Monthly Archives: February 2016

29Feb/16

The American Heroin Epidemic, Volume VII: Better Training For Doctors

In this final section of my interview with Sam Quinones, we discuss how doctors should receive more addiction training and the importance of continuing medical education units (CMEs). The discussion moves back to the concept of social isolation and how it has increased in lockstep with opiate abuse.

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Frank Greenagel: So, I have a question on doctors. I appreciate your mentioning earlier when we talked about Big Pharma that there’s not one Boogeyman. The medical community has some responsibilities here too. You spent a good amount of time on David Procter and the pill mills. Again, I’m not saying all doctors, or even most, but the medical establishment has a role here which you detail in Dreamland. One of the things I’m pushing for is at least 40 hours of addiction and treatment and recovery education with PAs and doctors and nurses and pharmacists. I’m also pushing for at least one day of continuing medical education for every two-year relicensing period. Right now, 49 of the 50 states have prescription monitoring programs. About 10 of them are mandated. I really want to see a universal PMP around the country that’s mandated that everyone has to access to and harsher penalties for doctors who overprescribe. That’s an omnibus medical package. Any comment on any of those policies, stuff that would work, not work? What your thoughts are about doctors and what we can do?

Sam Quinones: There’s no doubt that doctors across the country, far too many of them, lost their common sense when it comes to this stuff, that these drugs are somehow nonaddictive and that you knew this to be true for everybody is crazy. It just makes me want to go what Kool Aid were you drinking? That’s a crazy idea given the 3,000 year history we have with opiates. One thing that struck me is the story about isolation. The theme of this scourge is isolation. We’re talking about the destruction of communities, we’re talking about drugs that create isolation among people. Addicts find isolation preferable, not just okay, but preferable when they’re using their dope. That kind of thing. This is also true in the medical community. Do you know that there is no place that I’m aware of that brings together the three aspects of medicine that need to come together and talk about this all the time? That is addiction studies, pain management studies, and general practitioner medicine. There ought to be a journal, “Pain, Addiction, and General Practitioners,” or something like that. The Journal of Pain, Addiction, and General Practitioners. These folks don’t know each other. They don’t get together. They don’t meet in conferences. They don’t know each other socially. If those folks begin to come together and hear each other and be at the same conferences and go out for a beer later, I believe we would be able to, through the synergy of those voices and those great minds, come up with a whole bunch of solutions that are not presenting themselves right now because medicine is so siloed, in such isolation.

All of that stuff that you mentioned, I’m amazed that it doesn’t exist already. It’s like we need far more addiction preparation on the part of doctors. We need far more attention to pain and treatment on the part of general practitioner. We need addiction studies understanding that the problem that general practitioners face, which is that, yes, they do have a whole lot of people coming in great pain, so what are you going to do? You can’t just ban drugs. That’s not going to work. A lot of this, though, just seems to me, when I learned that it didn’t exist I was stunned. You’re talking about in medical school like, what, 4 hours of training in your entire medical school career?

Frank Greenagel: I know, that is stunning, especially when you think of that for a lot of general practitioners, the number one source of income as is pain management and the number one source of liability is pain management, and yet they’re getting so little education and little to no requirement for continuing medical education.

Sam Quinones: Exactly. Also, this is something they’re going to see daily. Who doesn’t go to the doctor without pain? That’s why you go to a doctor most of the time. All of that, I think, is extraordinarily important. I really do believe in the synergistic effect of bringing together the specialists and people from these different disciplines with medicine.

Frank Greenagel: I just want to be clear. I’ve got something I’m going to spend some time thinking about and see what I can do here in New Jersey too, at least get some nascent movement for general practitioners, pain specialists, and addiction providers. I think you’re absolutely right and it’s not something I’ve considered before, but obviously it makes perfect sense. I think that’s such a market inefficiency, that just getting them together is going to have some benefit and then maybe even something greater comes out of that. I think that’s a wonderful recommendation.

Sam Quinones: At least it needs to be tried. Who knows what will come of it? My feeling is that once people get together and actually do hear each other and go out for a beer, and then maybe go out and watch a ballgame or something, and get to know one another in ways that they simply do not right now, that that community created by that will also help create new approaches, solutions that hadn’t been thought of, whatever. Again, this is all about isolation versus community. That’s how I got into it, that we have a century of isolating ourselves and applauded ourselves for doing it. The effect or the end result has been widespread heroin abuse. It doesn’t surprise me now. It doesn’t surprise me because we have spent so much effort isolating ourselves, and making sure that we don’t know each other, and making sure that we don’t get together, and making sure that we don’t have the forums, and parks, and the places where we can meet and get to know one another publicly, being out in the public sphere. We have demeaned the public sphere so intensely in so many ways making sure that everyone is terrified of the child molester lurking around every tree that now everybody is so isolated that when it does happen, we can’t do anything about it. I think had we been more connected, or operating more as a community, that this plague would not nearly have spread so badly. It spread largely because people are alone. They’re alone in addiction; the family is alone thinking that no one else in the whole neighborhood has this problem, when actually probably 1 out of every 5 families might even have it. They’re alone and they don’t know who to go to. They make horrible mistakes and the kid ends up dying, easily avoidable mistakes because they don’t know who to talk to, they don’t know who to ask for help, they don’t know where to go. It’s all of this, this theme of this, is about America today and the isolation that we have created for ourselves and heroin is simply the expression of all those values in one substance.

