09:51 because 20 years later, you’re exactly right.
0:09:53 There is a very high likelihood I would have died.
0:09:56 – I have a really naive question
0:09:58 because fentanyl is so deadly
0:10:00 and because fentanyl is now so common
0:10:03 in the illicit drug supply,
0:10:05 why is that not enough to diminish demand?
0:10:09 – Yeah, that’s always a good one.
0:10:11 And to understand that,
0:10:12 you’ve got to understand a little bit
0:10:13 about the brain changes that happen in substance use.
0:10:16 Essentially what happens is you lose access
0:10:18 to the frontal lobe of your brain.
0:10:19 And the frontal lobe of your brain is only important
0:10:21 if you care anything about insight, judgment, and empathy.
0:10:24 – Okay, and so if you’ve got somebody
0:10:26 that’s solely driven by their pleasure center
0:10:28 with no override from that, you know,
0:10:30 insight, judgment, and empathy standpoint,
0:10:32 I think you can pretty clearly see
0:10:33 how come fentanyl doesn’t matter.
0:10:35 Today we’re like, well, we’re not gonna use that,
0:10:36 it’ll kill us.
0:10:37 But we have fully functioning frontal lobes
0:10:39 and people who are using don’t.
0:10:41 – How much is it that versus or in addition to the fact
0:10:45 that it’s just a great wild card in the drug supply?
0:10:49 In other words, even if you do know about fentanyl,
0:10:52 even if you are aware of its danger,
0:10:54 even if you’re willing to take a chance once in a while,
0:10:58 no one really knows how much of it is in the supplier,
0:11:01 whether it might be in a given batch.
0:11:04 So is that a bigger problem?
0:11:06 Or do you think the bigger problem is just the fact
0:11:08 that the high is too appealing
0:11:09 and that the logic chain doesn’t even happen?
0:11:12 – Oh, I think both of those things in combination
0:11:14 are the problem.
0:11:16 I mean, when I was using, I wanted the next thing
0:11:18 that would get me where I needed to be.
0:11:20 And if there was something that would get me there quicker
0:11:21 or more intensely, I mean, that was the goal.
0:11:24 Now you couple that with loss of that executive function
0:11:28 coming from your frontal lobe of your brain
0:11:30 and you can see, you know, how people get in trouble.
0:11:33 – This trouble became so severe, so widespread
0:11:36 that states and cities across the country
0:11:39 sued the manufacturers of the legal opioids
0:11:42 that started the crisis,
0:11:43 along with the distributors and consultants
0:11:45 who helped promote the drugs.
0:11:47 – A number of states have now agreed
0:11:49 to a $26 billion settlement
0:11:52 with three large drug distributors
0:11:54 and Johnson & Johnson
0:11:56 for their roles in the opioids epidemic.
0:11:59 CVS & Walgreens paying out $10 billion
0:12:02 to settle lawsuits over the opioid crisis.
0:12:05 – McKinsey & Company is gonna pay nearly $600 million
0:12:09 for consulting businesses
0:12:10 on how to sell more prescription opioid painkillers.
0:12:14 – Although, as I mentioned earlier,
0:12:16 the big one is still unresolved.
0:12:19 – Today, the Supreme Court will review
0:12:21 a $6 billion bankruptcy settlement
0:12:24 between Purdue Pharma, the maker of OxyContin
0:12:26 and the victims and communities
0:12:28 ravaged by the opioid crisis.
0:12:30 – Coming up after the break,
0:12:34 how will these billions be used
0:12:36 and what is it going to accomplish?
0:12:39 I’m Stephen Dubner.
0:12:40 This is Freakonomics Radio.
0:12:41 We will be right back.
0:12:42 (upbeat music)
0:12:45 – There have been a lot of bad actors
0:12:54 in the opioid crisis.
0:12:56 The most widely vilified is Purdue Pharma,
0:12:59 the private drug maker largely owned by the Sackler family,
0:13:02 which made and sold the pain medication OxyContin
0:13:05 under the false premise that it was less addictive
0:13:07 than other opioids.
0:13:09 But other companies have also been implicated.
0:13:11 Manufacturers like Johnson and Johnson,
0:13:14 Allergan and Teva, as well as distributors, pharmacies,
0:13:18 pharmacy benefit plans, and the consulting firm McKinsey,
0:13:22 which helped Purdue sell more drugs.
0:13:26 All this has prompted thousands of lawsuits,
0:13:28 some of them ongoing, but many already settled.
0:13:32 These settlements will direct around $55 billion
0:13:35 to the states to be distributed over the next 18 years.
0:13:39 The Sackler family’s bankruptcy settlement
0:13:41 could add another $6 billion to the settlement pool.
0:13:45 Most of the settlements require the states
0:13:48 to spend 85% of the money
0:13:50 to directly address the opioid crisis.
0:13:53 – This money has to go for certain things.
0:13:55 You can’t just use it to balance your budget
0:13:57 in your state or build roads and highways.
0:13:59 – That again is Stephen Lloyd,
0:14:01 the Tennessee physician who chairs
0:14:03 his state’s opioid abatement council.
0:14:06 – And so we’ve got an actual chance
0:14:07 at this one actually making a difference
0:14:09 for what it was intended to.
0:14:10 – Can you talk about the process in Tennessee?
0:14:13 How much is the money flowing so far
0:14:15 and where it’s being applied?
0:14:17 – Oh, it’s flowing, thank goodness, Stephen.
0:14:19 I’m really proud of that.
0:14:20 So Tennessee took 15% of their money
0:14:23 from the funded minister or it goes to our general assembly.
0:14:25 The politicians can spend it on what they want to.
0:14:27 – Okay, so 15% is essentially slush fund.
0:14:30 That’s not directly for opioids.
0:14:32 – Yeah, you said that, not me.
0:14:33 – Okay, fair enough.
0:14:34 And then another 15% went to Tennessee as 95 counties.
0:14:37 So another 15% went directly to those counties
0:14:40 based on a formula that was agreed upon,
0:14:42 population and problem.
0:14:44 So they can actually use that for anything they want.
0:14:46 So that’s 30% of the money.
0:14:48 – But that second 15%, the share was derived
0:14:51 from the amount of opioid trouble in that county though
0:14:54 or no?
0:14:55 – That’s exactly right.
0:14:56 – But even so it’s non-directed funds.
0:14:58 I can use it however I want.
0:14:59 – You can hire a dog catcher if you want.
0:15:01 – Got it.
0:15:02 – And then the remaining 70%,
0:15:03 the general assembly and our governor in Tennessee
0:15:05 set up an independent council that has decision-making
0:15:08 authority made up of 15 people appointed by our governor,
0:15:10 our speaker of the house and our lieutenant governor.
0:15:13 And they will decide how that 70% is spent.
0:15:16 Now, 35% of that 70% goes back to the counties again
0:15:20 based on that same formula from last time.
0:15:22 Only this time it has to go from something
0:15:25 called a remediation list.
0:15:27 And a remediation list even is basically
0:15:28 an abatement plan and we will hold them accountable.
0:15:31 So Tennessee has had two distributions to that one already,
0:15:34 both of them in excess of $30 million
0:15:37 that went to those individual counties.
0:15:39 Now that’s 35% of the 70, the remaining 65% of the 70
0:15:44 was made available through a competitive grant process,
0:15:47 which we just finished up the first round.
0:15:50 – Give me a list of some things where that money is going.
0:15:53 – Well, there’s four big buckets out there,
0:15:54 prevention, education, treatment
0:15:56 and something called harm reduction.
0:15:58 So how do you break that money up
0:16:00 in each of those individual buckets
0:16:01 and those strategies to get to the goal that you want,
0:16:03 which is actually shrink the number of people who use drugs.
0:16:06 And I think that is the challenge
0:16:07 and that is the ball that I see being dropped right now.
0:16:10 You know, they say, well, how did you decide
0:16:12 how much went in each of the four buckets in Tennessee?
0:16:14 And I said, well, we use something called a swag method,
0:16:16 scientific wild ass guess.
0:16:18 – Lloyd would like to replace that guesswork
0:16:22 with something more reliable.
0:16:24 He is a member of a consortium called the Helios Alliance,
0:16:27 which uses data science to try to learn
0:16:29 which interventions are most effective
0:16:31 and most cost effective.
0:16:33 – You start looking at this money as it comes in.
0:16:36 How do you allocate it to the individual strategies
0:16:39 to get to a result that you’re trying to look for?
0:16:42 Because if you just stick it out there, Stephen,
0:16:44 and you measure it on the back end,
0:16:45 how do you know if you’re even successful?
0:16:47 – Based on what he’s learned so far,
0:16:49 Lloyd says that of the four buckets,
0:16:51 prevention, education, treatment and harm reduction,
0:16:54 prevention offers the best return on investment.
0:16:58 For every $1 that you invest in prevention with opioids,
0:17:01 it’s an $11 downstream savings.
0:17:03 Nothing’s even close to that.
0:17:04 Treatments like one to four.
0:17:06 – What about education?
0:17:07 – Education, I would put as part of treatment.
0:17:10 Education is gonna break down the barriers
0:17:12 to people getting into treatment.
0:17:14 – And what about harm reduction?
0:17:15 – Harm reduction is simply keeping people alive.
0:17:18 And I’m not sure what the return on investment dollar is,
0:17:20 because right now, if Stephen Dubner overdoses,
0:17:23 and we take you to the hospital here at Vanderbilt,
0:17:25 you’re gonna be in there until they get you stable,
0:17:27 and then you’re gonna hit the door.
0:17:28 And there’s a good chance that you’re gonna overdose again
0:17:31 the same afternoon and be right back in there.
0:17:33 That happens all the time.
0:17:35 So you’re spending a lot of harm reduction dollars,
0:17:37 but a lot of times you’re spending it on the same people,
0:17:39 just rotating in and out of emergency departments
0:17:41 after the overdose.
0:17:42 And that’s where we need to look at this system of care
0:17:45 that your patient steps into.
0:17:47 So some of the ideas, let me give you a good one.
0:17:49 University of Tennessee Knoxville
0:17:51 has an emergency department program
0:17:52 where if you come in and you’ve overdosed,
0:17:54 as soon as they get you stable, they’ll call a peer.
0:17:56 Somebody who’s had this problem themselves,
0:17:58 they’ll come down and talk to you
0:17:59 and link you up to treatment right out
0:18:01 of the emergency department.
0:18:03 Those are the kind of things that I’m talking about.
0:18:06 One of the things I see that dismays me
0:18:08 is that a lot of people in this space
0:18:10 are only interested in their part of it.
0:18:12 I’m part of the treatment world myself.
0:18:14 The reality is, when it comes to addiction,
0:18:16 I’m a prevention guy,
0:18:18 because I think it’s the only way
0:18:19 that we move the needle going forward.
0:18:21 – But what if I hear you give this pitch
0:18:23 about these four buckets,
0:18:24 and then I hear that the return on investment
0:18:25 of prevention is $1 spent,
0:18:27 you get $11 on return, and that easily beats all the rest.
0:18:31 I say to you, oh, that’s fantastic.
0:18:33 Let’s not worry about the other stuff.
0:18:35 Let’s put it all in prevention.
0:18:36 What would you say to that?
