The History and Future of Harm Reduction

September 26, 2022

Information

9/22/2022

Maia Szalavitz

Author, Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction
Contributing Opinion Writer, New York Times

Kimberly Sue, MD, PhD
Assistant Professor of Medicine (General Internal Medicine)
Yale School of Medicine
Medical Director, National Harm Reduction Coalition

Moderator: Randi Hutter Epstein, MD, MPH
Writer in Residence, Yale School of Medicine

ID8117

To CiteDCA Citation Guide

00:00OK. Hello, everybody. I'm Anna
00:03Reesman, director of the Program
00:05for Humanities and Medicine.
00:06Thank you so much for joining us at the
00:08first event of our 202223 academic year.
00:13Welcome to the very small group
00:14here in person and to the much
00:18larger contingent on zoom.
00:19And this is our first experiment
00:20with the hybrid setup so you
00:21can let us know how it works.
00:23I am so excited to introduce you
00:25to our speakers for today's event
00:27just entitled the History and
00:29future of harm reduction. First
00:32of all, my salivates who was the
00:35author most recently of undoing drugs,
00:37The Untold story of harm
00:38reduction and Future education,
00:40which you can see on your
00:41screen, which is the first history
00:43of the harm reduction movement.
00:45She's a contributing opinion
00:46writer for the New York Times.
00:48Her New York Times bestseller Unbroken brain,
00:50a revolutionary new way of
00:52understanding addiction,
00:53wolf together in neuroscience
00:54and social science of her
00:56experience with heroin addiction.
00:58It won the 2018 Media award
00:59from the National Institute on.
01:02Her 2006 book,
01:04entitled Help at any cost,
01:06how the troubled teen industry
01:07cons parents and Hurts Kids,
01:10was the first to expose the
01:11damage caused by tough love,
01:13youth treatment and help
01:14spur congressional hearings.
01:16She's written for COVID and
01:18five other folks, including
01:19the classic on child trauma,
01:21The Boy who was raised as a dog
01:22and has written for numerous
01:24publications, including time,
01:25Wired and Scientific American.
01:27She lives with her husband and two squeaky
01:30cats in New York City. Would affect.
01:35OK, so and next to my is Doctor Kimberly Sue,
01:40who is an assistant professor of
01:41medicine with the program in addiction
01:43medicine at here at Yale
01:45University School of Medicine.
01:47She is the former medical director
01:49as of a few weeks ago at the National
01:51Harm Reduction Coalition in New York,
01:53which strives to improve the health and
01:55well-being of people who use drugs.
01:56Currently, she serves as an attending
01:58physician at the Central Medical Unit,
02:00the APT Foundation,
02:01which provides primary care to patients
02:03receiving methadone and other substance use.
02:05Treatment programs,
02:06treatment services,
02:07and supervises fellows and trainees within
02:09the Addiction Medicine Fellowship program.
02:12She also attends on the hospital based
02:14Yale Addiction Medicine Consult service.
02:17She's double board certified in
02:19internal medicine and addiction
02:21medicine and has a among other things,
02:24PhD and sociocultural anthropology.
02:26And she actually
02:27was here a couple of years ago to
02:29talk about her book before she was
02:30back to her getting raped women
02:32incarceration in the American opioid
02:34crisis that was published in 2019.
02:36Based on her research on women of opioid
02:38disorder, Massachusetts prison and jails,
02:42and today's moderator on my
02:44left is ***** Hutter Epstein,
02:46the writer in residence here
02:48at Yale School of Medicine.
02:50Randy also teaches in the English department
02:53here at Yale.
02:54She's also an associate professor at
02:56Columbia Graduate School of Journalism.
02:58She's written freelance articles
02:59about health and medicine
03:00for national publications,
03:01including the New York Times,
03:02the Washington Post.
03:03She's the author of two books
03:06Get Me Out a history of childbirth.
03:07In the Garden of Eden to
03:08sperm bank and aroused the
03:10history of hormones and how they
03:12control just about everything.
03:14She's working on her third book
03:15about the science of stress,
03:17and she said she would have
03:18finished it if she could just
03:19learn to relax and focus.
03:23She's a graduate of the University of
03:25Pennsylvania, where she studied history
03:26and sociology of science. She has
03:28a Masters degree from Columbia School
03:30of Journalism and MPH from Columbia,
03:32and an MD from Yale, and she
03:34lives in New York and has four grandchildren.
03:37We are also joined by Charlotte
03:39doing Cheryl Henderson doing the ASL
03:42interpretation and I want to say
03:43thanks to our Co sponsor the Yelp
03:45Program and Addiction Medicine and
03:47always to camera hold the program
03:50manager for Program for Humanities
03:52and Medicine and you on zoom,
03:55you know you know the routine.
03:57So please put your questions
03:58in the Question tab and we will
04:01draw from those later on.
04:02So thank you all for being here and
04:04I will hand over the MIC to Randy.
04:08I think we're going to
04:09start right away with Maya.
04:10I have a slew of questions,
04:12but I'm we're definitely in a safe room
04:15for questions in the chat and anyone
04:17who's here but my why don't you start?
04:22All right, great.
04:22Well, thanks so much for having me here.
04:24I'm really excited and and
04:26sighed and honored all of that.
04:28So I'm going to talk about the
04:30history of harm reduction,
04:31where it comes from, where it's going,
04:33and that is the subject of my
04:35latest book on doing drugs.
04:37I will start with my personal
04:39experience of harm reduction.
04:40Next slide, please.
04:42When I was injecting drugs in the late 1980s,
04:45the only reason I avoided getting
04:47AIDS was because an outreach worker
04:49who was visiting from San Francisco
04:52taught me that I was at risk and
04:54then I should avoid needle sharing
04:56or at least use bleach to clean
04:58needles if I had no other option.
05:00I didn't know it at the time,
05:02but I was being taught harm reduction,
05:04and this is a poster from San Francisco,
05:06where outreach to drug users
05:08even had its own superhero,
05:10and I would later learn that the woman.
05:12I've met and taught me to be safer
05:14and had worked for one of the
05:17organizations in the consortium
05:18that conducted this media campaign,
05:20and they even had these amazingly
05:22cheesy late night TV commercials with
05:25bleach man from the Planet Necklace,
05:27which is of course the chemical
05:30formula for bleach.