Frank Greenagel: Do you remember the book that came out in 1995 by Robert Putnam called Bowling Alone? He talked about the decline of the American communities. Our talk is hitting upon it a lot … Because he says in the ’50s, and not that I want to make the ’50s this bucolic time because obviously there was horrific segregation and other problems and we were reaping the economic benefits of winning World War II, but the reason he titled it Bowling Alone was because there were these bowling leagues and people were members of communities, and churches, and groups like that. He talked in the ’90s about the increasing self-isolation of Americans, and this is even before the internet and online video games and social media. Again, it’s a theme that you seem to be picking up on very adroitly here.

Sam Quinones: That was ’95. Twenty years later, people aren’t bowling alone; they’re shooting up alone. It’s a direct result, though. The lineage goes back to this idea that making money is top to happiness when really happiness accrues when you do something else that you love. Happiness comes from it. What they’re talking about is we’re seeking pleasure. Pleasure is not happiness. Pleasure does not lead to happiness and we as a country, I believe, sought pleasure over fulfillment way, way, way too much. Heroin is just the final embodiment of that.

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Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. In December, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump. The fourth volume focused on the Affordable Care Act, politicians and how regular Americans can influence public policy. Part five addresses how the collapse of communities and social isolation has contributed to the surge in prescription drug and heroin use. In the sixth edition, Mr. Quinones talked about how towns that have large recovery populations are rebounding from the heroin plague.

23Feb/16

The American Heroin Epidemic, Volume VI: How Recovery Can Change Towns

This is the sixth article that came out of my interview with Sam Quinones. In this edition, Mr. Quinones talks about how towns that have large recovery populations are rebounding from the heroin plague.

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Frank Greenagel: There’s a number of themes that you’ve hit upon here that you also obviously talked about in your book that are reminiscent of a book I read earlier this year by George Packer, the writer for  The New Yorker. He wrote a book called The Unwinding and it’s about the decline of the middle class and the loss of factory jobs and the ruination of communities. In your travels, have you seen any strong American community that’s resisted this or any small town or village that seems to be a tight community and as a result they’re doing okay? The reason I ask that is I was just over I Asia and I spent some time in some poor Thai villages where people didn’t have much, but there were a bunch of healthy kids. They didn’t have a drug problem. My translator looked at me and said, “Well, they live in a village. They know everybody else and they’re totally connected.” This was told to me just as I was reading your book. Now, you’ve also been talking to me about the decline of communities. Is there any place in America that’s doing a good job with the sense of a village or a community?

Sam Quinones: In the very town of Portsmouth you’re seeing some very interesting things going on. Now, it doesn’t look it. If you go to Portsmouth, you will see a town with a lot of abandoned building and a lot of fast food places. You would not think it, but if you get to know the town, it definitely seems to be putting in place a certain kind of … I think it’s a town that is rebounding. That it’s a town that for a long time many have given up or could have easily given up and did not. I think it’s a town that shows how important supply is in all this. Once they got those pill mills, remember those Ohio State legislature passed the law that got rid of those pill mills and those pill mills all shut down? All of a sudden now you have a recovery community in that town that’s enormous. Talk about 10% of the population, roughly. Those are estimates, but 10% of the population is in recovery from opiate addiction. The one thing that’s interesting, when you get a large percentage of people who are in recovery, it’s very much like getting a big influx of Mexican laborers. Mexican immigrants bring energy, optimism, a desire to break through any wall to get ahead, to move on with their lives, to reinvent themselves, and a huge dose of gratitude for a second chance. It turns out, in Portsmouth I think what you’re seeing is that recovering addicts provide the same kind of energy and excitement and gratitude. That’s a very, very healthy thing for a town that has been losing people for decades now and where fatalism had kind of overtaken the town and heroin and those damn pills were just part of that fatalism. I think people need to spend a little bit more time understanding what’s going on in Portsmouth because obviously it’s been dealing with this probably longer than most everybody. For me, I find there was a new attitude. Once you get rid of the supply, the attitude changes. People started getting into recovery and the attitude changes. People say yes we can instead of what’s the point, which is what they were saying for so many years. That’s a very, very potent thing. A mental change, a psychological change like that, is a very, very potent thing, particularly in an area where people have always said what’s the point for 35 years.

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Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. In December, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump. The fourth volume focused on the Affordable Care Act, politicians and how regular Americans can influence public policy. Part five addresses how the collapse of communities and social isolation has contributed to the surge in prescription drug and heroin use.

16Feb/16

The American Heroin Epidemic, Volume V: The Collapse of Communities

 

Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. Last month, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

This is the fourth of eight articles from that interview. In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump. The fourth volume focused on the Affordable Care Act, politicians and how regular Americans can influence public policy.

Part five addresses how the collapse of communities and social isolation has contributed to the surge in prescription drug and heroin use.

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Frank Greenagel: Your book takes the title from the town of Portsmouth, Ohio and the Dreamland Pool. You spent some time writing about the decline of working class towns how they’re hit hard with pain management clinics and pill mills. Later, they transition to heroin because it’s very cheap. The town loses job, the landscape is filled with broken dreams, empty pools and they use heroin to drown their sorrows. You also wrote about a bunch of more well-off towns, like Charlotte and Nashville, and how they’ve also been hit. It’s not a wonderful question, but I’m going to ask it anyway. What type of town seems to be more hit by the opiate epidemic? Is it the rich towns or is it the poor towns?