0:18:38 – Well, I would think I was talking
0:18:39 to somebody other than Stephen Dubner, first of all,
0:18:41 because now you’re talking about letting people die.
0:18:44 And I hope I never get to that point in my career,
0:18:46 because that argument has been made.
0:18:48 And here’s the problem with letting people die.
0:18:50 They leave people behind, and a lot of times they’re kids.
0:18:52 And if you look at the drivers of addiction
0:18:54 as being genetics, trauma, and opportunity,
0:18:57 you’re really not going to be able to kill your way
0:18:58 out of this because of what’s left behind.
0:19:00 So I have made the argument forever
0:19:03 that the first step in prevention
0:19:04 is treatment of mom and dad.
0:19:06 And I think I can make that argument stick.
0:19:08 Almost all of medicine is harm reduction.
0:19:11 We don’t cure diabetes, right?
0:19:12 We treat it to prevent the sequela, you know,
0:19:14 heart attacks and strokes,
0:19:16 but it’s hard to get people to see that
0:19:17 when it comes to substance use disorder.
0:19:19 In 2004, if somebody had said,
0:19:22 “Steve, you have this addiction to oxycontin,”
0:19:24 so what we’re going to do,
0:19:25 we’re just going to give you oxycontin,
0:19:26 all you want until you’ve had enough, okay?
0:19:29 I would have died.
0:19:31 So did we need to keep me alive?
0:19:33 I hope, yes, we did need to keep me alive,
0:19:35 but we also needed a path for me to get into recovery
0:19:37 so I could raise my family
0:19:39 and make sure I’m not creating
0:19:40 the next generation right behind me.
0:19:42 – When you talk about diabetes, it strikes me,
0:19:44 that could be a pretty apt comparison
0:19:46 in that a lot of cases of diabetes
0:19:49 are brought about by personal choices
0:19:51 and personal behavior, right?
0:19:52 Diet, nutrition, exercise or the lack thereof,
0:19:55 would you agree with that or not quite?
0:19:57 – Absolutely.
0:19:57 I mean, now type one’s different, right?
0:19:59 – Type one’s different, yeah, let’s cross that off.
0:20:01 – But far and away that, you know,
0:20:02 most common cause of diabetes is type two
0:20:04 and it’s behavioral.
0:20:06 Most of type two diabetes is because of, you know,
0:20:08 eating chocolate, cake and drinking Mountain Dew Code Red.
0:20:10 And we have no issues
0:20:13 with intervening with medication and diabetes.
0:20:15 What’s the first line treatment for diabetes?
0:20:16 Diet and exercise, all right?
0:20:18 And I challenge anybody out there
0:20:20 to show me five patients in their practice
0:20:22 that adhered to their diet and exercise
0:20:23 and control their blood sugar.
0:20:25 Yet, if you see somebody out there
0:20:27 who’s got their A1C less than 6.5
0:20:29 and they’re on three different medications
0:20:30 in order to do so, nobody’s asking them
0:20:32 when they’re gonna come off.
0:20:33 They’re just glad that they’re not at such high risk
0:20:36 to have these bad things happen.
0:20:38 Again, addiction is treated differently
0:20:40 than every other disease I can think of in our country.
0:20:43 (upbeat music)
0:20:46 – So Stephen, you have been sketching out
0:20:48 a lot of the problems here.
0:20:49 Do you have any good news?
0:20:52 You know, if you’re listening to this
0:20:53 and you wanna know what’s going on
0:20:54 with the money in your county,
0:20:56 then you need to get involved
0:20:57 and you need to make your voice heard,
0:20:58 particularly if you have lived experience.
0:21:00 And so I think there is good news, Stephen.
0:21:02 And I think there’s people out there
0:21:03 that are starting to listen
0:21:05 to some of the things that we’re talking about.
0:21:07 When that happens,
0:21:07 when it happens on a big enough scale,
0:21:09 then I think we have a chance
0:21:10 at tying some systems together
0:21:12 that have a chance to become a system of care
0:21:14 over the next two to three decades.
0:21:16 – How do you suggest people get involved?
0:21:18 – Starts at the local level.
0:21:19 A lot of this money is going directly to the counties
0:21:22 as I described to you.
0:21:23 I guarantee you that the mayor of your county
0:21:25 or the city commission or county commission where you live,
0:21:28 they know they got a big check.
0:21:29 Okay, came as a wire transfer.
0:21:31 Ask them what they’re doing with it.
0:21:32 Ask them what the process is and how to spend it.
0:21:34 (upbeat music)
0:21:37 – There’s also a way to track the $55 billion
0:21:40 in settlement money,
0:21:41 or at least try to track it.
0:21:43 That is thanks to this person.
0:21:45 – My name is Christine Minhee.
0:21:47 I am the founder of OpioidSettlementTracker.com.
0:21:50 Minhee received her law degree
0:21:52 from the University of Washington in 2019.
0:21:55 – I started the project after I got obsessed
0:21:58 with the big tobacco litigation as a law student,
0:22:02 quickly realized that we were hurtling
0:22:04 into the same dismal landscape of poor spending
0:22:08 with opioid settlements without any guardrails.
0:22:12 – In 1998, the four biggest tobacco companies in the US
0:22:16 agreed to what was called
0:22:17 the Tobacco Master Settlement Agreement.
0:22:20 This meant paying out some $250 billion to the states
0:22:24 to help cover the costs incurred
0:22:26 by the consumption of their product.
0:22:28 A product that like Oxycontin was legal,
0:22:32 but carried significant risks
0:22:34 that the manufacturers lied about.
0:22:37 That $250 billion has gone into state budgets
0:22:40 where it was spent on healthcare costs for smokers,
0:22:43 on anti-smoking campaigns,
0:22:46 but sometimes just to make up budget shortfalls.
0:22:49 That’s what Christine Minhee doesn’t want to see repeated
0:22:52 with the opioid settlement money.
0:22:54 – That nightmare of big tobacco spend
0:22:57 certainly cast a pall over the opioid settlement landscape.
0:23:01 So I didn’t trust that there was going to be another entity
0:23:05 that would watch how these settlements would be spent.
0:23:07 And I decided to just create a beta concept
0:23:11 that I imagined some agency would take over after.
0:23:15 But lo and behold, a number of years later,
0:23:17 I’m continuing to do this.
0:23:18 – As we heard earlier from Steven Lloyd,
0:23:20 there is a formula for how the opioid settlement money
0:23:23 is to be distributed.
0:23:25 – The way that they’re divvied up across the states
0:23:27 is determined by a single table
0:23:29 and the settlement agreements actually.
0:23:31 And this global allocation percentage table
0:23:35 is derived by using a formula that uses three factors,
0:23:40 how many pills were shipped to a particular jurisdiction,
0:23:43 how many folks have died
0:23:45 from an opioid use disorder related overdose,
0:23:48 and how many folks are currently suffering from OUD
0:23:52 within a particular jurisdiction.
0:23:54 – But once you get past that formula, Minhee found,
0:23:58 there wasn’t much in the way of accountability
0:24:00 of how the money would be spent.
0:24:02 – The reporting requirements attached
0:24:04 to the opioid settlement agreements
0:24:06 are virtually non-existent.
0:24:08 – With opioidsettlementtracker.com,
0:24:10 she is hoping to change that.
0:24:12 So far, 20 states do voluntarily report
0:24:16 all their settlement spending.
0:24:18 Others, including Tennessee,
0:24:20 are reporting some of their spending,
0:24:22 but some don’t make any information public.
0:24:25 – Texas has decided not to report its specific expenditures.
0:24:29 We have no official state promulgated proof of spend
0:24:34 for Texas’s $2.8 billion.
0:24:37 And that is a travesty for all of the million
0:24:41 moral reasons that I can input.
0:24:43 But it’s also a travesty from a data perspective
0:24:47 because we’re waltzing into this landscape
0:24:49 where we’re just gonna have no sense
0:24:51 of how these monies were actually spent
0:24:53 or whether or not they’re moving the needle on public health.
0:24:56 – You keep distributing money to the same things
0:25:01 that you’ve been distributing it for the last 20 years
0:25:03 that have led you here.
0:25:04 – Stephen Lloyd again.
0:25:05 – The only way to break that is to do something different.
0:25:08 I mean, the definition of insanity, right?
0:25:10 Doing the same thing over and over,
0:25:11 expecting a different result.
0:25:12 – When you talk about the money that’s been spent
0:25:14 and hasn’t achieved the goal,
0:25:16 how is that money historically or traditionally spent?
0:25:19 – It comes in from the federal government,
0:25:21 usually in block grant through its State Department
0:25:23 of Mental Health or Substance Abuse
0:25:24 or whatever their equivalent is.
0:25:25 And then they dole it out to their organizations
0:25:27 who are carrying out programs in their state.
0:25:30 And my issue with that,
0:25:31 and I’m not knocking the work that’s being done,
0:25:34 there’s a lot of people doing really, really good work.
0:25:37 I wanna see meaningful outcomes,
0:25:38 not how many people we were able
0:25:40 to do a physical exam on in 24 hours.
0:25:43 Is that important?
0:25:43 Yes, do I care?
0:25:45 No, I don’t care.
0:25:46 What I care about is how many of those people
0:25:48 went through the program and when they got out,
0:25:51 were able to sustain their recovery.
0:25:53 How many of them got back into their jobs?
0:25:55 How many of them got a new job?
0:25:56 How many of them were able to provide for their family?
0:25:58 I want meaningful data.
0:26:01 Just like we would for heart attack.
0:26:02 If you put a stint in somebody,
0:26:04 “Oh, we gotta stand in there and the flow was great.”
0:26:06 And two days later, they died of a heart attack.
0:26:08 Okay, if you just measured the flow and said that’s a success,
0:26:11 I would tell you that was a failure.
0:26:12 So it sounds like there is a greater than zero chance
0:26:16 that if we were talking 15 or 18 years from now,
0:26:20 that someone, maybe you, would have the same complaints
0:26:23 about how the money has been spent
0:26:25 that you’ve had about how the money has been spent,
0:26:28 for instance, in West Virginia over the past 20 years.
0:26:30 What do you think are the odds of that?
0:26:32 It’s my nightmare.
0:26:33 I mean, not very many things keep me up at night anymore.
0:26:37 This one keeps me up at night because I’m scared
0:26:39 that we’re going to, we’re going to blow it.
0:26:41 So when I speak with you, Stephen,
0:26:43 I get the sense that addiction is sort of a language
0:26:47 that if you don’t speak it, you don’t speak it.
0:26:50 And that’s a problem because you need people
0:26:53 who don’t speak the language to be involved in,
0:26:57 let’s say, the treatment or the teaching of that language.
0:27:01 If you have policymakers that don’t speak the language
0:27:03 and don’t understand what I just said,
0:27:05 think of some of the things
0:27:06 that you can come out of this with.
0:27:08 I mean, policy that’s harmful.
0:27:09 – So what kind of policies won’t be harmful?
0:27:15 That’s after the break, I’m Stephen Dubner,
0:27:17 and this is Freakonomics Radio.
0:27:19 The United States has the highest rate
0:27:31 of drug overdose deaths in the world.
0:27:33 And in recent years, the problem has continued to worsen.