05:31That someday I will finally put a
05:33video of them into this next slide.
05:36Please.
05:37But accidentally learning that I was
05:39at risk for deadly disease made me furious.
05:42Furious that I hadn't known I was
05:44at risk due to injecting drugs.
05:45Furious that there was a simple way to
05:47protect myself that I didn't know about.
05:49And outrage that New York and federal
05:52officials and even some AIDS organizations,
05:54not only didn't try to tell
05:56people like me about our risk,
05:57but they actively tried to stop others
06:00from providing life saving information.
06:02They were concerned, the politician said,
06:04that making injectors safer
06:06would send the wrong message.
06:08In the drug war. Next slide please.
06:10Our lives didn't account.
06:12We were only useful as object
06:14lessons for other people's children.
06:16Our role was to be damaged or even
06:18died to teach the salvageable kids
06:20to just say no and this way you're
06:23seeing people was important to me.
06:24So I began trying to fight back
06:26at first in small ways,
06:28like writing graffiti about how
06:29to use bleach in bathrooms where
06:31I knew that people shut up,
06:32and then in larger ways by becoming
06:34a journalist and trying to get
06:36this information out there.
06:37As much as I could use,
06:39here are some of my early.
06:41Yes, next.
06:43Well, there always been ideas about
06:45reducing harm as a policy goal,
06:47going back to the Hippocratic Oath and 1st,
06:49you know,
06:50harm.
06:51Modern harm reduction originates
06:52in the AIDS crisis,
06:54starting with syringe exchange.
06:56And it originates in a collaboration
06:58between people who use drugs and
07:00scholars and other health officials who
07:03recognize that without understanding and
07:05without centering people who use drugs,
07:08they would not be able to find effective
07:10ways to change risky behavior.
07:12The first needle exchange.
07:14Program was founded by this man here,
07:16Nico Adriaans,
07:17who was a Dutchman and he used drugs himself.
07:21He also started the world's first drug
07:24user union, or junkie button, in Dutch.
07:26He chose to use that charge for Junkie
07:30deliberately in order to fight stigma,
07:32and he started this exchange in 1981,
07:35before HIV was even discovered,
07:38because of an especially deadly outbreak
07:40of hepatitis B, where he lived.
07:43Next please.
07:44Meanwhile, in the UK in the mid 80s,
07:47a catastrophe was underway in Edinburgh,
07:49Scotland.
07:50Economic decline,
07:51a loss of factory jobs and the supply
07:54of heroin from Afghanistan and Iran
07:56has led to a huge rise in drug
07:59injecting among teens and young adults.
08:01In response the city crackdown,
08:04squeezing needle suppliers and
08:06arresting people who use drugs now.
08:09Making matters worse,
08:10the authorities decided that addiction
08:12was best treated only by complete.
08:14Accidents.
08:15So they shut down the cities
08:17only method of program.
08:18Basically what they did is everything
08:20HIV would have wanted them to do if it
08:23were a thing that could have intentions.
08:25And this enabled the spread of
08:28the virus so quickly that when
08:30doctors in Edinburgh tried a newly
08:33available test for HIV,
08:3450% of these young people
08:37were already infected.
08:38Now, not far away,
08:40the city of Liverpool had virtually the
08:42same economic conditions and a heroin.
08:44Outbreak but HIV had not yet
08:47reached its its IV drug users.
08:50Next please enter Alan Parry and Upper right,
08:54Peter McDermott.
08:55On the lower left, Russell Newcomb,
08:57Alan would Matthews,
08:58Pat O'Hare and Doctor John Box.
09:00Together they would create what was
09:02first known as the Mersey model for
09:05dealing with HIV and drug risk,
09:07and this would include multiple
09:08strategies for improving the
09:10health of people who use drugs,
09:11from needle exchange to education
09:13on wound care.
09:14Two harshly providing pharmaceutical
09:17heroin and pharmaceutical cocaine.
09:19Next please.
09:20Now this is doable because the UK
09:22had never outlawed medical use of
09:25these substances to treat addiction,
09:27unlike the US here.
09:28After the Harrison Act made non medical
09:31use of opium and cocaine illegal.
09:33In 1914,
09:34the Supreme Court interpreted this
09:36law to me that prescribing these
09:39medications to treat addiction
09:41is not legitimate medicine and
09:43could never be a part of.
09:45Legitimate medicine.
09:45If you were trying to put comfort and addict,
09:49that was not considered medicine.
09:51However, the British do the
09:52opposite around the same time,
09:54and they explicitly allowed prescribing in
09:56what became known as the British system.
09:58Next please.
10:00By 1987,
10:01Russell Newcom,
10:02a psychologist and drug user himself,
10:04had come up with a memorable term to
10:07encompass all of these approaches,
10:08and that was not pain reduction.
10:12They did not have
10:13very good coffee in theaters at this
10:15small publication when he published it.
10:17Actually, now it is corrected,
10:19so you would never know this if
10:20you didn't have the old copy.
10:22Liverpool, however, avoided an HIV
10:25epidemic entirely among people who
10:28inject drugs by doing harm reduction.
10:30No one had to share needles,
10:32so HIV didn't catch the foothold there.
10:34Next please.
10:36And not surprisingly,
10:37the harm reduction is wanted to
10:39share their success with others
10:40and they wanted to start a movement
10:42to promote it and so to spread the
10:44word deliberately and founded a
10:46journal which is now called the
10:47International Journal of Drug Policy.
10:49And they began holding conferences
10:51and just speaking all over the place
10:53to try to get the idea out there.
10:55And because harm reduction was pragmatic
10:57and seemed like common sense to
10:59people who were in the public health field,
11:01if not always to people
11:02in the addiction field,
11:03it began to catch on throughout Europe next.
11:06Is production also captured the
11:08attention of Americans who would bring
11:11it into the fight against AIDS here.
11:14The first would be to the social
11:16worker and I drug user Nikki Springer.
11:18She met Liverpool's Alan Parry,
11:20who would come to New York to
11:22proselytize for harm reduction,
11:24and she and he not only gave language
11:26to work that Edith was already doing,
11:28but gave her a whole new way of staying.