Sam Quinones: Basically, I think it happens first in Appalachia. It happens in Appalachia and it’s allowed to spread from there because we, as a country, are used to not paying attention to Appalachia. It’s a bunch of poor white people whose dysfunctionality has been notorious for generations. No one paid any attention. We might not be having this conversation had there been real different prescribing guidelines put in place in 2001, say, or 2003 maybe. Nobody paid any attention to that place and so then it reached out to the wealthy areas.

Which is more heavily impacted? I would say probably Appalachia because it could least afford it. It’s interesting. This is something I’ve thought about a lot. They say that addiction doesn’t discriminate, cuts across all races, etc, etc. Yeah, that’s not true here. It’s all white people. It’s entirely white people. I defy you to find like 10% of the population of new addicts who is actually non-white. I have not seen it. I’ve never found it. Every drug counselor I’ve ever talked to about this. There are some lingering addicts from the 70s who are black or Latino, but by and large, the new wave is almost … I’ll say it’s 90% white. I think it’s probably more like 98% white honestly. What it doesn’t discriminate along is economic lines. It’s all levels of the economy with just white people. What’s fascinating to me, though, as part of this, is that when you talk about some of the economically better cities, like Charlotte, like Nashville, Minneapolis, Indianapolis, Reno, Salt Lake City, etc., you’re talking about a population of kids whose families have done extraordinarily well in the last 20-25 years. You would think, judging from their neighborhoods, that they really don’t have many problems. Why is it the class that’s done best in the last 25 years and probably lives better than anybody in the history of the world, almost literally the history of the world, why is it that they are turning and getting addicted to drugs used to numb pain?

Frank Greenagel: That leads into the next question. I listened to a podcast of yours with the people from Ohio State, and you talked about social isolation and I want to pinpoint that a little bit more. Then I also want to break it down into maybe a workable policy recommendation even though I know your thing is stories. I’m a policy guy, so I’m always trying to think about what I can do to address this. I have a friend that’s an Australian lawyer. After the Sandy Hook Elementary School shooting, he talked about the American Soul Sickness because we have all these gun deaths that no other industrialized nation has. Very recently, a UN report said that basically the heroin problem is far worse in America than anywhere else and there’s far more overdose deaths here than there are in other countries. So, we have all this gun violence and then we have the world’s leading opiate epidemic. The overdose numbers overtook car crashes in America in 2011, but the latest figures from 2014 state it’s 47,000 people die from overdoses versus 36,000 from car crashes, so it’s running away with the number one cause of accidental death now and just getting worse. I’ve been haunted by my friend’s words for the last three years, the American Soul Sickness. Do you think there’s something to that?

Sam Quinones: I would say this. I believe that we have spent decades now, at least 35 years and maybe some more, shredding communities in our country. I believe the antidote to heroin is not naloxone. It is community. We have done a marvelous job of demeaning despising government and all that can it can do to create community and public infrastructure. We don’t want to pay our taxes because, oh, look it’s so inefficient, and oh it’s a bunch of people who don’t work more than a few hours a day. It’s all I think nonsense, but it feels good to say that and that’s a terrific rationalization for not properly funding all kinds of infrastructure. As I talk to you now, I’m driving on roads that are … They look like Mexican roads honest to God. I’m in California. We have done a magnificent job at destroying community, of demeaning, of despising government as a way of very superficially not paying taxes that we should be paying. At the same time, very conveniently, we have exalted the private sector. We have applauded these kings of finance whose job it is apparently to devise new gimmicks and new rationales for sending all our jobs to Mexico, Malaysia, China, and wherever else. We have sat around, and this is again a perfect example, this opiate epidemic is the perfect example of that. We have seen one family, the Sackler family, become one of the wealthiest in America because they made Oxycontin. The profits from this scourge have all accrued to a few companies and the costs again have gone to the public sector.

We have destroyed certain things, like Dreamland Pool is a stand-in for a lot of things that we have allowed to die or we have actively destroyed that create community. These could be factories. These could be not properly funding parks, a variety of things. We now have a situation in which we have suburbia that is horrible isolated, yet we call these towns prosperous. We have people terrified of the public sphere. Parents won’t let their kids outdoors. They hover over them. The outdoors is this horrible threat to them. We look at people who let their kids go outside without hovering them as somehow deviant. These parents must be awful parents for letting their kids play outside when all the while, this scourge has taken place. If you talk to addicts about, it so often takes place in private bedrooms where the kids are all alone isolated from everybody else. It’s the perfect place to hide your dope. It’s the perfect place to use your dope. It’s a private bedroom. This has been our creation over the last 35 years and we are a country that has suffered mightily from it.

The embodiment, the extreme … What’s the term I want to use here, expression of all these values, is heroin. Heroin is one drug … We’ve spent years exalting the consumer, believing that consumption was the way to happiness, but pleasure seeking was the way to happiness. Heroin embodies all of that. It is a drug that turns every addict into a solitary, narcissistic, self-absorbed, hyper consumer. It is the poster drug for our generation without a doubt. That is what I believe to be the case. Does America have a soul sickness? I’m not sure I’m qualified to say, but I do believe, yes, that we have isolated ourselves so mightily from each other, from ourselves, even within families. People are isolated horribly to the point where parents don’t have a clue what their kids are up to in those private bedrooms. That lack of connection, that lack of contact, that fettering of community that I relate in the destruction of pools called Dreamland, is all across this country. Therefore, why do we wonder that heroin is everywhere? Why should we be surprised that heroin is all over the country? When I started this book, I thought it was a book about drugs and drug trafficking, that kind of a crime book, that kind of thing. I realized midway through it that, no. This is a book about who we are as a people right now and what we’ve created in the pursuit of exalting the private sphere, the private sector, what we have created along the way to that. It’s a scary thing. Heroin is really the poster drug of our time.