0:27:37 As we’ve been discussing over these past two episodes,
0:27:40 the opioid epidemic has a variety of causes,
0:27:44 but what about the consequences?
0:27:46 The death and suffering and broken families,
0:27:50 those are all front and center, but there are others.
0:27:54 Because this crisis originated
0:27:56 with the legal medical distribution
0:27:59 of an addictive substance,
0:28:01 the medical community especially has fought back hard.
0:28:05 Everyone now admits that opioids
0:28:07 were wildly overprescribed for a long time.
0:28:10 And since 2010, the rate of opioid prescription
0:28:15 has fallen by at least 50%.
0:28:17 The system has made it significantly harder
0:28:20 to get certain drugs.
0:28:22 But this too has had a cost.
0:28:25 A lot of people who need these drugs for pain management
0:28:29 aren’t able to get them.
0:28:31 Most people who use prescription opioids don’t become addicted,
0:28:35 but because some do, and because this addiction
0:28:39 to illegal product created a massive market
0:28:42 for illegal versions of that product,
0:28:45 the legitimate prescription of some opioids
0:28:47 by legitimate physicians has been constrained.
0:28:51 And people have suffered because of that too.
0:28:54 In 2022, the CDC issued new prescription guidelines
0:28:58 that continue to emphasize opioid alternatives,
0:29:01 but also call for flexibility
0:29:04 to allow their use when needed.
0:29:06 Perhaps all these wrinkles shouldn’t surprise us.
0:29:10 Every epidemic has its own history,
0:29:13 its own trajectory and rebound effects,
0:29:16 its own way of making trouble.
0:29:18 I asked Stephen Lloyd if he could point to an epidemic
0:29:22 from history, whether ancient or modern,
0:29:25 that seems to parallel the opioid epidemic.
0:29:28 – Stephen, I think the opioid epidemic
0:29:30 is this generation’s HIV and AIDS.
0:29:33 There’s so many parallels.
0:29:34 I’m getting ready to be 57.
0:29:36 And so I lived through that in the early ’80s.
0:29:38 First of all, it’s the descents.
0:29:40 If somebody had HIV disease, they were gonna die
0:29:41 and we knew it.
0:29:43 The really big thing was stigma.
0:29:44 Don’t swim in the pool with these kids
0:29:46 and really the biggest hurdle
0:29:47 because we actually had AZT pretty early on
0:29:49 in the AIDS epidemic,
0:29:50 but there were barriers to getting the treatment.
0:29:53 And then you had these groups.
0:29:54 The one I remember is ACT UP.
0:29:56 Got out and made a lot of noise
0:29:57 and started fast-tracking medications through the FDA.
0:30:00 And then you had several notable cases
0:30:02 that started to change the face of it.
0:30:04 Ryan White, Arthur Ashe, Urban Magic Johnson.
0:30:07 You look at HIV disease and AIDS.
0:30:09 And now when’s the last time you saw an article on it?
0:30:11 My son just turned 30 years old
0:30:13 and he doesn’t remember HIV and AIDS being a descents.
0:30:17 And if you parallel that to what we’re seeing
0:30:19 with the opioid epidemic, there are so many similarities.
0:30:21 What’s the biggest thing that prevents people
0:30:23 from getting treatment right now, stigma?
0:30:25 But it’s been a while now.
0:30:27 Why do you think the stigma has not receded?
0:30:29 People just look at addiction differently, Stephen.
0:30:32 Last night, I was in a rural town here
0:30:34 just east of Nashville and the decision makers
0:30:37 in that town understood almost nothing about addiction.
0:30:40 You’re still under the impression that,
0:30:42 well, this little town doesn’t need
0:30:44 what you wanna bring here because we’re not Memphis
0:30:46 or we’re not Nashville or New York City.
0:30:48 And that’s somebody who doesn’t understand
0:30:50 the demographics of this.
0:30:52 I mean, this started out as a rural problem
0:30:53 and it still is a rural problem.
0:30:55 And so you’re off base there,
0:30:57 but then you wanna send somebody away for 10, 20, 30 days
0:31:00 and have them come back fixed.
0:31:02 And that’s not how this works.
0:31:03 It’s a lifelong process.
0:31:04 And so if those are the people driving your policy,
0:31:07 then you can start to imagine some of the things
0:31:09 you come out of this with and you actually have people
0:31:11 that will die never knowing that there’s life-saving
0:31:13 medication out there to help them.
0:31:15 Sometimes I feel like I’m working
0:31:17 in the days of the Salem witch trials
0:31:19 because we know so much about addiction.
0:31:21 Now, we know things that are effective.
0:31:23 We know medications that are effective,
0:31:25 but when you start getting in rural territories,
0:31:27 you’re right back to those times
0:31:30 where you’re looking at this as a moral failure
0:31:31 and the only treatment is a higher power or a deity.
0:31:35 I ran into it last night in front of that zoning commission
0:31:38 and I couldn’t overcome it.
0:31:40 I lost.
0:31:41 – You said you couldn’t get them to buy
0:31:43 what you were selling.
0:31:43 What were you selling in that case?
0:31:45 – I was trying to show them the fact that addiction
0:31:48 is like any other medical disease
0:31:50 that deserves the same opportunities for treatment.
0:31:53 That’s it.
0:31:54 – Were you proposing a facility?
0:31:55 Were you proposing?
0:31:56 – Facilities that did everything.
0:31:58 Behavioral health counseling, mental health issues,
0:32:00 getting a family of origin issues,
0:32:02 all the stuff that goes around addiction
0:32:04 like housing, stable food source, income,
0:32:06 and then for the population that needs it, medication.
0:32:09 And when you start talking medication,
0:32:10 particularly in rural areas,
0:32:12 the thing that pops out right off the bat,
0:32:13 oh, you’re just trading one drug for another.
0:32:15 That’s it.
0:32:16 They seem to not understand that we’re going to save lives.
0:32:20 And if I’m completely honest,
0:32:22 the biggest drawback that I have in the States I work in
0:32:25 is the church.
0:32:26 – Because the church has a kind of bright line
0:32:28 over use, don’t use?
0:32:30 – Absolutely.
0:32:31 If you pray enough and you walk enough little old ladies
0:32:33 across the street, then you won’t have this issue.
0:32:36 One of the arguments last night is,
0:32:38 and these are their words, not mine,
0:32:39 ’cause I don’t use these words,
0:32:40 but we’re gonna bring drug addicts in here.
0:32:43 Well, I’ve been working in that particular town
0:32:45 for a good while, and I can promise you,
0:32:47 they’re already there.
0:32:48 – This is a paraphrase of you describing
0:32:50 how the Helios model works.
0:32:53 The idea is to use statistical modeling
0:32:55 and artificial intelligence to simulate the opioid crisis,
0:32:58 predict which programs will save the most lives
0:33:01 and help local officials to decide
0:33:03 the best use of settlement dollars.
0:33:05 It sounds good, but I could also see someone hearing that
0:33:08 and saying, oh, that just sounds like consultants
0:33:12 getting their piece of this.
0:33:14 And it doesn’t sound close enough to the ground to me.
0:33:18 It doesn’t sound like it’s going to physically address
0:33:22 the actuality of this epidemic.
0:33:24 What would you say to that suspicion?
0:33:26 – First of all, I’ve never been accused
0:33:28 of being a consultant,
0:33:29 and I’m certainly not McKenzie material.
0:33:32 It’s what I see, and I saw it when we modeled the cases,
0:33:35 ’cause my job in the cases was to show causation, right?
0:33:38 To draw a direct line from the mispromotion
0:33:40 of the drug oxycontin to today’s heroin
0:33:41 and fentanyl epidemic, that’s my job.
0:33:44 And when I saw what modeling did to reinforce the story
0:33:48 that I told that I physically saw and experienced
0:33:51 as a patient and a provider, I was overwhelmed by it.
0:33:55 And so it may sound like consultants speak
0:33:57 and maybe somebody cleaned my words up.
0:33:59 I mean, you’ve talked to me long enough to know
0:34:01 that I probably can’t talk that well.
0:34:02 – Yeah, I was going to say those words on the page
0:34:04 don’t really sound like you sound now that I’m talking to you.
0:34:07 – They don’t, so somebody cleaned them up,
0:34:09 but the idea is the same.
0:34:10 And the idea is that we have to know
0:34:12 what our current assets are, what our current system is.
0:34:14 We have to be able to model that
0:34:16 so that we can make the best decisions
0:34:17 on how to allocate the money.
0:34:19 And that’s Steve Lloyd’s words.
0:34:20 – Stephen Lloyd plainly believes
0:34:24 that the stigma associated with addiction
0:34:26 is a major reason this epidemic has continued to rage on.
0:34:31 In part one of this series,
0:34:32 we featured the Stanford Drug Researcher
0:34:34 and Policy Advisor, Keith Humphries.
0:34:37 He believes that stigma is important,
0:34:39 that if you remove all the barriers from drug use,
0:34:43 not just legal barriers, but social barriers,
0:34:46 then you are inviting trouble.
0:34:49 That said, Humphries and Lloyd do agree
0:34:51 that the opioid crisis has gone on far too long,
0:34:55 that there are ways to stop it,
0:34:57 and that the settlement money coming in now
0:34:59 from the opioid producers is a key to all of that.
0:35:03 We went back to Humphries for his take
0:35:05 on how the money should be spent.
0:35:08 – These settlements are massive.
0:35:09 They are multi-billion dollar settlements.
0:35:12 They are, however, paid out over very long periods.
0:35:15 So I was talking to a governor about what impact it has.
0:35:19 She said, it’s like an extra 6% of our budget
0:35:22 for the next 25 years.
0:35:24 So when you thought of it that way,
0:35:25 it’s like, oh, that’s not really that much.
0:35:26 I mean, you know, it’s at billions,
0:35:27 but if it’s paid out over very long times, right?
0:35:30 So, you know, the question will be
0:35:33 since this is to abate the problem
0:35:34 is how do municipalities and states
0:35:38 use it as wisely as possible?
0:35:40 And what I tell them is like,
0:35:41 don’t spend any money on anything
0:35:43 some other funding stream covers.
0:35:46 Like building a clinic, that’s,
0:35:48 where do you get money to build?
0:35:49 Medicaid, Medicare will not pay to build a clinic.
0:35:51 But if you build a clinic and if you have staff,
0:35:53 then Medicaid and Medicare will pay your staff sorry forever.
0:35:57 I’ve also been pitching,
0:35:57 please do something for prevention
0:35:59 because, you know, we have funding streams,
0:36:02 private and public insurance,
0:36:04 that pay for the care of people who are ill,
0:36:05 but there really isn’t, you know,
0:36:07 good funding streams for prevention
0:36:09 for people who are not yet ill, mainly kids.
0:36:13 – There is an organization at the University of Washington
0:36:15 that Humphrey sees as a good model
0:36:17 for setting up youth prevention systems.
0:36:20 They’re called communities that care
0:36:21 and they consult with various communities
0:36:24 to in their language,
0:36:25 promote the healthy development of young people.
0:36:28 – Making investments in kids around the ages of 10, 11, 12
0:36:32 has many good outcomes.
0:36:34 A lot of people don’t think about prevention enough.