11:31In 1988, Springer was working with
11:33a group called ADAPT,
11:35which was led by a woman named Yolanda.
11:38Both Serrano and Springer were tired of
11:40losing people that they love to AIDS.
11:42Both fought to free people
11:44from Rikers Island,
11:46where the AIDS ward was
11:48absolutely a horrific mess.
11:50And remember,
11:50in Rikers Island,
11:51you're not there because you've
11:52been convicted of something.
11:53Usually you're there and innocent,
11:56supposedly until proven guilty.
11:58And they were just letting
12:00people die like paper.
12:01Blankets and and just not
12:04even touching them anyway.
12:06They start up a hunger strike and
12:07they got the conditions improved
12:09and they also just got a lot of
12:11people out on compassionate release.
12:12Next please.
12:13Now both Edith and Yolanda also
12:15led adapt out into the community
12:18going into shooting galleries
12:20with bleach to teach people about
12:23how to protect themselves.
12:24And here we see Yolanda in a shooting
12:27gallery with a journalist who you may
12:29recognize as a very young Geraldo Rivera.
12:32Next please.
12:33Now further outreach work.
12:35Serrano soon got the label the
12:37Avon Lady of AIDS prevention,
12:39while Edith Springer because of her
12:41trainings and they were so inspiring.
12:43She became the goddess of harm reduction.
12:46And crucially, in early 1990,
12:48Serrano would spur the AIDS activist
12:50Group Act up to start illegal needle
12:53exchanges after New York's mayor shut
12:55down the legal pilot program that we
12:58briefly had for political reasons.
13:00Next place now.
13:02One Parker who some of you hear me now
13:05with another fee harm reduction is
13:07at this time former used former drug
13:09user turned medical student at Yale.
13:12He was moved to take action after
13:14one of his lecturers wrote off drug
13:16users simply doomed to die of AIDS.
13:18He said no the you know gay men will,
13:21you know, prevent for themselves
13:22but those strategies are worthless.
13:24And he stood up and said no,
13:25that's not true. Next place.
13:28So Don Parker soon got his own key nickname.
13:32The New York Times called him
13:33the Johnny Appleseed of Needles.
13:35And this is not the New York Times,
13:36but it's another publication that.
13:39Watch picked up on it.
13:42And he got this name because in the late
13:4580s he had begun deliberately getting
13:47arrested in cities up and down the East
13:49Coast in order to challenge the laws
13:52that made syringe exchange illegal.
13:54And here next, please. Sorry.
13:57Oh, by 50 slide. Sorry.
13:58But anyway, go back to the other one for now.
14:01No. There we go.
14:05OK, and so he was this photo here is
14:08him distributing meals in New Haven.
14:11He was actually expelled from medical
14:13school because he was basically
14:15neglecting studies in favor of
14:17doing the needle exchange work.
14:19But he did manage to get into
14:21the School of Public Health.
14:23And in early 1990,
14:24he joined forces with act up to
14:27get arrested in New York City
14:29for distributing clean deals.
14:31Now the next one.
14:34In New York,
14:35John Parker and these active members
14:37who are shown here became the Needle 8,
14:39and they won their case by arguing
14:42that syringe exchange is necessary
14:43to protect public health because the
14:45laws that made syringe exchange,
14:47laws that make syringe possession illegal,
14:49we're absolutely doing the opposite of that.
14:52Next please.
14:53And that trial,
14:55which was very dramatic and the judge
14:57completely agreed with them and said,
14:59yes, they're doing necessary work.
15:02Along with a very clever study by
15:05Yale's Robert Heimer and Edward Kaplan,
15:08this paved the way for New York to
15:11finally legalize needle exchange.
15:13So basically what happened was
15:14critics of syringe exchange,
15:16because of the stereotypes that
15:18people use drugs, are all liars.
15:20They had long argued that all
15:22the research on needle exchange
15:23could not be believed because it
15:26was based on self report.
15:27In fact,
15:28we now know from a ton of research
15:30that people who inject drugs
15:31are as likely to be honest.
15:33As everyone else,
15:34as long as they aren't going to
15:36be punished for telling the truth,
15:37which is just how human nature is, right?
15:39So anyway,
15:41Heimer and Kaplan and their colleagues
15:43got around his objection by testing
15:46the needles themselves for HIV.
15:48And they found that the more the syringes,
15:50the the more syringes exchange distributed,
15:53the less likely there was to be HIV
15:56in the works when people return them.
15:59So this got over those objections
16:02about self report only.
16:03And also it helps that New Haven
16:07had a black mayor who trusted
16:10this research in New York had
16:12a black mayor who trusted him,
16:13and they went forward and
16:15finally we got me
16:17look straight. Even.
16:18Springer, meanwhile,
16:19went on to train thousands of people
16:21and how to do harm reduction,
16:22including nearly all of the
16:25movements first graders next place.
16:27One of them was Chicago standing.
16:30And he recognized that people on the street,
16:32not just doctors,
16:33should have access to the loxone which
16:35everyone here knows what naloxone is.
16:37And he spread that message and the
16:40drug itself across the country.
16:43He would go out with a duffel bag full of it.
16:45And at a conference,
16:47he would just go to people,
16:48come on, take some.
16:49You can save the life.
16:51You can, you know,
16:52create a program in your community
16:54that will literally put life saving
16:57tools in people's hands and and
16:59be the difference for people.
17:01And you did this and spread
17:02it all over the country.
17:04Without Dan Naloxone might still only be
17:07available in ambulances and hospitals.
17:10And his work has saved at least
17:12hundreds of thousands of lives.
17:13And obviously he didn't do it alone.
17:15But if he hadn't pushed it the way he did,
17:18we would be in a very different
17:20situation next place.
17:21Now,
17:21another social worker and drug user who's
17:24trained by Edith Springer was Keith Kyler,
17:27and he was one of the Co founders.
17:31Of Housing Works,
17:33and that was probably America's
17:35first housing first program.
17:38And with housing first means is that you
17:40don't have to be absent to get housed.
17:42We're not going to expect that you
17:44are going to go from being actively
17:47addicted and probably also mentally
17:48ill and probably also traumatized on
17:51the street to instantly following
17:53rules and being totally abstinent
17:54and not getting kicked out of your
17:57housing because you don't fall anyway.