12Feb/16

Wasted Money: The Story of “Partnership for a Drug Free America”

When the NJ Heroin and Opiate Task Force held hearings around the state in 2012, we heard testimony from medical professionals, treatment providers, law enforcement, politicians, bureaucrats, representatives of 12-step organizations, people in recovery, the parents of dead kids, policy experts, and advocacy groups. Everyone told a story, some provided data, and most offered up a few suggestions. There was a representative from Partnership for a Drug Free NJ that testified. He told us we were doing a good job and, as far as I remember, did not offer up any specific suggestions (though I’m pretty sure he said he’d like to help us).

Last week, I testified before the NJ State Senate Health Committee about the opiate epidemic (I talked about a number of failed bills I liked, made a bunch of suggestions, and levied criticism at a number of industries, politicians and programs). Partnership for Drug Free NJ sent the same representative again, and he told the Senate they were doing a good job and offered no suggestions. Everyone else that testified that day had something substantive to say, regardless of whether I agreed with it or not. The testimony was empty. It irritated me. After careful thought, I realized that they show up to events just to put in an appearance, but they clearly do not like to stake out positions. This is almost certainly because they do not want to upset their donors.

The Partnership for a Drug Free America was founded in 1985 in New York City. It is a private non-profit that enjoys 501c status. They created well known ads such as This Is Your Brain On Drugs and I Learned It From Watching You. None of their ads addressed alcohol or tobacco use. This was probably because some of the major donors during the first 12 years of their existence were Phillip Morris, Anheuser-Busch and RJ Reynolds. After the donations from the tobacco and alcohol industries became public, PDFA stopped taking their money in 1997.

PDFA never criticized the Just Say No campaign. It never expressed a concern about the draconian sentences and mass incarceration of petty drug users. It would not mention the dangers of prescription drugs until the 2000s, and it was careful to never criticize the pharmaceutical industry. This is clearly because three of the top seven donors in 2013 were Jazz Pharmaceuticals, Mallinckrodt Pharmaceuticals and Purdue Pharma. Mallinckrodt makes Exalgo (hydromorphone) and generic forms of Hydrocodone, Oxycodone and Dextroamphetamine (DXM). Purdue Pharma released Oxycontin in 1996 and is the company that most aggressively oversold the benefits of prescription opioids and understated the negative side effects. Purdue Pharma also produces other drugs made from fentanyl, codeine, and hydrocodone. To see a complete list of the PDFA’s 2013 donors, click here.

In 2014, those three pharmaceuticals were again among the top nine donors. Joining them was the Pharmaceutical Research and Manufactures of America, a trade organization that represents the pharmaceutical industry. To see a complete list of the 2014 donors, click here.

Near the end of 2013, PDFA issued a news release about the increase of Adderall abuse by high school students. The only stance that PDFA took was that this was a concern. It did not address the aggressive marketing of Adderall, the misdiagnosing of ADHD, nor the overprescribing of many of the ADHD medications (like Ritalin, Vyvanse, Concerta). Their position on those topics is that they had no position. To be clear, there was no criticism of the pharmaceutical industry or doctors.

Earlier that fall, Mike Males wrote a stinging critique of PDFA. He discussed how PDFA had started to label prescription drug abuse as “the nation’s worst crisis” but only focused on teens. In 2013, Mr. Males wrote that “the middle aged epidemic” was far worse (in November of 2015, the New York Times reported that middle aged whites were dying at huge and ever-increasing rates due to prescription drug overdoses). In 2014, PDFA changed their name to Partnership for a Drug Free Kids (PDFK) and said they would focus exclusively on people under the age of 18 and their parents.

In September of 2015, the Food and Drug Administration (FDA) announced that it had approved Oxycodone for use by teens between the ages of 11 and 16. I was outraged and wrote an article comparing this to how Paxil was once considered safe for teens, until it was discovered it wasn’t 14 years later. PDFK posted an article on their site about the approval of Oxycodone. It included statements from the FDA about why this was necessary. This appeared to be a perfect opportunity for PFDK to protect its primary group by admonishing the FDA and Purdue Pharma. The only criticism offered was by Senator Joe Manchin (D-WV), who said, “This recent decision by the FDA to prescribe OxyContin to children as young as 11 years old is a horrifying example of the disconnect between the FDA approval process and the realities the deadly epidemic of prescription drug abuse are having on our communities.”

Another top donor to PDFK over the years has been the FDA. That might explain why they have apparently never criticized the FDA.

On their website, PDFK states that they support Prescription Drug Monitoring Programs (PMP or PDMP). Their position is that they should be in all 50 states (only Missouri does not have one) and that they should be interconnected (I completely agree). This is not noteworthy, as almost every politician and policy expert supports  PMPs. The only controversy is whether they should be mandated or not (I am very much in favor of mandating them). PDFK does not have a published stance on whether or not PMPs should be mandated. Their site also states that they support Good Samaritan Laws, the use of Naloxone and Medication Assisted Therapies. If they have actively contributed through messaging or funding to the passage of those laws and programs in any state, I have not been able to find it.

In the 1980s and 1990s, the PFDA released a number of strong anti-marijuana ads. An infamous ad in 1987 said that marijuana “flattens brain waves.” The Schaffer Library of Drug Policy wrote a powerful rebuke of the ad:

In the commercial, a normal human brain wave was compared to what was supposedly the (much flatter) brain wave of a 14-year-old high on marijuana. It was actually the brain wave of a coma patient. PDFA lied about the data, and had to pull the commercial off of the air when researchers complained to the television networks.