0:36:36 They think about the current crisis,
0:36:37 but you have to think long-term
0:36:38 if you want to deal with epidemics.
0:36:40 So I would use this money for things,
0:36:42 nothing else can pay for.
0:36:43 So that would be prevention with kids
0:36:45 ’cause there is no funding stream for that.
0:36:47 I would certainly do infrastructure.
0:36:50 There’s places where there are no methadone clinics.
0:36:52 So you need a building.
0:36:53 You can’t pay for a building with health insurance,
0:36:55 but you could pay for it with this.
0:36:57 Could also potentially do some things with technology.
0:36:59 So you can have investments for telehealth.
0:37:01 So people don’t have to come in as often
0:37:04 that often there’s a way to retain them and care better.
0:37:06 That’s something we could do.
0:37:08 Let’s think, what hangs over all this
0:37:09 is the shadow of the tobacco settlement.
0:37:11 Very little of it was spent on tobacco.
0:37:14 You know, pottles and that kind of thing.
0:37:15 So there’s far more monitoring
0:37:16 and far more transparency of where the money is going.
0:37:20 However, these decisions, remember,
0:37:21 these are city, states, counties, the Fed.
0:37:23 The levels of decision-making are varied.
0:37:27 And there will be places where they say,
0:37:28 well, what we need are new police cruisers.
0:37:31 So there’s gonna be problems for sure of misallocation.
0:37:34 I think that’s just inevitable.
0:37:36 – You wrote in 2019,
0:37:38 if no Sacklers end up behind bars,
0:37:40 an entire class of people will continue to feel
0:37:42 that writing a check is the worst thing
0:37:44 that will happen to them no matter what they do.
0:37:47 As far as I know, no Sacklers in jail,
0:37:48 what’s your position now, a few years later?
0:37:51 – I’m only more cynical
0:37:52 ’cause not only did no Sacklers go to jail,
0:37:54 but another company they own, Moondi Pharma,
0:37:57 is now selling Oxycontin all over the world
0:37:59 just like they sold it here.
0:38:00 So they haven’t been punished
0:38:02 and they’re continuing to profit.
0:38:04 – Moondi Pharma, headquartered in England,
0:38:08 is indeed owned by members of the Sackler family,
0:38:11 although they may be required to dispose of it
0:38:14 as part of Purdue Pharma’s bankruptcy settlement.
0:38:17 So what happens next?
0:38:20 Does the opioid crisis spread to other parts of the world?
0:38:24 Does the US create a successful playbook
0:38:28 to fight the crisis here?
0:38:30 I hope these are the questions that people in power
0:38:33 are asking themselves right now.
0:38:36 I also hope that we don’t find ourselves back here
0:38:39 in another five years making yet another episode
0:38:42 about this epidemic.
0:38:43 I’d like to thank Stephen Lloyd, Keith Humphries,
0:38:47 Christine Minhee, and last week,
0:38:49 David Cutler and Travis Donahoe for speaking with us.
0:38:54 And most of all, I’d like to thank you,
0:38:55 as always, for listening.
0:38:57 Let us know what you’re thinking.
0:38:59 Our email is radio@freakinomics.com.
0:39:03 Coming up next time on the show.
0:39:07 – So this is an amazing story.
0:39:09 – Tom Whitwell is a bit like Superman,
0:39:13 mild-mannered, toiling away at his work,
0:39:15 mostly hidden from the world.
0:39:17 But once a year, he emerges with a list,
0:39:22 a list of the 52 things he’s learned that year.
0:39:26 For instance.
0:39:27 – Fondue was invented by the cheese industry.
0:39:30 – Some of these things are true things
0:39:31 that we didn’t know to be true.
0:39:33 – The basic story was the NHS uses 10% of remaining pages.
0:39:37 – And some are things we’ve been told are true
0:39:40 that quite likely aren’t.
0:39:42 The whole idea of blue zones, for instance.
0:39:46 That’s next time on the show.
0:39:48 Until then, take care of yourself.
0:39:50 And if you can, someone else too.
0:39:53 Freakinomics Radio is produced by Stitcher and Renbud Radio.
0:39:56 You can find our entire archive on any podcast app also
0:40:00 at freakinomics.com, where we publish transcripts
0:40:03 and show notes.
0:40:04 This episode was produced by Alina Cullman and Zak Lipinski.
0:40:08 Our staff also includes Augusta Chapman,
0:40:11 Dalvin Abouaji, Eleanor Osborne, Elsa Hernandez,
0:40:14 Gabriel Roth, Greg Rippin, Jasmine Klinger,
0:40:16 Jeremy Johnson, Julie Canfer, Lyric Bowditch,
0:40:19 Morgan Levy, Neil Carruth, Rebecca Lee Douglas,
0:40:22 Sara Lilly, and Teo Jacobs.
0:40:24 Our theme song is “Mr. Fortune” by the Hitchhikers.
0:40:27 Our composer is Luis Guerra.
0:40:29 – Big hockey game tonight.
0:40:34 For a kid to grow up in the South
0:40:36 and realize that there’s a hockey team in Nashville,
0:40:38 it’s kind of a weird thing.
0:40:39 – The Freakinomics Radio Network.
0:40:45 The hidden side of everything.
0:40:51 Stitcher.
0:40:52 you
0:40:54 you
0:00:02 When I say the opioid crisis or the opioid epidemic,
0:00:08 you probably say enough already.
0:00:12 I understand, you are sick of hearing about it.
0:00:15 We are more than 25 years in
0:00:17 if you use the introduction of OxyContin
0:00:20 as the onset of this crisis,
0:00:21 which most smart people in the field do.
0:00:24 OxyContin is a powerful medical pain reliever
0:00:27 that its manufacturer, Purdue Pharma,
0:00:30 promised would not addict its users
0:00:32 away other opioids can.
0:00:33 This was a big deal
0:00:35 since many millions of people seek out pain relief,
0:00:38 whether intermittently or regularly.
0:00:41 But that non-addictive promise, it turned out to be wrong.
0:00:46 Addiction to OxyContin,
0:00:47 and then similar drugs from other pharma firms,
0:00:51 spiraled into a public health catastrophe.
0:00:54 In 2023, 81,000 people in the US died from an opioid overdose,
0:00:59 more than 10 times the number in 1999.
0:01:03 So the problem has continued to worsen.
0:01:06 Many of the current overdoses
0:01:08 aren’t from prescription drugs like OxyContin,
0:01:10 but from black market versions
0:01:12 or from other drugs that contain fentanyl.
0:01:15 That’s another synthetic opioid
0:01:17 that began as a medical drug,
0:01:20 and which is far more powerful than most opioids.
0:01:23 Fentanyl has now worked its way into the supply
0:01:26 of street drugs in the US,
0:01:28 most of it smuggled across the Mexican border
0:01:31 by American citizens.
0:01:34 A great many people,
0:01:35 policymakers, medical professionals and regulators,
0:01:38 parents, law enforcement,
0:01:40 they’ve all spent the past few decades
0:01:42 trying to end the opioid crisis,
0:01:44 but without much success.
0:01:46 So as sick as you may be of hearing about it,
0:01:50 imagine being the parent of someone who died from fentanyl
0:01:53 or the husband or the child.
0:01:56 Although you might not have to imagine,
0:01:59 you probably know someone
0:02:01 who’s experienced this kind of tragedy.
0:02:03 It’s that common.
0:02:05 Last week in part one of this two-part series,
0:02:08 we asked a simple question, why?
0:02:10 Why is the opioid crisis still raging after all these years?
0:02:15 There are actually a lot of correct answers to that question.
0:02:19 Here’s one.
0:02:20 So it looks like it’s spreading through social networks,
0:02:24 areas of the country that have more Facebook friends.
0:02:26 Those areas also have more deaths.
0:02:28 Sometimes the physical product will spread through networks
0:02:32 and sometimes just the idea,
0:02:34 oh, when I was in pain, I got this opioid
0:02:37 and maybe you should try this opioid.
0:02:39 That was David Cutler, a health economist at Harvard.
0:02:42 We also heard last week from Keith Humphries,
0:02:44 a drug researcher and policy advisor at Stanford.
0:02:48 Humphries thinks that part of the blame goes to advocates
0:02:50 who want to make drugs easier to get
0:02:52 and want to remove the stigma of drug use.
0:02:56 The faith that the advocates had
0:02:58 that if you removed all pressure
0:03:00 and you removed all shame from, you know,
0:03:04 sitting on a park bench using fentanyl,
0:03:06 then people would seek out care,
0:03:09 proved to be completely incorrect.
0:03:11 Today on Freakonomics Radio, a dissenting voice
0:03:15 who thinks that shame is a big part of the problem.
0:03:18 Sometimes I feel like I’m working
0:03:20 in the days of the Salem Witch trials.
0:03:22 Also, billions of settlement dollars
0:03:25 have started to flow from the pharmaceutical firms,
0:03:29 although not Purdue Pharma,
0:03:30 yet they are still fighting over a bankruptcy plan.
0:03:33 How the states are spending that money
0:03:36 is not always transparent.
0:03:39 Observers say this is not only a moral travesty.
0:03:42 It’s also a travesty from a data perspective
0:03:45 because we’re just going to have no sense
0:03:47 of how these monies were actually spent.
0:03:50 Why is the opioid epidemic still raging?
0:03:53 Part two begins now.
0:03:55 This is Freakonomics Radio,
0:04:10 the podcast that explores the hidden side of everything
0:04:13 with your host, Stephen Dubner.
0:04:16 Stephen Lloyd is a physician in Nashville, Tennessee.
0:04:29 The U.S. has more fatal drug overdoses per capita
0:04:32 than any other country in the world,
0:04:34 and within the U.S., Tennessee is right near the top,
0:04:37 along with West Virginia, the District of Columbia,
0:04:40 Delaware, and Louisiana.
0:04:42 Lloyd works as an addiction recovery specialist,
0:04:45 and he is chair of the Opioid Abatement Council of Tennessee,
0:04:49 which helps direct the settlement money
0:04:51 that is being dispersed to states.
0:04:53 We first spoke with Lloyd several years ago
0:04:55 for an earlier series we did on the opioid crisis.
0:04:59 Here’s what Lloyd was advocating for back then.
0:05:03 I think anytime you lessen the stigma
0:05:05 associated with addiction,
0:05:07 you increase people’s opportunity
0:05:08 to step out of the shadows and ask for help.
0:05:10 So when we got back in touch with Lloyd now,
0:05:13 I asked if the stigma has declined.
0:05:16 He says no.
0:05:18 The opioid crisis has affected everybody
0:05:20 from politicians’ sons to people who are unhoused.
0:05:24 And so you would think that the stigma
0:05:26 would be easier to break here, but it just hasn’t.
0:05:28 I went back and looked to find the first doctor
0:05:30 in the United States that described addiction
0:05:33 as a disease and not a moral failure.
0:05:34 It was actually Benjamin Rush.
0:05:36 And he did it before 1776.
0:05:39 So we’ve known for a really long time
0:05:41 that this is not a moral failure,
0:05:43 but it’s still the predominant thought out there right now.
0:05:46 I don’t know how to break through that.
0:05:47 – Lloyd is the chief medical officer
0:05:49 for a chain of clinics called Cedar Recovery.