17:59We now know from research on housing.
18:01Of course that when it is
18:04supported adequately,
18:04they dramatically reduce
18:06chronic homelessness.
18:08In fact,
18:09a little publicized 50% decline
18:12in homelessness nationally among
18:14veterans between 2009 and 2019
18:16was accompanied by widespread
18:19expansion of housing 1st.
18:21And so when people say it doesn't work,
18:24it's government policy because it does work,
18:26although that's rare.
18:27Oftentimes government policy does not work,
18:29but this is one of the rare
18:31instances where it is evidence.
18:32Next,
18:33please.
18:34Now there's of course thousands
18:35of others who deserve recognition
18:37for their work on harm reduction,
18:39but I will stop here because I'd
18:41like to discuss the future of
18:43harm reduction in our panel and
18:45thank you so much for listening.
18:47Thank you so much.
18:48I think that gives us a good
18:49foundation that we might want to go
18:51back to some of the people at Yale
18:53that you mentioned since we're here
18:55at Yale and talking about them.
18:57But I just want to sort of.
19:00Take a step back and think,
19:02you know,
19:02harm reduction is a term that anyone
19:04in public health or medicine hears a lot.
19:07I think outside of medicine still
19:09either people have never heard about it
19:11or they just think about a needle exchange.
19:13You had bestseller books.
19:15You've written about tough love.
19:16You've written your own book about addiction.
19:18You write about neuroscience all the time.
19:19Why did you think it's important
19:22to write a book on the history of
19:24harm reduction for a lay audience?
19:26Basically, it's going to be the only
19:28way we can have successful policy
19:31around drugs and around other risky
19:34behaviors that humans engage in,
19:36because humans, especially teenage humans,
19:39will always engage in some
19:41form of risky behavior.
19:43And our current drug war,
19:46the entire approach has been,
19:48will make it more dangerous and more harmful,
19:50and then will deter people and so
19:53other people won't follow that bad
19:55path that clearly does not work.
19:57We now have the history's
20:00worst overdose crisis,
20:01with over 100,000 people
20:03being killed every year now.
20:05And so harm reduction offers a better way,
20:10a more moral approach, actually,
20:12even though the people who
20:13promote the other side.
20:14Say they're on the side of God.
20:17But, you know,
20:18I feel like not using people as
20:20instruments and seeing everybody's
20:23life as valuable and treating
20:25people with dignity and respect
20:28and not requiring somebody to not
20:31do what you don't want them to do.
20:34Is, you know,
20:37is not the way to deal with people.
20:41I may have just said the opposite of
20:42what I intended because I got distracted,
20:43but anyway, I will.
20:45Harm reduction is basically the
20:48idea that we should focus on
20:51stopping people from getting hurt,
20:53not stopping them from getting high
20:55or engaging in other risk behaviors.
20:57Because people are, you know,
20:59we're human, we're going to do stuff.
21:02So how do we keep everybody as
21:05healthy and happy as possible?
21:07By recognizing that, say, you know,
21:10people are not going to not socialize.
21:12Forever.
21:12And maybe we got to wear a mask,
21:14you know?
21:15So that is really the fundamental
21:18idea of harm reduction.
21:20And it's really about meeting people
21:23where they are with love and respect
21:27and support and recognizing that you
21:30can't just judge somebody and expect
21:34them to instantly change because you say so.
21:37And I want him to jump in,
21:38but maybe we can do the stop
21:41share so people can see.
21:42People can see Maya and Kim Big.
21:46There we go, OK?
21:47Ohh, I was just going to,
21:50I'm going to egg you on a little bit,
21:52talk about what Maya said,
21:54but here I also want to
21:55jump in and talk about that.
21:56In addition to everything else you're
21:59doing with patients with harm reduction,
22:01you're also called on from
22:03the media a lot to speak.
22:04In addition,
22:05as you totally even John Oliver's
22:07people reached out to you.
22:09But here's my question for both
22:11of you and I want Kim to start
22:14your you get annoyed if the media
22:17doesn't ask you the right questions.
22:19You want them to ask in questions
22:22in the right way.
22:23So there's probably people listening
22:25that may one day be calling you
22:28and want to quote from you or want
22:30some background info.
22:31And they're like, oh, I don't want to
22:33be one of those people that annoy you.
22:35So what do you expect from the media
22:37when they're asking you questions?
22:39And then I'm going to ask the
22:41same tamaya was in the media.
22:43What ****** you off in terms of
22:45what some of your colleagues do
22:46and what should they be doing?
22:50Well, thank you so much, Randy.
22:51Yeah, I mean.
22:52Let me just say I wanted to add
22:55something to my comments before too,
22:57which is that I feel like the
23:00what when you forgot to mention
23:02is like how we need this history
23:06written down and and I mean I know,
23:09I know you spent so much time
23:10going over and Edith is like 96 or
23:13something like Edith is old, right.
23:15So I mean I think it's really
23:17wonderful to have everything
23:19sort of recorded and I think,
23:22you know, compiled because.
23:23It is not something new.
23:25You know what I mean?
23:26And I think,
23:27I think building off of sort of
23:29and the way and we could talk about
23:31the writing later on and how you
23:33triangulated all these characters
23:34of people and and, you know,
23:36this diversity of experience,
23:37which is really important.
23:39But I just think having that
23:41history helps us advocate for that.
23:43The policy in the future that we know is,
23:46you know,
23:47part of this social movement
23:48and it really helps,
23:49helps payment really in the US context,
23:52not in Portugal.
23:53Not in, you know,
23:55not in Switzerland, right, right.
23:56I mean this is like we are dealing
23:59with very specific US beliefs and and
24:02cultural values that I think you address.
24:05So when the media comes to me and,
24:07you know, I, I'm.
24:09I'm very happy when they've,
24:11when they've done some initial research,
24:14I'm very happy when they have
24:16talked to people who use drugs.
24:19I'm very happy when they have
24:23sort of done some background that
24:25shows they have some sensitivity
24:28to people's lived experience.
24:30And so if you have sort of a combination
24:33of one or more of those things,
24:35I'll be pretty happy, you know, I think it's.
24:39It's very hard for you know I think
24:42it's very hard for me to the more
24:45specific the questions can be the
24:47the better and and the way that way
24:49I can direct people to the right
24:51people or to the right resources
24:53and and the framing is very,
24:55very important.