A number of experts have argued that the exaggerated claims about the dangers of marijuana created a mistrust of anti-drug messaging (much like the movie Reefer Madness did in 1937). PDFA’s 1987 ad was not only contained manufactured data, but it may have made it harder for prevention messages to be effective. This is the opposite of what their supposed mission is. In 2016, PDFK has a very different message about marijuana. On the FAQ section on their site, they provide their stance on marijuana legalization:

As the country debates new policies on marijuana – medicalization, decriminalization and legalization – none address our sole concern: the health and well-being of young people. We recognize that the status quo is changing. We do not believe that any drug use, including alcohol, should be treated as primarily a law enforcement issue, but rather a health issue. Further, we acknowledge the discriminatory way in which marijuana prohibition has been implemented in the United States. The Partnership for Drug-Free Kids supports what is in the best interest of families and their kids’ health, and the use of marijuana or any substance in adolescence is an unhealthy behavior for kids.

Their only clear opinion is that they don’t want kids smoking marijuana. That is uncontroversial. They make no statements about legalization, decriminalization, or criminalization. They do write that more research should be done to see if there are any benefits to medical marijuana. In short, all their statements are bland and add nothing to our national conversation on drug prevention, treatment or policy. The Partnership for Drug Free Kids spends almost $100 million* a year and they have almost** nothing substantive to show for it. It’s time for them to go away.

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*In 2013, the PDFA reported expenses of $85.7 million. In 2014, the PDFK reported expenses of $96.7 million. To read about their financials, click here. This is their 2013 tax return and 2014 tax return.

** PDFK helped spread messaging about securing medicine cabinets in the 2000s.

4/5/2016: An earlier version of this piece claimed the executive that testified at the 2012 and 2016 hearings was from PFDA rather than Partnership for Drug Free NJ. I have corrected that. It was that testimony that caused me to look closely at PFDA (now PFDK). I also have written up a follow-up piece after speaking with the President of PFDK and a volunteer. It can be read here.

08Feb/16

The American Heroin Epidemic, Volume IV: The New Hampshire Primary

Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. Last month, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

This is the fourth of eight articles from that interview. In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump.

This fourth volume focuses on the Affordable Care Act, politicians and how regular Americans can influence public policy. With the New Hampshire primary on Tuesday, this is the time to publish that exchange.

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Frank Greenagel: You mentioned that the legislature in Ohio passed laws that got rid of the pill mills. Is there anything else that the state of Ohio did that you think was helpful toward bringing Portsmouth back a little bit?

Sam Quinones: Oh, most definitely. Yeah. John Kasich, now running for president, definitely deserves a huge tip of the hat for going around a Republican legislature and making Medicaid available to all Ohioans. The reason he did that was because he knew that people who were suffering with addiction, that their families most likely were tapped out. They didn’t have the ability to pay for this and the only way they were going to get people into treatment was through Medicaid. He risked a lot politically…

Frank Greenagel: …by taking the Affordable Care Act expansion of Medicaid.

Sam Quinones: Over the objection of the Republican legislature. That is amazing, so a tip of the hat to John Kasich because that guy understood what he needed to do and he didn’t play politics, and he didn’t obey the political dictates of the people in his party, many of whom did block it in other states. It’s huge! That is so big, I mean so big, that so many people now who before could not afford it, either because they were too poor initially or because addiction had tapped out all their funds, can now get treatment. I think it’s a big … Here’s another thing I think that’s coming out of this. I believe that there will be far less support than a lot of Republicans believe for doing away with Obamacare because Obamacare allows states to fund addiction treatment, rehab treatment, and that was something that was denied to a lot of people. There’s a lot of people out there for whom this issue is enormous and a lot of people who are quite conservative for whom this issue is enormous. I’m not sure that, maybe in the next Congress, that the Republicans will find as much support as they think is out there for doing away with that because that’s a huge part now of the approach in many parts of the country.

Frank Greenagel: Yeah, you see that in Kentucky. The Medicaid expansion was hugely popular and so the idea that Mitch McConnell and some of the other Republicans there have talked about doing away with Obamacare but maybe they can keep the Medicaid. But really, the Medicaid expansion was a crucial aspect of the Affordable Care Act.

Sam Quinones: Exactly right. You talk about terminology that … We’ll call it this, we won’t call it Obamacare, but we’ll keep all the major provisions of it. I don’t know, but it’s dawning on me when I get to some of these areas that people are not going to go along with that. I’d be very surprised in some areas. Now, some areas maybe the problem isn’t as bad and so these folks may not have the political voice they might have in other areas, but my feeling is, yes. States like Kentucky. And certainly Ohio, John Kasich is roundly applauded by people in very conservative parts of that state because of what he did.

Frank Greenagel: I’ve been very critical of my own state governor, Governor Christie. He got a lot of press a month ago by giving an impassioned speech about his mother’s tobacco use and his law school buddy’s drug problem. Conservatives liked it and Democrats liked it and he was praised on MSNBC. I’ve heard the speech before, but when push comes to shove, he doesn’t fund anything. He still criminalizes marijuana; I’m for the decriminalization of it. He criminalizes marijuana, he hasn’t funded treatment bills, he resisted naloxone expansion, he resisted the Good Samaritan law. There’s point after point after point, so his rhetoric soars high above his actual policies. What happened after his speech is that politicians on both sides of the aisle have been tripping over themselves in announcing that they have a friend who is an addict. Or my family member is an alcoholic. I’d like you to speak to that. I know you like what Governor Kasich did in Ohio. Is there anyone else or anyone that has any kind of policies that said anything that seems to get it or is it all just a kind of campaign bravado, like I’ve seen from Governor Christie?