0:05:52 Most of their funding comes from the federal government.
0:05:55 – We do outpatient treatment of people
0:05:57 with opioid use disorder.
0:05:58 – I realize this is gonna sound flip,
0:06:00 but I would guess business is booming, unfortunately, yes?
0:06:03 – Yeah, sadly, and I’m with you.
0:06:05 I hope one of these days to be out of business,
0:06:07 but yes, unfortunately,
0:06:08 it’s growing faster than any of us would like.
0:06:10 If I make it till July 8th of this year,
0:06:12 I’ll be 20 years in recovery myself.
0:06:14 – Congratulations.
0:06:15 – You know, a unique spin with not only being a doctor,
0:06:18 but a doctor who was addicted earlier in his career
0:06:21 to the very drugs that started all this
0:06:23 with pain pills and really the drug OxyContin.
0:06:25 – Does that give you an advantage
0:06:27 as a physician in this kind of treatment mode?
0:06:29 – I sure think so because I’ve been there.
0:06:31 I’ve stolen pills out of people’s medicine cabinets.
0:06:34 I’ve been dope sick more times than I can shake a stick at.
0:06:36 So when somebody comes in to me
0:06:38 and I can see that they’re in withdrawals,
0:06:40 it’s not something I blow off.
0:06:42 – Do you tell them about your background
0:06:44 and how does that affect your treatment of them?
0:06:46 – Most of the time, they know coming in,
0:06:48 but I always lead off with it
0:06:50 because one of the hardest things to do
0:06:51 is overcome the shame and the stigma.
0:06:53 So I just let them know that their doctor’s been there
0:06:55 and I had to overcome the same things.
0:06:57 – When you look at what’s been happening
0:07:00 with opioid abuse and opioid overdose death
0:07:03 in the last several years since we first spoke,
0:07:07 I never would have predicted
0:07:08 it would have continued to rise like it has.
0:07:11 What’s your best assessment,
0:07:14 whether it’s opinion or informed by data
0:07:17 of why there’s still so much opioid overdose and abuse?
0:07:21 – I think the last time we talked was four or five years ago
0:07:24 and I’m with you,
0:07:25 but I don’t think either one of us saw COVID-19
0:07:28 and COVID really changed the landscape
0:07:31 because if you think about addiction
0:07:32 and realizing that the solution is community
0:07:35 and relationship, it’s about connection.
0:07:37 And then look at how we treated COVID
0:07:39 and I’m not saying things were done wrong.
0:07:41 We were all isolated, right?
0:07:42 We were in our homes, we were working from home,
0:07:43 we weren’t interconnecting.
0:07:45 I knew that it was gonna kill our folks and it did.
0:07:48 Overdose rates in the South were up between 40 and 50%.
0:07:51 Any state you looked at.
0:07:52 So when you and I first talked, I never saw this,
0:07:54 but of course I didn’t see COVID-19.
0:07:56 – Do you feel it’s plateaued?
0:07:58 – I’m hoping, you know, I work in a lot of states
0:08:00 and so I’m starting to see some evidence of some plateauing.
0:08:03 I know that here in Tennessee, it does look like that,
0:08:06 but even if we spend our open abatement dollars
0:08:08 very, very wisely, it’ll take at least until the year 2046
0:08:12 to get back to pre-1996 numbers,
0:08:15 which is a pretty daunting thought.
0:08:16 – Those numbers that Lloyd just cited
0:08:21 that overdose death rates in the South
0:08:23 were up 40 or 50% during COVID, I was skeptical.
0:08:27 So I went and looked up the numbers.
0:08:29 Turns out he was actually understating the COVID spike.
0:08:33 Overdose deaths in Alabama, Louisiana and Tennessee
0:08:36 were up more like 100% from 2018 to 2021,
0:08:41 a doubling during COVID.
0:08:43 So this gets me to wanting to ask you about fentanyl.
0:08:49 When you were addicted, it was a different scenario really.
0:08:54 Can you talk about the substances now
0:08:57 and how that’s changed the game?
0:08:59 – It’s so weird you ask me this
0:09:00 ’cause I’ve actually struggled a little bit
0:09:02 over the past couple of weeks
0:09:03 because my sobriety date’s coming up July 8th
0:09:06 and between May and July are usually fairly tough times for me
0:09:09 because I go back 20 years and remember where I was.
0:09:12 And the thing I realized was that when I was using back
0:09:14 in early 2000s, fentanyl was not a thing.
0:09:17 I mean, it was a drug and it was in the hospital
0:09:19 and they were using it in surgeries
0:09:20 and for cancer patients with patches and sprays,
0:09:23 but it wasn’t illicit powder fentanyl
0:09:25 that’s in absolutely everything now.
0:09:27 And it dawned on me that it’s very likely
0:09:30 towards the end of my using when I had to go to the street
0:09:32 to get my supply that I would have run across fentanyl.
0:09:34 So the landscape is night and day compared to 2004.
0:09:38 – It sounds like what you’re saying is
0:09:41 that if you’d been born 20 years later
0:09:42 and lived the same life, you’d have been dead by now.
0:09:44 – I’d have died, yeah, and that was the struggle
0:09:46 because I recently become a grandparent.
0:09:49 I can’t help myself, but to go there sometimes
0:09:51 because 20 years later, you’re exactly right.
0:09:53 There is a very high likelihood I would have died.
0:09:56 – I have a really naive question
0:09:58 because fentanyl is so deadly
0:10:00 and because fentanyl is now so common
0:10:03 in the illicit drug supply,
0:10:05 why is that not enough to diminish demand?
0:10:09 – Yeah, that’s always a good one.
0:10:11 And to understand that,
0:10:12 you’ve got to understand a little bit
0:10:13 about the brain changes that happen in substance use.
0:10:16 Essentially what happens is you lose access
0:10:18 to the frontal lobe of your brain.
0:10:19 And the frontal lobe of your brain is only important
0:10:21 if you care anything about insight, judgment, and empathy.
0:10:24 – Okay, and so if you’ve got somebody
0:10:26 that’s solely driven by their pleasure center
0:10:28 with no override from that, you know,
0:10:30 insight, judgment, and empathy standpoint,
0:10:32 I think you can pretty clearly see
0:10:33 how come fentanyl doesn’t matter.
0:10:35 Today we’re like, well, we’re not gonna use that,
0:10:36 it’ll kill us.
0:10:37 But we have fully functioning frontal lobes
0:10:39 and people who are using don’t.
0:10:41 – How much is it that versus or in addition to the fact
0:10:45 that it’s just a great wild card in the drug supply?
0:10:49 In other words, even if you do know about fentanyl,
0:10:52 even if you are aware of its danger,
0:10:54 even if you’re willing to take a chance once in a while,
0:10:58 no one really knows how much of it is in the supplier,
0:11:01 whether it might be in a given batch.
0:11:04 So is that a bigger problem?
0:11:06 Or do you think the bigger problem is just the fact
0:11:08 that the high is too appealing
0:11:09 and that the logic chain doesn’t even happen?
0:11:12 – Oh, I think both of those things in combination
0:11:14 are the problem.
0:11:16 I mean, when I was using, I wanted the next thing
0:11:18 that would get me where I needed to be.
0:11:20 And if there was something that would get me there quicker
0:11:21 or more intensely, I mean, that was the goal.
0:11:24 Now you couple that with loss of that executive function
0:11:28 coming from your frontal lobe of your brain
0:11:30 and you can see, you know, how people get in trouble.
0:11:33 – This trouble became so severe, so widespread
0:11:36 that states and cities across the country
0:11:39 sued the manufacturers of the legal opioids
0:11:42 that started the crisis,
0:11:43 along with the distributors and consultants
0:11:45 who helped promote the drugs.
0:11:47 – A number of states have now agreed
0:11:49 to a $26 billion settlement
0:11:52 with three large drug distributors
0:11:54 and Johnson & Johnson
0:11:56 for their roles in the opioids epidemic.
0:11:59 CVS & Walgreens paying out $10 billion
0:12:02 to settle lawsuits over the opioid crisis.
0:12:05 – McKinsey & Company is gonna pay nearly $600 million
0:12:09 for consulting businesses
0:12:10 on how to sell more prescription opioid painkillers.
0:12:14 – Although, as I mentioned earlier,
0:12:16 the big one is still unresolved.
0:12:19 – Today, the Supreme Court will review
0:12:21 a $6 billion bankruptcy settlement
0:12:24 between Purdue Pharma, the maker of OxyContin
0:12:26 and the victims and communities
0:12:28 ravaged by the opioid crisis.
0:12:30 – Coming up after the break,
0:12:34 how will these billions be used
0:12:36 and what is it going to accomplish?
0:12:39 I’m Stephen Dubner.
0:12:40 This is Freakonomics Radio.
0:12:41 We will be right back.
0:12:42 (upbeat music)
0:12:45 – There have been a lot of bad actors
0:12:54 in the opioid crisis.
0:12:56 The most widely vilified is Purdue Pharma,
0:12:59 the private drug maker largely owned by the Sackler family,
0:13:02 which made and sold the pain medication OxyContin
0:13:05 under the false premise that it was less addictive
0:13:07 than other opioids.
0:13:09 But other companies have also been implicated.
0:13:11 Manufacturers like Johnson and Johnson,
0:13:14 Allergan and Teva, as well as distributors, pharmacies,
0:13:18 pharmacy benefit plans, and the consulting firm McKinsey,
0:13:22 which helped Purdue sell more drugs.
0:13:26 All this has prompted thousands of lawsuits,
0:13:28 some of them ongoing, but many already settled.
0:13:32 These settlements will direct around $55 billion
0:13:35 to the states to be distributed over the next 18 years.
0:13:39 The Sackler family’s bankruptcy settlement
0:13:41 could add another $6 billion to the settlement pool.
0:13:45 Most of the settlements require the states
0:13:48 to spend 85% of the money
0:13:50 to directly address the opioid crisis.
0:13:53 – This money has to go for certain things.
0:13:55 You can’t just use it to balance your budget
0:13:57 in your state or build roads and highways.
0:13:59 – That again is Stephen Lloyd,
0:14:01 the Tennessee physician who chairs
0:14:03 his state’s opioid abatement council.
0:14:06 – And so we’ve got an actual chance
0:14:07 at this one actually making a difference
0:14:09 for what it was intended to.
0:14:10 – Can you talk about the process in Tennessee?
0:14:13 How much is the money flowing so far
0:14:15 and where it’s being applied?
0:14:17 – Oh, it’s flowing, thank goodness, Stephen.
0:14:19 I’m really proud of that.
0:14:20 So Tennessee took 15% of their money
0:14:23 from the funded minister or it goes to our general assembly.
0:14:25 The politicians can spend it on what they want to.
0:14:27 – Okay, so 15% is essentially slush fund.
0:14:30 That’s not directly for opioids.
0:14:32 – Yeah, you said that, not me.
0:14:33 – Okay, fair enough.
0:14:34 And then another 15% went to Tennessee as 95 counties.
0:14:37 So another 15% went directly to those counties
0:14:40 based on a formula that was agreed upon,
0:14:42 population and problem.
0:14:44 So they can actually use that for anything they want.