24:55You know I think we're seeing with
24:58more and more media coverage of harm
25:01reduction that people also haven't
25:03even thought about their own biases
25:05or their own experiences and and the
25:07ways in which you know and and a lot of.
25:10What we are talking about is,
25:13is innovative,
25:13you know and and there may or
25:15may not be that research base
25:17for example that some of the
25:19articles on safer supply or things
25:20like that are going to be.
25:22So I'm interested in your thoughts on
25:24that too because we are seeing
25:26better and not so good,
25:28you know and and we are,
25:30we are actually part of a
25:32collective call changing the
25:34changing narrative which started I
25:36think a couple of four years ago.
25:40But you can you can tell them about that too,
25:42which is like, you know,
25:43some common mistakes that at journalists,
25:46that science reporters,
25:48that health communicators,
25:50people trying to get into this
25:52topic have have made.
25:53Thanks, yeah. No.
25:55And you're absolutely right.
25:57I think the.
25:59The fact that this has a history
26:01and what it means to the people
26:04who created it helps tell the story
26:06of why it's a worthwhile thing.
26:08And so I I think that is,
26:11and I think a lot of times journalists
26:13just they see the phrase and they're like,
26:16oh, harm reduction reducing harm,
26:17OK, that's good.
26:18And they don't.
26:19They just sort of make up what
26:21the history would have been.
26:22They they just like assume that
26:24it's just sort of one of these ideas
26:27floating around the ether rather than.
26:29An idea that actually has a story
26:32and it has people now in terms of
26:35speaking with the media and that whole thing.
26:38I had the experience of being
26:40on Doctor Phil yesterday.
26:42It has not yet aired,
26:44but one of the things that was
26:47really interesting about it,
26:48aside from my ultimate terror of
26:51the situation, was that, you know,
26:55he he could not believe that I
26:58said enabling was not a thing.
27:00It just kind of blew his mind that
27:03anybody would even suggest that
27:05he couldn't take it in somehow.
27:08But you just yeah.
27:10So what?
27:11You know,
27:11the idea is that if you
27:13give people clean needles,
27:15if you give people free heroin,
27:16if you are nice to people with addiction,
27:19if you are supportive of them,
27:21you are enabling them and you are
27:24preventing them from hitting bottom
27:26and reaching glorious abstinence.
27:28And if you. Keep enabling them.
27:31Their addiction will last longer.
27:33In reality,
27:34when you look at the research about what
27:36happens when you give people clean needles,
27:39what happens when you
27:40give people free heroin?
27:41What happens when you're nice to people?
27:44It actually sustains their lives,
27:46but it does not make the addiction
27:48any longer than it would have been
27:50had they just been left on their own.
27:53Because if you look at,
27:54for example,
27:55compare people who participate in needle
27:57exchange versus not the needle exchange,
27:59participants are five times
28:01more likely to get treatment.
28:03So that implies that needle
28:06exchange is not enabling,
28:08it's not deterring people
28:10from getting further help on.
28:13It is actually.
28:14Teaching people that they are valuable.
28:17And when people can value themselves a
28:20little bit more, they can feel more hope.
28:22And if you feel more hope,
28:24you can get ready to make the
28:26difficult changes that have to be
28:28made if you're going to recover.
28:30And so a lot of times the media
28:32just has these cultural ideas
28:35like enabling and like everybody
28:37needs to hit bottom and go to a
28:40that are just built into American
28:43popular culture and news.
28:44And so they don't even.
28:46You know,
28:47there's this line in
28:48journalism school where they
28:49say, like, oh, if your mother says she
28:50loves you, check it out like would
28:53that we actually behave this way not
28:55towards our mothers, but towards the
28:58facts around drugs and addiction.
29:02You know, like right now we're having this
29:04ridiculous panic over rainbow fentanyl.
29:06And the idea is supposed to be that like,
29:09oh, the evil drug Lords are creating
29:11pre colored fentanyl so that they
29:13can attract children. Why?
29:15Why would you want to attract?
29:17Children to fentanyl, it makes no sense.
29:19Killing children is really
29:20not a good business plan.
29:21Like, where's the future in that?
29:24You know, like, where's the profit?
29:26Like, little children don't even have
29:28money to buy more if they survive.
29:29So, you know,
29:30and they're also going to rat you out.
29:32So why would you do this?
29:34You know, it makes zero sense.
29:36It's much more likely to be a
29:38branding thing or just whatever they
29:39happen to have lying around me.
29:41Did that color and it was the cheapest
29:43thing they could buy into, like, be filler.
29:46So you know it.
29:48It's just like.
29:49Journalists need to be I I sort of
29:52used to say the drug War acts as an
29:55anti skeptic to journalists and we
29:58need to like not have that happen anymore.
30:01We need to really.
30:02People need to actually educate
30:05themselves and question everything.
30:07You know,
30:07everything you learned in dare
30:09is not all you need to know if
30:11you want to write about drugs.
30:12In fact,
30:13most of it is not true and everything you
30:16learn from the police report also not true.
30:19You know exactly.
30:21Exactly.
30:21So, so I think this becomes an
30:24obstacle to getting harm reduction out
30:26there because people are just like,
30:29wait a minute, you're being nice to people.
30:31And I was told we're supposed to like,
30:33humiliate them and and, you know,
30:34throw them out of the house.
30:37And so, Kim,
30:38I want you to jump in on this as a clinician.
30:41So two things. One is how does this play out?
30:44I mean, one thing to talk in,
30:46in public about, you know,
30:48public health and communities
30:50of what we need.
30:52How does this work for one-on-one
30:54with a patient like you just say you
30:56do a little less or how does harm
30:58reduction work one-on-one and how
31:00do you have these conversations?
31:01And as you're talking about that,
31:04we probably have some residents
31:06and medical students. Out there.
31:07Do you think it's important for all
31:10doctors to become activists and
31:12writing and enter the public discourse?
31:15I mean not, you know,
31:16there's a bunch of introverts out there.
31:18Yeah.
31:18Well, this is my, you know,
31:20my life's work so far and it continues to be.
31:25We do harm reduction strategies
31:28in the clinic are super easy.