Sam Quinones: Regardless of what follow-throughs he did or did not do, the mere fact that people are beginning to talk about it is really important and remarkable. I don’t know his record in New Jersey in funding programs are and passing laws. I did think it was interesting to listen to him to say that because those words spoken 15 years before would have disqualified him from the Republican nomination. His campaign would have halted right then. Now, you can see these Republicans now are, again, as you say, tripping over themselves trying to tell the most gripping story of addiction in their family, which I think is a huge step forward. I really do. I think it’s very important. I don’t know that I see anyone who has understood the issue well enough. Nor do I even think Barack Obama does. I watched him at the Charleston, West Virginia town hall meeting that he held and it seemed to me that it was an issue that was far off for him. He did not feel comfortable with it, didn’t know how to pronounce Naloxone and this kind of thing. That’s understandable. He’s got ISIS. He’s got a million other things that are important, but it seems to me that it’s still in the phase where people are approaching this, or not entirely comfortable with this topic yet.

I’m not sure how you get there exactly, but I would hope that at a certain point people would come to the idea that they need to understand this in a deeper way, but that’s just where we are as a country. We do not understand this. I really didn’t understand it too well. I still have a lot to learn, I would say. I’m not proposing myself an expert on this. I’m not an addict myself, so I don’t have a deep reservoir of experience on all this. I look around the political stage and I don’t see a lot of folks, honestly, who figured this out.

Not long after the book came out, Hillary Clinton’s health policy campaign adviser called me and wanted to ask about what do we do about this. I gave her a bunch of policy prescriptions that I thought might have been helpful. I’m not a policy expert. I’m not the guy to set policy for a major presidential candidate, but I did feel like talking about it, getting it out there, making it part of the national discussion is necessary.

Here’s what needs to happen, though. All the people with a lot of stake in this game, and I mean counselors, public health people, and coroners, and judges, but above all, parents, need to make this, need to push this issue to the forefront. They’re the only ones who are going to do it. Candidates oftentimes follow what they perceive as the interests or the desires of whoever they seem to be talking to or whatever state they happen to be in. If you are not at a town hall meeting, if you are not at the campaign rally with signs saying, “What about addiction?”, “What are we going to do about the heroin problem?”, “What are we going to do about the doctors who prescribe this for wisdom teeth extraction?”, these pills, then it’s never going to be the issue that it ought to be. I think I would say that at the end, that basically this needs to be something really that is pushed by those actors who really feel it, who have to deal with it day-in, day-out, who have dealt with it day-in, day-out maybe for a decade or more now. They need to be the ones pushing that. If they don’t, I would say that I would find it hard to imagine it becoming the issue that it ought to be.

Next week: We discuss the collapse of American towns and communities, social isolation and what a friend of mine called “the American soul sickness.”

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Some final thought before the New Hampshire primaries tomorrow. Governor Christie was deemed by many to have won Saturday night’s debate, particularly in the way he dressed down Senator Rubio and exposed him as someone with canned, robotic statements. Christie hammered Rubio on the fact that he doesn’t answer questions, but rather digresses onto other topics. A few people that are up in New Hampshire wrote me and said that Governor Christie has sounded great all week and that he spoke movingly about addiction. I can not stress enough how he does not follow through with actual policy or significant funding. Here is a link to my appearance on NPR last November, where I gave very specific instances about that.

Both Governor Bush and Carly Fiorina have talked about addiction in their families. Despite their personal experiences, neither have offered up substantive policy recommendations. I wrote about that last month. Even though Dr. Ben Carson’s campaign is all but over, here is a link to his disastrous response about addiction treatment and policy.

I agree with Hillary Clinton wanting to move marijuana from a schedule I (completely illegal, no medical value) to a schedule II drug (controlled, prescribed, some medical value). Moving marijuana would allow for more research. While I disagree with the notion that marijuana can help 200+ medical conditions, I am willing to look at data that suggests it might help with 5 or 6 problems. Secretary Clinton is still woefully behind on Suboxone.

The candidate who probably has both the best understanding and track record about the Heroin Epidemic is Governor Kasich.

President Obama’s latest plan to combat heroin addiction was well received by most people in the treatment field, but I was less than pleased. You can read my reaction here.

04Feb/16

Cancer? Paid for. Addiction? Ba Fangul.

On January 21, I attended a press conference at Damon House in New Brunswick, NJ, where Congressman Frank Pallone announced a package of bills to address the nation’s heroin problem that would be introduced to Congress a few days later (it would get lost in the shuffle of Obama’s announcement earlier this week – I’m unhappy how both of them approach Suboxone, and I’ve made my views quite clear). Joel Pomales told his story at that event, which I released here the next day. Larry Redmond, a veteran in long-term recovery, also spoke there and told a moving story about how his cancer treatment was paid for without question but that he had to fight every few days to get his son’s addiction treatment covered. He has graciously typed it up for me to publish here.

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My name is Larry Redmond. I am person in Long Term Recovery. In 1968, while serving in the United States Army, I was introduced to various drugs including heroin. Needless to say I became addicted to the heroin very quickly. In November of 1971, I entered my first rehab (Discovery House). In those days, the Therapeutic Community model was used. Programs like Discovery House, Daytop Village, and Integrity House all used a similar model of breaking the addict down and rebuilding their character. The length of time you spent in treatment was usually 18 months. Twelve months in the House and six months in the Re-Entry phase of the program. During the Re-Entry phase you did certain things that normal members of society did on a daily basis. You got a job, set up a budget, paid bills, and handled your other obligations.