0:14:46 So that’s 30% of the money.
0:14:48 – But that second 15%, the share was derived
0:14:51 from the amount of opioid trouble in that county though
0:14:54 or no?
0:14:55 – That’s exactly right.
0:14:56 – But even so it’s non-directed funds.
0:14:58 I can use it however I want.
0:14:59 – You can hire a dog catcher if you want.
0:15:01 – Got it.
0:15:02 – And then the remaining 70%,
0:15:03 the general assembly and our governor in Tennessee
0:15:05 set up an independent council that has decision-making
0:15:08 authority made up of 15 people appointed by our governor,
0:15:10 our speaker of the house and our lieutenant governor.
0:15:13 And they will decide how that 70% is spent.
0:15:16 Now, 35% of that 70% goes back to the counties again
0:15:20 based on that same formula from last time.
0:15:22 Only this time it has to go from something
0:15:25 called a remediation list.
0:15:27 And a remediation list even is basically
0:15:28 an abatement plan and we will hold them accountable.
0:15:31 So Tennessee has had two distributions to that one already,
0:15:34 both of them in excess of $30 million
0:15:37 that went to those individual counties.
0:15:39 Now that’s 35% of the 70, the remaining 65% of the 70
0:15:44 was made available through a competitive grant process,
0:15:47 which we just finished up the first round.
0:15:50 – Give me a list of some things where that money is going.
0:15:53 – Well, there’s four big buckets out there,
0:15:54 prevention, education, treatment
0:15:56 and something called harm reduction.
0:15:58 So how do you break that money up
0:16:00 in each of those individual buckets
0:16:01 and those strategies to get to the goal that you want,
0:16:03 which is actually shrink the number of people who use drugs.
0:16:06 And I think that is the challenge
0:16:07 and that is the ball that I see being dropped right now.
0:16:10 You know, they say, well, how did you decide
0:16:12 how much went in each of the four buckets in Tennessee?
0:16:14 And I said, well, we use something called a swag method,
0:16:16 scientific wild ass guess.
0:16:18 – Lloyd would like to replace that guesswork
0:16:22 with something more reliable.
0:16:24 He is a member of a consortium called the Helios Alliance,
0:16:27 which uses data science to try to learn
0:16:29 which interventions are most effective
0:16:31 and most cost effective.
0:16:33 – You start looking at this money as it comes in.
0:16:36 How do you allocate it to the individual strategies
0:16:39 to get to a result that you’re trying to look for?
0:16:42 Because if you just stick it out there, Stephen,
0:16:44 and you measure it on the back end,
0:16:45 how do you know if you’re even successful?
0:16:47 – Based on what he’s learned so far,
0:16:49 Lloyd says that of the four buckets,
0:16:51 prevention, education, treatment and harm reduction,
0:16:54 prevention offers the best return on investment.
0:16:58 For every $1 that you invest in prevention with opioids,
0:17:01 it’s an $11 downstream savings.
0:17:03 Nothing’s even close to that.
0:17:04 Treatments like one to four.
0:17:06 – What about education?
0:17:07 – Education, I would put as part of treatment.
0:17:10 Education is gonna break down the barriers
0:17:12 to people getting into treatment.
0:17:14 – And what about harm reduction?
0:17:15 – Harm reduction is simply keeping people alive.
0:17:18 And I’m not sure what the return on investment dollar is,
0:17:20 because right now, if Stephen Dubner overdoses,
0:17:23 and we take you to the hospital here at Vanderbilt,
0:17:25 you’re gonna be in there until they get you stable,
0:17:27 and then you’re gonna hit the door.
0:17:28 And there’s a good chance that you’re gonna overdose again
0:17:31 the same afternoon and be right back in there.
0:17:33 That happens all the time.
0:17:35 So you’re spending a lot of harm reduction dollars,
0:17:37 but a lot of times you’re spending it on the same people,
0:17:39 just rotating in and out of emergency departments
0:17:41 after the overdose.
0:17:42 And that’s where we need to look at this system of care
0:17:45 that your patient steps into.
0:17:47 So some of the ideas, let me give you a good one.
0:17:49 University of Tennessee Knoxville
0:17:51 has an emergency department program
0:17:52 where if you come in and you’ve overdosed,
0:17:54 as soon as they get you stable, they’ll call a peer.
0:17:56 Somebody who’s had this problem themselves,
0:17:58 they’ll come down and talk to you
0:17:59 and link you up to treatment right out
0:18:01 of the emergency department.
0:18:03 Those are the kind of things that I’m talking about.
0:18:06 One of the things I see that dismays me
0:18:08 is that a lot of people in this space
0:18:10 are only interested in their part of it.
0:18:12 I’m part of the treatment world myself.
0:18:14 The reality is, when it comes to addiction,
0:18:16 I’m a prevention guy,
0:18:18 because I think it’s the only way
0:18:19 that we move the needle going forward.
0:18:21 – But what if I hear you give this pitch
0:18:23 about these four buckets,
0:18:24 and then I hear that the return on investment
0:18:25 of prevention is $1 spent,
0:18:27 you get $11 on return, and that easily beats all the rest.
0:18:31 I say to you, oh, that’s fantastic.
0:18:33 Let’s not worry about the other stuff.
0:18:35 Let’s put it all in prevention.
0:18:36 What would you say to that?
0:18:38 – Well, I would think I was talking
0:18:39 to somebody other than Stephen Dubner, first of all,
0:18:41 because now you’re talking about letting people die.
0:18:44 And I hope I never get to that point in my career,
0:18:46 because that argument has been made.
0:18:48 And here’s the problem with letting people die.
0:18:50 They leave people behind, and a lot of times they’re kids.
0:18:52 And if you look at the drivers of addiction
0:18:54 as being genetics, trauma, and opportunity,
0:18:57 you’re really not going to be able to kill your way
0:18:58 out of this because of what’s left behind.
0:19:00 So I have made the argument forever
0:19:03 that the first step in prevention
0:19:04 is treatment of mom and dad.
0:19:06 And I think I can make that argument stick.
0:19:08 Almost all of medicine is harm reduction.
0:19:11 We don’t cure diabetes, right?
0:19:12 We treat it to prevent the sequela, you know,
0:19:14 heart attacks and strokes,
0:19:16 but it’s hard to get people to see that
0:19:17 when it comes to substance use disorder.
0:19:19 In 2004, if somebody had said,
0:19:22 “Steve, you have this addiction to oxycontin,”
0:19:24 so what we’re going to do,
0:19:25 we’re just going to give you oxycontin,
0:19:26 all you want until you’ve had enough, okay?
0:19:29 I would have died.
0:19:31 So did we need to keep me alive?
0:19:33 I hope, yes, we did need to keep me alive,
0:19:35 but we also needed a path for me to get into recovery
0:19:37 so I could raise my family
0:19:39 and make sure I’m not creating
0:19:40 the next generation right behind me.
0:19:42 – When you talk about diabetes, it strikes me,
0:19:44 that could be a pretty apt comparison
0:19:46 in that a lot of cases of diabetes
0:19:49 are brought about by personal choices
0:19:51 and personal behavior, right?
0:19:52 Diet, nutrition, exercise or the lack thereof,
0:19:55 would you agree with that or not quite?
0:19:57 – Absolutely.
0:19:57 I mean, now type one’s different, right?
0:19:59 – Type one’s different, yeah, let’s cross that off.
0:20:01 – But far and away that, you know,
0:20:02 most common cause of diabetes is type two
0:20:04 and it’s behavioral.
0:20:06 Most of type two diabetes is because of, you know,
0:20:08 eating chocolate, cake and drinking Mountain Dew Code Red.
0:20:10 And we have no issues
0:20:13 with intervening with medication and diabetes.
0:20:15 What’s the first line treatment for diabetes?
0:20:16 Diet and exercise, all right?
0:20:18 And I challenge anybody out there
0:20:20 to show me five patients in their practice
0:20:22 that adhered to their diet and exercise
0:20:23 and control their blood sugar.
0:20:25 Yet, if you see somebody out there
0:20:27 who’s got their A1C less than 6.5
0:20:29 and they’re on three different medications
0:20:30 in order to do so, nobody’s asking them
0:20:32 when they’re gonna come off.
0:20:33 They’re just glad that they’re not at such high risk
0:20:36 to have these bad things happen.
0:20:38 Again, addiction is treated differently
0:20:40 than every other disease I can think of in our country.
0:20:43 (upbeat music)
0:20:46 – So Stephen, you have been sketching out
0:20:48 a lot of the problems here.
0:20:49 Do you have any good news?
0:20:52 You know, if you’re listening to this
0:20:53 and you wanna know what’s going on
0:20:54 with the money in your county,
0:20:56 then you need to get involved
0:20:57 and you need to make your voice heard,
0:20:58 particularly if you have lived experience.
0:21:00 And so I think there is good news, Stephen.
0:21:02 And I think there’s people out there
0:21:03 that are starting to listen
0:21:05 to some of the things that we’re talking about.
0:21:07 When that happens,
0:21:07 when it happens on a big enough scale,
0:21:09 then I think we have a chance
0:21:10 at tying some systems together
0:21:12 that have a chance to become a system of care
0:21:14 over the next two to three decades.
0:21:16 – How do you suggest people get involved?
0:21:18 – Starts at the local level.
0:21:19 A lot of this money is going directly to the counties
0:21:22 as I described to you.
0:21:23 I guarantee you that the mayor of your county
0:21:25 or the city commission or county commission where you live,
0:21:28 they know they got a big check.
0:21:29 Okay, came as a wire transfer.
0:21:31 Ask them what they’re doing with it.
0:21:32 Ask them what the process is and how to spend it.
0:21:34 (upbeat music)
0:21:37 – There’s also a way to track the $55 billion
0:21:40 in settlement money,
0:21:41 or at least try to track it.
0:21:43 That is thanks to this person.
0:21:45 – My name is Christine Minhee.
0:21:47 I am the founder of OpioidSettlementTracker.com.
0:21:50 Minhee received her law degree
0:21:52 from the University of Washington in 2019.
0:21:55 – I started the project after I got obsessed
0:21:58 with the big tobacco litigation as a law student,
0:22:02 quickly realized that we were hurtling
0:22:04 into the same dismal landscape of poor spending
0:22:08 with opioid settlements without any guardrails.
0:22:12 – In 1998, the four biggest tobacco companies in the US
0:22:16 agreed to what was called
0:22:17 the Tobacco Master Settlement Agreement.
0:22:20 This meant paying out some $250 billion to the states
0:22:24 to help cover the costs incurred
0:22:26 by the consumption of their product.
0:22:28 A product that like Oxycontin was legal,
0:22:32 but carried significant risks
0:22:34 that the manufacturers lied about.
0:22:37 That $250 billion has gone into state budgets
0:22:40 where it was spent on healthcare costs for smokers,
0:22:43 on anti-smoking campaigns,
0:22:46 but sometimes just to make up budget shortfalls.
0:22:49 That’s what Christine Minhee doesn’t want to see repeated
0:22:52 with the opioid settlement money.
0:22:54 – That nightmare of big tobacco spend
0:22:57 certainly cast a pall over the opioid settlement landscape.
0:23:01 So I didn’t trust that there was going to be another entity
0:23:05 that would watch how these settlements would be spent.
