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