You also had to learn to drink responsibly (editor’s note: TC’s stopped letting drug addicts drink in the 1980s). I was soon on my way to becoming an alcoholic. The next 15 years brought me to many Intensive Outpatient Programs (IOPs) and private counselors. I was put on a variety of various Valium-like drugs. At one point, I was put on methadone to treat my opiate problem. None of this kept me on the right track.

In 1986, while married to my second and present wife, I entered what was to be my final rehab. I credit my wife with saving my life. She gave me an ultimatum which brought me to a detox in Union, NJ and then to a rehab in Pennsylvania. I was there for 45 days and have been sober ever since. While in sobriety, I finished college and have built a great life with my wife and two children. I have served as an elected official: both on the Town Council and the Board of Education. I am currently the vice-chairman of the county LACADA Board and am an advocate with NCADD (editor’s note: these are both groups that deal with some aspect of addiction policy). I sponsor a couple of young guys in AA and attend two family support group meetings each week.

I could go on about my accomplishments and the depths of where I crawled out of but I would rather discuss my family situation. I first realized that my son was an addict when he was in high school. I am a cancer survivor who had a stem cell transplant (bone marrow) in 2010. While I was going through chemo in 2008, my son started getting into trouble. He also had left home a couple of times and was involved with the Juvenile Justice System. One morning, before we left for a court appearance he started throwing up. My wife thought he was sick because of the stress, but I knew. He had gotten into the pain medications that I had been given for my cancer treatment. I never even thought about locking them up. Even with all my knowledge, I fell victim to the same parental cluelessness that so many of us suffer from. Thus began our horrendous odyssey through the rehab and insurance system.

I don’t know who paid for my 1971 rehab stay. I never was asked for insurance information. I was not working and had no insurance. But I stayed in treatment for 18 months. In the beginning of our journey, our son was in Touchtone Hall in Northern New Jersey. I would have to get on the phone every 5 days along with staff at the rehab to fight for another 5 days worth of payment under the medical necessity rule. After a couple of weeks he left the rehab. He was sent there by the courts so he violated probation by leaving. Over the next few years it was the same story everywhere we went. He finally managed to get a three week stay at New Hope in Secaucus. He did not get better. He left and went to a variety of Florida rehabs. He got arrested down there. I did find that the Florida facilities found a way to take our insurance. I spoke about our issues at a parody hearing at Stockton University with Patrick Kennedy. He said he had heard our story hundreds of times before.

My son’s issues are not only drug related. He also has Bipolar Disorder. This did manage to get him on SSI and Medicaid. It was a little better than traditional insurance when it came to rehabs in NJ. He is in supportive housing for the mentally ill in Plainsboro, NJ, right now. After a stint in a mental health facility, he seems to be on the right path. He recently celebrated 90 days clean and sober and gave me my 29-year medallion last December. I still don’t know which made me happier.

We have a crisis in our state right now. There are nowhere near enough beds for the people who need detox and treatment and even less ways to pay for them. John Brooks Recovery Center in Atlantic City is scheduled to close this April. They account for 42% of the South Jersey beds and 33% of the NJ’s detox beds. If we want to save our state this needs to change. Let me put this in perspective for you. While my son was suffering from a life threatening disease, I had to fight for his treatment every five days and sometimes I lost the battle. When I was in the foremost cancer hospital in the world for my stem cell transplant for 32 days, that same insurance company paid a quarter of a million dollars for my treatment. I never had to pick up the phone. Stigma is the problem. Until we change that we will never solve the addiction crisis.

 

02Feb/16

I’m Tired of Being the Scientist in the Opiate Disaster Movie

My three favorite disaster movies of the 1990’s were Jurassic Park, Independence Day and Armageddon. In two of them, Jeff Goldblum plays a scientist who furiously warns those in power about the impending doom that awaits all of them if they continue to ignore the reality of the situation.

The modern opiate epidemic has been with us since 2005 and has been in full force since 2010. It continues to get worse every year (I am simply defining worse here as more deaths and am not looking at other rampant problems such as declining academic performance, workplace productivity issues, a glutted criminal justice system, or over-crowded, poorly performing treatment programs).

The opiate epidemic has been covered in the media, has led to the deaths of several high profile celebrities, has caused law enforcement to change their strategies and policies, and it has become the current fad for politicians on the local, state and federal levels to talk about. More people died from opiate overdoses in 2013 than in 2012. More died in 2014 than in 2013. When the numbers come in, I expect this to hold true for 2015.

I get it. People are concerned and those in power are trying. We have made important strides in the areas of prevention, treatment, recovery support and policy development. I am extremely appreciative of all the media attention that has been given to the opiate epidemic. And the money that has been set aside is far better than it was in the past.

It’s not enough. It’s not enough.

Today, the White House announced a $1.1B spending increase to “address the prescription opioid abuse and heroin use epidemic.” There are numerous programs and policies that are going to be established, funded or improved upon, and many of them are really good ideas. If you break down the money, it works out to be $11M per state for two years. It’s not enough.

There are three key points that the Federal Government could address but have not so far:

1) Before we increase the number of buprenorphine scripts that MDs can write, we must mandate the urine screens and counseling along with it. I’ve written about this, most recently for Hazelden (in an article that has already become the one most ever read on their site).