31:33There are tips that we have
31:35from national harm reduction.
31:37Coalition how to work with
31:39people who use drugs.
31:40We put out a pamphlet in like
31:422012 about it and really like it.
31:47A couple things.
31:48So I start off with say, you know,
31:50wanting to know what people's goal is for
31:52themselves in regards to their substance.
31:55I always ask people sort of why they use
31:58their substance of choice or substances
32:00of choice and what they like about it.
32:02And we don't talk enough about,
32:05you know, why, why people benefit,
32:08what benefits that that
32:09substances do for people.
32:11And and if people are trying to
32:13stop a harmful behavior, then try.
32:15You really need to understand that.
32:17Part of that, that psychology and what else
32:20is going on in people's lives that, you know,
32:22may or may not be related to substance use.
32:25So those are the, that's the floor.
32:28Often people like,
32:29I do not expect that people who use
32:31drugs are going to talk to me honestly.
32:34I do not expect that they
32:36are going to disclose.
32:37I mean police have often acted
32:39like cops and still do act
32:41like cops around this country.
32:43Doctors.
32:45Yes, sorry, somebody. OK.
32:47But also like if people are
32:49coming in for a specific issue,
32:52I'm going to address that issue.
32:53If you're coming in for a rash and,
32:55you know, you don't want to talk
32:57about substance use like that
32:59is a relationship, you know.
33:00And so I want to create that compassionate
33:03relationship and I want to, you know,
33:05understand people's goals and and give
33:07them the resources that they need to be
33:10able to achieve those and and, you know,
33:13whether that's prescribing syringes.
33:15Or, you know,
33:15whether that's treatment for their,
33:17you know, stimulant, you know,
33:19for their ADHD or stimulants or
33:20or ways that we can we can think
33:23creatively and work together.
33:25And I think having a harm
33:26reduction approach in the clinic,
33:28and I've said this many times,
33:29actually decreases the frustration
33:31that you might feel.
33:33You're not forcing anyone to do anything.
33:35So the friction that people feel is like
33:37he doesn't do what I say or he didn't.
33:40You really can like actually
33:42partner with people,
33:43which is incredible and you can really.
33:45And you are not going to go
33:47out and act the plan, you know,
33:48Myers, my patient,
33:49Myers gonna go out and and live her life
33:51and I want, you know, want to empower,
33:53educate and and support her in that life.
33:56But I'm not going to go out and be
33:58there with her or or like, you know,
34:00stand over her and you know,
34:01you know, you know.
34:03So I do think having that relationship
34:05actually improves the feeling of
34:07our relationship as a doctor and
34:09a patient and and I feel like it's
34:12really rewarding and satisfying
34:13and there's no other field.
34:15Where you can really just sit and
34:17and talk to people and address their,
34:19you know feel,
34:21you know like you're recognizing their
34:23humanity and and and working with
34:25people in a in a partnership way.
34:27So I I'm really happy that there's
34:30hopefully a lot of trainees out there who,
34:34who do this and who can,
34:35who can do harm reduction where they are.
34:37And the the important part of it is like,
34:41you know, if you're in Texas,
34:43you know, I need you.
34:44I need your medical student.
34:46I need you to be. We need your voices.
34:48We need your activism.
34:50Right?
34:50Because.
34:50When I go to Texas,
34:53everything that my talks about in
34:55the book and everything that I talk
34:57about in my talks is criminalized.
34:59It's illegal.
35:00I can say, OK,
35:02I would like you to use one new
35:05syringe per each injection syringe.
35:07Syringe possession is paraphernalia there.
35:10People are not going to ask.
35:11You cannot access it.
35:12So how am I going to, you know,
35:15how can we change that law partnering
35:17with the Texas Drug users union,
35:19you know,
35:20like ways and we really need people.
35:22Who are seeing witnessing on a daily
35:24basis in healthcare and and people who
35:27partnering with people who use drugs
35:29to change the laws or break the laws,
35:31you know or do do what they need to do.
35:33Yeah, I want to.
35:34I want to add to that because one of
35:37the things that I was really struck
35:39by when I was talking to Edith was
35:42that she said you know she had to meet
35:44providers where they are not just not
35:46just patients and if you wanted people to,
35:50you know understand harm reduction,
35:51she had to. Deal with the frustrations
35:54and the things you were talking about.
35:56They don't do what I say.
35:57Everybody's failing.
35:58Everybody relapses.
35:59Nobody ever gets better.
36:00And she said, well, wait a minute,
36:02if we look at recovery.
36:05As people getting better,
36:07not as people turning perfect.
36:10I'm paraphrasing, I just made that,
36:12but the, but the the point is the same.
36:15And so she would she would have people,
36:17she would, you know, generate empathy,
36:19have people talk about like, well,
36:20I had this client and you know,
36:22they they were smoking crack every day.
36:26Now they're smoking weed, you know,
36:29they're not getting any better.
36:31And it's like, wait a minute,
36:33we need is like very much.
36:35Less dangerous than crack and,
36:37Oh yeah, they have a job now,
36:38you know,
36:39so you have to like,
36:40you have to measure success properly
36:43and harm reduction gives you a
36:45much better way of doing that.
36:47And we can also see a sort of horrible
36:49example of what happens when you
36:51measure the wrong thing in what's
36:53going on now with opioid prescribing.
36:55Because what we're seeing is that
36:57people have been on opioids for years
36:59for chronic pain and are stable,
37:01are just getting cut off because
37:03CDC guidelines and I don't want
37:04to get prosecuted.
37:05From the doctor's perspective.
37:07And then,
37:09you know,
37:09we now have studies of what's happening
37:11to these patients and there's a
37:13triple risk of triple the risk of
37:15suicide and quadruple the risk of overdose.
37:17I may be getting those backwards,
37:18but they're both very,
37:20very high odds ratios.
37:21And so, you know, we're measuring, look,
37:25we we reduced opioid prescribing 60%.
37:27Well, that's great,
37:28except overdose deaths went up.
37:30You know,
37:30I'm not going to have the number in my hand,
37:33but an enormous percent more than that.
37:35Because we just did not
37:38focus on reducing harm,
37:39we focused on we need to get
37:42these drugs reduced.