0:23:07 And I decided to just create a beta concept
0:23:11 that I imagined some agency would take over after.
0:23:15 But lo and behold, a number of years later,
0:23:17 I’m continuing to do this.
0:23:18 – As we heard earlier from Steven Lloyd,
0:23:20 there is a formula for how the opioid settlement money
0:23:23 is to be distributed.
0:23:25 – The way that they’re divvied up across the states
0:23:27 is determined by a single table
0:23:29 and the settlement agreements actually.
0:23:31 And this global allocation percentage table
0:23:35 is derived by using a formula that uses three factors,
0:23:40 how many pills were shipped to a particular jurisdiction,
0:23:43 how many folks have died
0:23:45 from an opioid use disorder related overdose,
0:23:48 and how many folks are currently suffering from OUD
0:23:52 within a particular jurisdiction.
0:23:54 – But once you get past that formula, Minhee found,
0:23:58 there wasn’t much in the way of accountability
0:24:00 of how the money would be spent.
0:24:02 – The reporting requirements attached
0:24:04 to the opioid settlement agreements
0:24:06 are virtually non-existent.
0:24:08 – With opioidsettlementtracker.com,
0:24:10 she is hoping to change that.
0:24:12 So far, 20 states do voluntarily report
0:24:16 all their settlement spending.
0:24:18 Others, including Tennessee,
0:24:20 are reporting some of their spending,
0:24:22 but some don’t make any information public.
0:24:25 – Texas has decided not to report its specific expenditures.
0:24:29 We have no official state promulgated proof of spend
0:24:34 for Texas’s $2.8 billion.
0:24:37 And that is a travesty for all of the million
0:24:41 moral reasons that I can input.
0:24:43 But it’s also a travesty from a data perspective
0:24:47 because we’re waltzing into this landscape
0:24:49 where we’re just gonna have no sense
0:24:51 of how these monies were actually spent
0:24:53 or whether or not they’re moving the needle on public health.
0:24:56 – You keep distributing money to the same things
0:25:01 that you’ve been distributing it for the last 20 years
0:25:03 that have led you here.
0:25:04 – Stephen Lloyd again.
0:25:05 – The only way to break that is to do something different.
0:25:08 I mean, the definition of insanity, right?
0:25:10 Doing the same thing over and over,
0:25:11 expecting a different result.
0:25:12 – When you talk about the money that’s been spent
0:25:14 and hasn’t achieved the goal,
0:25:16 how is that money historically or traditionally spent?
0:25:19 – It comes in from the federal government,
0:25:21 usually in block grant through its State Department
0:25:23 of Mental Health or Substance Abuse
0:25:24 or whatever their equivalent is.
0:25:25 And then they dole it out to their organizations
0:25:27 who are carrying out programs in their state.
0:25:30 And my issue with that,
0:25:31 and I’m not knocking the work that’s being done,
0:25:34 there’s a lot of people doing really, really good work.
0:25:37 I wanna see meaningful outcomes,
0:25:38 not how many people we were able
0:25:40 to do a physical exam on in 24 hours.
0:25:43 Is that important?
0:25:43 Yes, do I care?
0:25:45 No, I don’t care.
0:25:46 What I care about is how many of those people
0:25:48 went through the program and when they got out,
0:25:51 were able to sustain their recovery.
0:25:53 How many of them got back into their jobs?
0:25:55 How many of them got a new job?
0:25:56 How many of them were able to provide for their family?
0:25:58 I want meaningful data.
0:26:01 Just like we would for heart attack.
0:26:02 If you put a stint in somebody,
0:26:04 “Oh, we gotta stand in there and the flow was great.”
0:26:06 And two days later, they died of a heart attack.
0:26:08 Okay, if you just measured the flow and said that’s a success,
0:26:11 I would tell you that was a failure.
0:26:12 So it sounds like there is a greater than zero chance
0:26:16 that if we were talking 15 or 18 years from now,
0:26:20 that someone, maybe you, would have the same complaints
0:26:23 about how the money has been spent
0:26:25 that you’ve had about how the money has been spent,
0:26:28 for instance, in West Virginia over the past 20 years.
0:26:30 What do you think are the odds of that?
0:26:32 It’s my nightmare.
0:26:33 I mean, not very many things keep me up at night anymore.
0:26:37 This one keeps me up at night because I’m scared
0:26:39 that we’re going to, we’re going to blow it.
0:26:41 So when I speak with you, Stephen,
0:26:43 I get the sense that addiction is sort of a language
0:26:47 that if you don’t speak it, you don’t speak it.
0:26:50 And that’s a problem because you need people
0:26:53 who don’t speak the language to be involved in,
0:26:57 let’s say, the treatment or the teaching of that language.
0:27:01 If you have policymakers that don’t speak the language
0:27:03 and don’t understand what I just said,
0:27:05 think of some of the things
0:27:06 that you can come out of this with.
0:27:08 I mean, policy that’s harmful.
0:27:09 – So what kind of policies won’t be harmful?
0:27:15 That’s after the break, I’m Stephen Dubner,
0:27:17 and this is Freakonomics Radio.
0:27:19 The United States has the highest rate
0:27:31 of drug overdose deaths in the world.
0:27:33 And in recent years, the problem has continued to worsen.
0:27:37 As we’ve been discussing over these past two episodes,
0:27:40 the opioid epidemic has a variety of causes,
0:27:44 but what about the consequences?
0:27:46 The death and suffering and broken families,
0:27:50 those are all front and center, but there are others.
0:27:54 Because this crisis originated
0:27:56 with the legal medical distribution
0:27:59 of an addictive substance,
0:28:01 the medical community especially has fought back hard.
0:28:05 Everyone now admits that opioids
0:28:07 were wildly overprescribed for a long time.
0:28:10 And since 2010, the rate of opioid prescription
0:28:15 has fallen by at least 50%.
0:28:17 The system has made it significantly harder
0:28:20 to get certain drugs.
0:28:22 But this too has had a cost.
0:28:25 A lot of people who need these drugs for pain management
0:28:29 aren’t able to get them.
0:28:31 Most people who use prescription opioids don’t become addicted,
0:28:35 but because some do, and because this addiction
0:28:39 to illegal product created a massive market
0:28:42 for illegal versions of that product,
0:28:45 the legitimate prescription of some opioids
0:28:47 by legitimate physicians has been constrained.
0:28:51 And people have suffered because of that too.
0:28:54 In 2022, the CDC issued new prescription guidelines
0:28:58 that continue to emphasize opioid alternatives,
0:29:01 but also call for flexibility
0:29:04 to allow their use when needed.
0:29:06 Perhaps all these wrinkles shouldn’t surprise us.
0:29:10 Every epidemic has its own history,
0:29:13 its own trajectory and rebound effects,
0:29:16 its own way of making trouble.
0:29:18 I asked Stephen Lloyd if he could point to an epidemic
0:29:22 from history, whether ancient or modern,
0:29:25 that seems to parallel the opioid epidemic.
0:29:28 – Stephen, I think the opioid epidemic
0:29:30 is this generation’s HIV and AIDS.
0:29:33 There’s so many parallels.
0:29:34 I’m getting ready to be 57.
0:29:36 And so I lived through that in the early ’80s.
0:29:38 First of all, it’s the descents.
0:29:40 If somebody had HIV disease, they were gonna die
0:29:41 and we knew it.
0:29:43 The really big thing was stigma.
0:29:44 Don’t swim in the pool with these kids
0:29:46 and really the biggest hurdle
0:29:47 because we actually had AZT pretty early on
0:29:49 in the AIDS epidemic,
0:29:50 but there were barriers to getting the treatment.
0:29:53 And then you had these groups.
0:29:54 The one I remember is ACT UP.
0:29:56 Got out and made a lot of noise
0:29:57 and started fast-tracking medications through the FDA.
0:30:00 And then you had several notable cases
0:30:02 that started to change the face of it.
0:30:04 Ryan White, Arthur Ashe, Urban Magic Johnson.
0:30:07 You look at HIV disease and AIDS.
0:30:09 And now when’s the last time you saw an article on it?
0:30:11 My son just turned 30 years old
0:30:13 and he doesn’t remember HIV and AIDS being a descents.
0:30:17 And if you parallel that to what we’re seeing
0:30:19 with the opioid epidemic, there are so many similarities.
0:30:21 What’s the biggest thing that prevents people
0:30:23 from getting treatment right now, stigma?
0:30:25 But it’s been a while now.
0:30:27 Why do you think the stigma has not receded?
0:30:29 People just look at addiction differently, Stephen.
0:30:32 Last night, I was in a rural town here
0:30:34 just east of Nashville and the decision makers
0:30:37 in that town understood almost nothing about addiction.
0:30:40 You’re still under the impression that,
0:30:42 well, this little town doesn’t need
0:30:44 what you wanna bring here because we’re not Memphis
0:30:46 or we’re not Nashville or New York City.
0:30:48 And that’s somebody who doesn’t understand
0:30:50 the demographics of this.
0:30:52 I mean, this started out as a rural problem
0:30:53 and it still is a rural problem.
0:30:55 And so you’re off base there,
0:30:57 but then you wanna send somebody away for 10, 20, 30 days
0:31:00 and have them come back fixed.
0:31:02 And that’s not how this works.
0:31:03 It’s a lifelong process.
0:31:04 And so if those are the people driving your policy,
0:31:07 then you can start to imagine some of the things
0:31:09 you come out of this with and you actually have people
0:31:11 that will die never knowing that there’s life-saving
0:31:13 medication out there to help them.
0:31:15 Sometimes I feel like I’m working
0:31:17 in the days of the Salem witch trials
0:31:19 because we know so much about addiction.
0:31:21 Now, we know things that are effective.
0:31:23 We know medications that are effective,
0:31:25 but when you start getting in rural territories,
0:31:27 you’re right back to those times
0:31:30 where you’re looking at this as a moral failure
0:31:31 and the only treatment is a higher power or a deity.
0:31:35 I ran into it last night in front of that zoning commission
0:31:38 and I couldn’t overcome it.
0:31:40 I lost.
0:31:41 – You said you couldn’t get them to buy
0:31:43 what you were selling.
0:31:43 What were you selling in that case?
0:31:45 – I was trying to show them the fact that addiction
0:31:48 is like any other medical disease
0:31:50 that deserves the same opportunities for treatment.
0:31:53 That’s it.
0:31:54 – Were you proposing a facility?
0:31:55 Were you proposing?
0:31:56 – Facilities that did everything.
0:31:58 Behavioral health counseling, mental health issues,
0:32:00 getting a family of origin issues,
0:32:02 all the stuff that goes around addiction
0:32:04 like housing, stable food source, income,
0:32:06 and then for the population that needs it, medication.
0:32:09 And when you start talking medication,
0:32:10 particularly in rural areas,
0:32:12 the thing that pops out right off the bat,
0:32:13 oh, you’re just trading one drug for another.
0:32:15 That’s it.
0:32:16 They seem to not understand that we’re going to save lives.
0:32:20 And if I’m completely honest,
0:32:22 the biggest drawback that I have in the States I work in
0:32:25 is the church.
0:32:26 – Because the church has a kind of bright line
0:32:28 over use, don’t use?