2) Sober homes and recovery housing (and whatever else people want to call it) must be regulated. There should be no exemptions (Oxford Houses have avoided regulation). Regulations include adequate and clean living space, reasonable access to transportation, reasonable access to treatment, reasonable access to 12-step meetings, minimum staffing guidelines, supervision and regular urine screens. A majority of sober homes and recovery houses do not meet these basic standards, and several cases, they are causing harm.  They fight regulation claiming that these standards are too arduous and that they won’t stay open. Tell that to the parents of Chris Pesce, who died in a substandard sober house.

3) 49 of the 50 states have a prescription drug monitoring program (PMP or PDMP). Missouri does not. Only a handful of those programs are mandated, which means that the prescribers that are the worst actors with overprescribing are not checking the PMP nor entering information into it. I have told policymakers and politicians for years about the importance of having mandated PMPs in all 50 states and have them interconnected, so that as a clinician in NJ, I can check to see if my clients have gone to doctors or pharmacies in NY, CT, PA, DE, or MD.

We’ll finish with the immortal words of Richard Dreyfuss (Dr. Hooper) to the town mayor in Jaws (1:18 for those you that want to skip to it):

I think that I am familiar with the fact that you are going to ignore this particular problem until it swims up and bites you in the ass.

 

01Feb/16

The American Heroin Epidemic, Volume III: Supply and Demand

 

Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. Last month, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

This is the third of eight articles from that interview. In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In this third edition, we discuss how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touch upon Donald Trump.

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Frank Greenagel: I appreciate your giving a contrast between the areas and the nuance of the violence issue. I want to stick with the race, though. You spent a lot of time discussing Mexican immigrants from the town of Xalisco. They are the major traffickers of black tar heroin, so anti-immigranters and Trumpsters would have a field day with that information. How should our drug policy address immigration issues?

Sam Quinones: Wow. I don’t know. That’s a good question. It’s possible that they will have a field day with it. My feeling is if I as a reporter, if reporters spent all their time worrying about how certain people might use the stories that they write, they’d never write anything. I just felt like I don’t bind myself that way.

Frank Greenagel: You just want to get the information out there.

Sam Quinones: I want to tell a story and I want to get the information out and these guys are, they’re not the only ones, but they are among the most important black tar heroin traffickers from Mexico. Particularly, years ago, before everyone figured out the market, they were really important. I’m not sure if I know what to propose with regard to immigration policy. I’ll tell you a couple of things. First of all, we have had a lot of arguments over the years, over the decades, about what comes first. What’s more important in igniting these drug scourges, is it demand or is it supply? My feeling is truthfully that it is supply. Supply creates demand, it’s not the other way around. This one was created by doctors prescribing way too much. Way too much. That massive increase in pills out there, and very, very liberal and aggressive prescribing, and a variety of things like that, all helped create new addicts. They were not addicted before they had an abundant supply available to them of these drugs and constantly having them pushed on them. It’s unclear to me that we would have much of a heroin problem if there wasn’t so much heroin splashing around the United States. Think again. My feeling, I’m not sure I had an answer to that question before, but after this, I definitely believe supply helps create demand. Then, demand goes wild. It’s also true with the Colombians and cocaine. We didn’t really have a big market for cocaine until the Colombians in the early 1980s forced all that coke through Miami and into south Florida, etc. Then, of course, there became a demand for it, but they, like all these drug traffickers, like great marketers, understand if you provide it and market it in the right way, you will find that people respond to it. For me, honestly, this latest one starts with doctors, doctors overprescribing way, way, way overprescribing for all kinds of things. You know probably as well as I do, wisdom teeth extraction, minor surgery, all this stuff that you used to get ibuprofen for, now you’re getting basically opiates for. That being the case, we have to keep in mind that traffickers will take this. That’s really what happened. The heroin traffickers follow the market for pills. I think that we need to understand that we have a border … We now have essentially a sealed border. I do a lot of immigration reporting along the border and stuff and I’ve been down to Tijuana several times. I know that city fairly well.

Frank Greenagel: That’s what your first couple of books were about, was about Mexico and some of the immigrant and border issues, correct?

Sam Quinones: Exactly. My feeling is that the border is sealed. The reason I say that is it now costs an immigrant $6,000-$10,000 depending on where they go and that kind of thing to cross, whereas not so long ago, it was in the $300-$500 range and then it got up to maybe $1,000 or $2,000, which was still fine, but now it’s well beyond a lot of immigrants’ ability to pay. The border is now effectively sealed. However, we have to always keep in mind that we will never really, really be able to seal the border, not if we want to have trade with Mexico. It simply won’t happen. I mean, there will be ways people and substances will leak across so it behooves us to understand that when we are designing new policies and drug policies in particular. When the FDA decides that this is a really good idea to market this stuff and to make this stuff available, they might want to take into consideration that there is going to be a black market in it. I just find it amazing that no one would have thought that. They might have, but they didn’t put enough emphasis on it. Getting back to your original point, I’ve had that question asked to me before and my feeling is that I really don’t care. I like stories not based on whether it makes a certain group look good or bad and I write stories that I think are great, great tales that need to be told that no one’s telling, and that’s what I think I did with this book. You can see my other books and see how that might reflect on Mexico and make your own decisions about the country, but I lived there for 10 years. I didn’t live there because someone put a gun to my head. I love the country, but I’m also not going to shy away when I see a huge story, no matter what Donald Trump or anybody else says or how they might use it. Otherwise, I’d never write a thing.