37:45So you mentioned Yale and New
37:48Haven and bit in your talk,
37:50and we probably have an audience that's
37:52hungry to hear a little more gossip,
37:54whether it's in your book or it's not
37:56in your book because I know you had to
37:58leave out a lot of information in the book.
38:00So can you just go back in time?
38:03And then I want Kim to talk about what's
38:05going on in Yale and New Haven now,
38:07but in the history, John Parker,
38:10was he welcome of what was
38:12going on and what years?
38:14Was he here?
38:17Why?
38:17How did he end up at Yale?
38:19What was he doing before?
38:21And then also, I know you touched on it,
38:23Kaplan study, but it's really crucial.
38:25Did they can you tell us if there was any
38:27relationship between Parker and Cameron?
38:29And yeah, now that I don't know,
38:32but I do know that Parker was.
38:35He said, like carmatic guy and
38:37sometimes very difficult like
38:40many charismatic folks are.
38:42And so he butted heads with a lot of people,
38:46whether it was the medical school.
38:48Was like, you know,
38:49you failed your boards.
38:52The you know or just he actually had a
38:57fist fight with some black community
39:00members in Boston who were not happy
39:04with him doing needle exchange there
39:06and there was a real unfortunate thing
39:09in the history of needle exchange
39:11where because of our historical racism
39:16on the black community thought, oh,
39:18you want to give us needles you're
39:19not going to give us treatment.
39:21And. They were just like,
39:22you just want us all to kill ourselves.
39:24Like it was not seen as HIV for there.
39:27They were like saying, oh,
39:29they're going to put HIV in the needle
39:30so that they will like actually,
39:32you know, commit genocide on us even
39:34more than it's already going on.
39:36So you know,
39:37when a white activist like Parker
39:39or when some of that act up folks
39:42would go on to try to convince the
39:45communities that we're really,
39:47you know, the most affected and that
39:50we've had incredibly high levels of.
39:53And it was spreading from the IV drug
39:56users to heterosexual women and to babies.
39:59And it was just this
40:01horrible political fight.
40:03And I write in the book a little
40:05bit about how the the very,
40:08the black activist for harm reduction felt
40:12split in half because they recognized.
40:16That their community was,
40:19you know, furious about this.
40:21But they also knew that, like,
40:22we need to stop the spread
40:24of HIV and this does that.
40:26So, you know,
40:27it was really and they got called, you know.
40:32Black gay men, just who were especially,
40:34who were active junctures,
40:35just got it from all sides.
40:37So, you know,
40:38John Parker was sort of not at
40:39all sensitive to any of this.
40:41He just went in and did it.
40:42And there's times when you want
40:44people to just go in and do stuff.
40:46And then there's times when you
40:48really need people who are community
40:50organizers and who work within
40:51the community and meet it where it
40:53is and and everything like that.
40:55But what was amazing about him
40:57is that he just put himself,
40:59put his body on the line.
41:00I don't know.
41:01I don't remember how many states.
41:02But I think it was like at least eight
41:05where he went and got arrested and,
41:06you know,
41:07he could have gone to jail for
41:08a long time for this.
41:09And and he had had prior experience
41:13with jail and prison because
41:15he grew up really poor.
41:17And I believe he,
41:19I'm going to forget the
41:21precise details of this,
41:23but I'm pretty sure that he either
41:26injected drugs for the first time
41:28or used heroin for the first time
41:31while in juvenile detention. And he.
41:34Was, you know, seemed you know.
41:38By high school,
41:39he seemed like he was not
41:41headed for a good place at all.
41:43No Yale was at all apparent in his future.
41:46I don't think he even graduated
41:48high school and so on, you know?
41:52But when when he did finally
41:55get treatment and was
41:57ready for it, he went back to school,
42:00finished high school on went to college,
42:04and I think he was at Hampshire College.
42:09And people can read the book.
42:13Yeah, and not just go by my memory,
42:14but anyway. Yes. So?
42:16So then he decided that he wanted to
42:20be a doctor and when he came to Yale.
42:24He heard a lecturer saying that, you know,
42:28people with addiction don't care,
42:30they're probably not using
42:31nice person first language,
42:33almost certainly not the way I just did.
42:36You know, they were just like let
42:38him die and he stood up and said,
42:40no, we're not doing that and went
42:43out and started what he called the
42:46AIDS Brigade and would just go out.
42:49He was driving a taxi to get the money
42:52to support himself and buy the needles.
42:55You would go to states where you could
42:57buy them over the counter and bring them,
42:59you know, so that he could help
43:02people on truly an amazing character.
43:06It would be somebody should write
43:08a a good book on him.
43:10It's hard because he's gone
43:12a little strange now,
43:14but it's like the story is really incredible.
43:19And he wrote on,
43:21he wrote a version of version of a memoir,
43:23which is of course from.
43:24From jail to Yale,
43:26and which has this picture of him looking
43:29quite gorgeous on the front of it.
43:32You can probably say because of the
43:35Yale system and the way it really was in
43:37the 90s and 80s where we had no exams at all,
43:40that really did help him in some ways so that
43:43he could just be doing all he had to do.
43:45It just didn't help him pass the boards
43:48for the first or second or third time.
43:51But Kim,
43:52can you talk a bit about, I mean,
43:55so we hear this history of not
43:58welcoming needle exchange in New Haven.
44:01Do you see,
44:02are you optimistic about the future?
44:03Do you think there's been a big change
44:06that there's still more work to be
44:08done here and we have people like you,
44:10but what is,
44:12is there tension with the community?
44:15Yeah, yeah.
44:15I mean, I think, you know,
44:17while Mia was telling, you know,
44:20his story, I was just thinking,
44:22like, what if he was black?
44:23You know what I mean?
44:24I was just like, what?
44:26Like the structural racism,
44:27like, let's just talk about the
44:29structural racism of war on drugs.
44:31And, you know,
44:32sometimes they talk about,
44:34you know,
44:34and my,
44:35my speaks very eloquently
44:36about her experience,
44:37you know, which,
44:38you know and and and and
44:39and not only structure,
44:40you know and privilege,
44:42you know,
44:42and in class and and and all those things
44:44combined can make some people vulnerable.