0:32:30 – Absolutely.
0:32:31 If you pray enough and you walk enough little old ladies
0:32:33 across the street, then you won’t have this issue.
0:32:36 One of the arguments last night is,
0:32:38 and these are their words, not mine,
0:32:39 ’cause I don’t use these words,
0:32:40 but we’re gonna bring drug addicts in here.
0:32:43 Well, I’ve been working in that particular town
0:32:45 for a good while, and I can promise you,
0:32:47 they’re already there.
0:32:48 – This is a paraphrase of you describing
0:32:50 how the Helios model works.
0:32:53 The idea is to use statistical modeling
0:32:55 and artificial intelligence to simulate the opioid crisis,
0:32:58 predict which programs will save the most lives
0:33:01 and help local officials to decide
0:33:03 the best use of settlement dollars.
0:33:05 It sounds good, but I could also see someone hearing that
0:33:08 and saying, oh, that just sounds like consultants
0:33:12 getting their piece of this.
0:33:14 And it doesn’t sound close enough to the ground to me.
0:33:18 It doesn’t sound like it’s going to physically address
0:33:22 the actuality of this epidemic.
0:33:24 What would you say to that suspicion?
0:33:26 – First of all, I’ve never been accused
0:33:28 of being a consultant,
0:33:29 and I’m certainly not McKenzie material.
0:33:32 It’s what I see, and I saw it when we modeled the cases,
0:33:35 ’cause my job in the cases was to show causation, right?
0:33:38 To draw a direct line from the mispromotion
0:33:40 of the drug oxycontin to today’s heroin
0:33:41 and fentanyl epidemic, that’s my job.
0:33:44 And when I saw what modeling did to reinforce the story
0:33:48 that I told that I physically saw and experienced
0:33:51 as a patient and a provider, I was overwhelmed by it.
0:33:55 And so it may sound like consultants speak
0:33:57 and maybe somebody cleaned my words up.
0:33:59 I mean, you’ve talked to me long enough to know
0:34:01 that I probably can’t talk that well.
0:34:02 – Yeah, I was going to say those words on the page
0:34:04 don’t really sound like you sound now that I’m talking to you.
0:34:07 – They don’t, so somebody cleaned them up,
0:34:09 but the idea is the same.
0:34:10 And the idea is that we have to know
0:34:12 what our current assets are, what our current system is.
0:34:14 We have to be able to model that
0:34:16 so that we can make the best decisions
0:34:17 on how to allocate the money.
0:34:19 And that’s Steve Lloyd’s words.
0:34:20 – Stephen Lloyd plainly believes
0:34:24 that the stigma associated with addiction
0:34:26 is a major reason this epidemic has continued to rage on.
0:34:31 In part one of this series,
0:34:32 we featured the Stanford Drug Researcher
0:34:34 and Policy Advisor, Keith Humphries.
0:34:37 He believes that stigma is important,
0:34:39 that if you remove all the barriers from drug use,
0:34:43 not just legal barriers, but social barriers,
0:34:46 then you are inviting trouble.
0:34:49 That said, Humphries and Lloyd do agree
0:34:51 that the opioid crisis has gone on far too long,
0:34:55 that there are ways to stop it,
0:34:57 and that the settlement money coming in now
0:34:59 from the opioid producers is a key to all of that.
0:35:03 We went back to Humphries for his take
0:35:05 on how the money should be spent.
0:35:08 – These settlements are massive.
0:35:09 They are multi-billion dollar settlements.
0:35:12 They are, however, paid out over very long periods.
0:35:15 So I was talking to a governor about what impact it has.
0:35:19 She said, it’s like an extra 6% of our budget
0:35:22 for the next 25 years.
0:35:24 So when you thought of it that way,
0:35:25 it’s like, oh, that’s not really that much.
0:35:26 I mean, you know, it’s at billions,
0:35:27 but if it’s paid out over very long times, right?
0:35:30 So, you know, the question will be
0:35:33 since this is to abate the problem
0:35:34 is how do municipalities and states
0:35:38 use it as wisely as possible?
0:35:40 And what I tell them is like,
0:35:41 don’t spend any money on anything
0:35:43 some other funding stream covers.
0:35:46 Like building a clinic, that’s,
0:35:48 where do you get money to build?
0:35:49 Medicaid, Medicare will not pay to build a clinic.
0:35:51 But if you build a clinic and if you have staff,
0:35:53 then Medicaid and Medicare will pay your staff sorry forever.
0:35:57 I’ve also been pitching,
0:35:57 please do something for prevention
0:35:59 because, you know, we have funding streams,
0:36:02 private and public insurance,
0:36:04 that pay for the care of people who are ill,
0:36:05 but there really isn’t, you know,
0:36:07 good funding streams for prevention
0:36:09 for people who are not yet ill, mainly kids.
0:36:13 – There is an organization at the University of Washington
0:36:15 that Humphrey sees as a good model
0:36:17 for setting up youth prevention systems.
0:36:20 They’re called communities that care
0:36:21 and they consult with various communities
0:36:24 to in their language,
0:36:25 promote the healthy development of young people.
0:36:28 – Making investments in kids around the ages of 10, 11, 12
0:36:32 has many good outcomes.
0:36:34 A lot of people don’t think about prevention enough.
0:36:36 They think about the current crisis,
0:36:37 but you have to think long-term
0:36:38 if you want to deal with epidemics.
0:36:40 So I would use this money for things,
0:36:42 nothing else can pay for.
0:36:43 So that would be prevention with kids
0:36:45 ’cause there is no funding stream for that.
0:36:47 I would certainly do infrastructure.
0:36:50 There’s places where there are no methadone clinics.
0:36:52 So you need a building.
0:36:53 You can’t pay for a building with health insurance,
0:36:55 but you could pay for it with this.
0:36:57 Could also potentially do some things with technology.
0:36:59 So you can have investments for telehealth.
0:37:01 So people don’t have to come in as often
0:37:04 that often there’s a way to retain them and care better.
0:37:06 That’s something we could do.
0:37:08 Let’s think, what hangs over all this
0:37:09 is the shadow of the tobacco settlement.
0:37:11 Very little of it was spent on tobacco.
0:37:14 You know, pottles and that kind of thing.
0:37:15 So there’s far more monitoring
0:37:16 and far more transparency of where the money is going.
0:37:20 However, these decisions, remember,
0:37:21 these are city, states, counties, the Fed.
0:37:23 The levels of decision-making are varied.
0:37:27 And there will be places where they say,
0:37:28 well, what we need are new police cruisers.
0:37:31 So there’s gonna be problems for sure of misallocation.
0:37:34 I think that’s just inevitable.
0:37:36 – You wrote in 2019,
0:37:38 if no Sacklers end up behind bars,
0:37:40 an entire class of people will continue to feel
0:37:42 that writing a check is the worst thing
0:37:44 that will happen to them no matter what they do.
0:37:47 As far as I know, no Sacklers in jail,
0:37:48 what’s your position now, a few years later?
0:37:51 – I’m only more cynical
0:37:52 ’cause not only did no Sacklers go to jail,
0:37:54 but another company they own, Moondi Pharma,
0:37:57 is now selling Oxycontin all over the world
0:37:59 just like they sold it here.
0:38:00 So they haven’t been punished
0:38:02 and they’re continuing to profit.
0:38:04 – Moondi Pharma, headquartered in England,
0:38:08 is indeed owned by members of the Sackler family,
0:38:11 although they may be required to dispose of it
0:38:14 as part of Purdue Pharma’s bankruptcy settlement.
0:38:17 So what happens next?
0:38:20 Does the opioid crisis spread to other parts of the world?
0:38:24 Does the US create a successful playbook
0:38:28 to fight the crisis here?
0:38:30 I hope these are the questions that people in power
0:38:33 are asking themselves right now.
0:38:36 I also hope that we don’t find ourselves back here
0:38:39 in another five years making yet another episode
0:38:42 about this epidemic.
0:38:43 I’d like to thank Stephen Lloyd, Keith Humphries,
0:38:47 Christine Minhee, and last week,
0:38:49 David Cutler and Travis Donahoe for speaking with us.
0:38:54 And most of all, I’d like to thank you,
0:38:55 as always, for listening.
0:38:57 Let us know what you’re thinking.
0:38:59 Our email is radio@freakinomics.com.
0:39:03 Coming up next time on the show.
0:39:07 – So this is an amazing story.
0:39:09 – Tom Whitwell is a bit like Superman,
0:39:13 mild-mannered, toiling away at his work,
0:39:15 mostly hidden from the world.
0:39:17 But once a year, he emerges with a list,
0:39:22 a list of the 52 things he’s learned that year.
0:39:26 For instance.
0:39:27 – Fondue was invented by the cheese industry.
0:39:30 – Some of these things are true things
0:39:31 that we didn’t know to be true.
0:39:33 – The basic story was the NHS uses 10% of remaining pages.
0:39:37 – And some are things we’ve been told are true
0:39:40 that quite likely aren’t.
0:39:42 The whole idea of blue zones, for instance.
0:39:46 That’s next time on the show.
0:39:48 Until then, take care of yourself.
0:39:50 And if you can, someone else too.
0:39:53 Freakinomics Radio is produced by Stitcher and Renbud Radio.
0:39:56 You can find our entire archive on any podcast app also
0:40:00 at freakinomics.com, where we publish transcripts
0:40:03 and show notes.
0:40:04 This episode was produced by Alina Cullman and Zak Lipinski.
0:40:08 Our staff also includes Augusta Chapman,
0:40:11 Dalvin Abouaji, Eleanor Osborne, Elsa Hernandez,
0:40:14 Gabriel Roth, Greg Rippin, Jasmine Klinger,
0:40:16 Jeremy Johnson, Julie Canfer, Lyric Bowditch,
0:40:19 Morgan Levy, Neil Carruth, Rebecca Lee Douglas,
0:40:22 Sara Lilly, and Teo Jacobs.
0:40:24 Our theme song is “Mr. Fortune” by the Hitchhikers.
0:40:27 Our composer is Luis Guerra.
0:40:29 – Big hockey game tonight.
0:40:34 For a kid to grow up in the South
0:40:36 and realize that there’s a hockey team in Nashville,
0:40:38 it’s kind of a weird thing.
0:40:39 – The Freakinomics Radio Network.
0:40:45 The hidden side of everything.
0:40:51 Stitcher.
0:40:52 you
0:40:54 you
Thanks to legal settlements with drug makers and distributors, states have plenty of money to boost prevention and treatment. Will it work? (Part two of a two-part series.)
- SOURCES:
- Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford University.
- Stephen Loyd, chief medical officer of Cedar Recovery and chair of the Tennessee Opioid Abatement Council.
- Christine Minhee, founder of OpioidSettlementTracker.com.
- RESOURCES:
- “Court Conflicted Over Purdue Pharma Bankruptcy Plan That Shields Sacklers From Liability,” by Amy Howe (SCOTUSblog, 2023).
- NationalOpioidSettlement.com.
- OpioidSettlementTracker.com.
- The Helios Alliance.
- EXTRAS:
- “The Opioid Tragedy, Part 2: ‘It’s Not a Death Sentence,’” by Freakonomics Radio (2020).