44:46You know,
44:47I talk, you know,
44:47underwrite and writes about his addiction
44:50to alcohol and cocaine and multiple times,
44:53you know, with, you know,
44:55pipes used to smoke crack and,
44:57you know,
44:58all of these towns and
45:00and rehabs and States and,
45:02you know, rental cars and all,
45:04you know,
45:04a lot of things that would have
45:06led other people of different
45:08means to go to prison and
45:10jail. He never had to, you know,
45:12he doesn't have a record,
45:13you know, that's that is a
45:15reflection of structural privilege.
45:16And and and and protection from the,
45:19you know, the carceral state.
45:21So I think that that's very
45:24interesting and it's infused in a
45:26lot of the work that we do now.
45:28And really talking about, you know,
45:30I've talked to people who are,
45:32you know, black harm reductionists
45:33who are out there and they say,
45:35you know, when I when the white
45:37lady from the health departments
45:38doing out certain service program,
45:39she doesn't get stopped when I'm out here,
45:41I get frisked.
45:42You know, I won't carry this because of,
45:45because of the risk that I'm going to be,
45:48you know, carted off or I will carry
45:50naloxone because of the risk that.
45:52You know, in North Philly because of the
45:54risk that I'm going to get, you know,
45:56locked up or I won't carry a fentanyl test,
45:58I won't do these things.
46:00And so that is the reality is we
46:03still have a carceral system.
46:05Harm reduction is not a well funded you know,
46:09at the the state of Connecticut,
46:10for example, ran out of money for syringes.
46:12So they they asked me how are we
46:14going to get them for people,
46:15you know like that they're still sort of
46:17out and then we've been finding ways to,
46:19you know, get around it.
46:20But really it's like.
46:22You know this this is like an essential
46:24part of disease infectious disease
46:26prevention and we've been scrambling
46:28like how do you prescribe them,
46:30you know and and that is that is a shame,
46:33right when they need to be fully funded,
46:35you know there's money on the federal table
46:37for for more syringe service program funding.
46:40But it's it's just it's just not enough.
46:43And we and we then we have HIV outbreaks and
46:45then we kind of swing back and forth between,
46:48you know and it's still, you know,
46:49technically in the in the registry, you know.
46:52Syringe service programs are
46:54still technically, you know,
46:55in the federal registry, not.
46:56You know you can't allocate,
46:59you know money.
47:01From from the feds,
47:02so we can you you can allocate money,
47:05but for everything but the actual syringes.
47:09How do you think there's some sort
47:11of exceptions and certain cases
47:12where you can and it it depends
47:13on the funding disbursement,
47:14but it's still technically,
47:15it's still in there and it hasn't been,
47:18it hasn't been.
47:18I know that like whenever they're
47:20trying to do new legislation,
47:22they're always trying to get get rid of it,
47:23but it still stays, you know.
47:25So we still have a largely criminalized
47:27approach to drug use in this country.
47:30We are still prohibitionist,
47:32we still, you know,
47:33funnel how many billions of
47:36dollars to the DEA.
47:38Yeah,
47:38no,
47:38and I mean I think one of the
47:41things that I feel like as a person
47:43who was great greatly benefited
47:45from privilege for because I was,
47:48I was selling drugs when I was in
47:50college and I am not in jail still,
47:53which I would have probably
47:54been or I black person.
47:57And I feel like if you benefit from that,
48:01you have the obligation to
48:02speak out against that.
48:04And you know, I'm not saying we
48:06should lock up more like I'm saying.
48:08Which will have fewer people in general?
48:11You know, it's it's just,
48:13it's it doesn't work.
48:14And I mean, I think one of the
48:16things that's so important in this
48:18sort of harm reduction philosophy
48:20and thinking about our production,
48:22OK, does arresting someone for
48:24drugs reduce harm or increase heart?
48:27OK, let's look at the data.
48:30It increases.
48:30I think I was just reading this,
48:32just 13% of all COVID cases in the
48:35United States originated in transmission
48:38chains from jails or prisons.
48:41It double s or triples the rate of suicide.
48:44I think it's gender dependent.
48:45It might be five times more
48:47in women and twice in men.
48:49It at least double s HIV
48:52risk on hepatitis C risk.
48:55There's a study that's just out
48:58about how it increases cancer risk,
49:01and there is a couple of are a couple
49:03of clarifying studies which show that
49:06every year spent incarcerated takes
49:082 years off of your life expectancy.
49:10So.
49:10Talk about a death penalty that we're not,
49:13you know, so, OK, so does that.
49:15Are you more likely to get
49:17treatment if you go to jail?
49:18Actually, no.
49:19On jail, in jail, in prison,
49:21maybe about 7:00 or 8% of people
49:23have access to treatment.
49:24And this doesn't say anything about
49:26the quality, 99%, which is horrible.
49:29But out in the community,
49:3110% of people have access treatment.
49:34So it doesn't even, you know,
49:36the people who want to argue,
49:37well,
49:38let's just arrest them and then
49:39put them in treatment.
49:40That doesn't even make sense.
49:42Also,
49:42you come out with a criminal record
49:45and this decreases your opportunity
49:48for employment and housing,
49:50and so if you look at people
49:53who are unhoused.
49:54The number of people who
49:56were previously incarcerated,
49:57and I don't have this statistic off
49:59the top of my head, but it's huge.
50:01And so basically what you do
50:03by locking someone up for drug
50:05possession is you make it less
50:08likely for them to recover and you
50:10make it more likely for them to get
50:13a whole slew of horrible diseases.
50:16So why are we doing this?
50:20You know,
50:20I think it's to me like obviously
50:23part of the answer,
50:24a large part of the answer is racism.
50:26But if we actually want drug
50:29policy to be about drugs,
50:31then it has to be about reducing harm
50:34because people are always going to get high.
50:36I always say this,
50:38but cats have catnip.
50:39Before humans evolved into humans,
50:42animals were getting high.
50:43And sadly we are not involved from cats.
50:48But anyway, the the point is that,
50:51like, there's no human culture
50:53and no time in history when there
50:55was not psychoactive drug use.
50:57So we can either accept the fact that
51:00this is part of human nature and
51:02reduce the harm associated with it,
51:04or we can use it to scapegoat
51:07people and cultures we don't like
51:09and spend an awful lot of money
51:11doing an awful lot of work.
51:15I think on that note,
51:17we might want to open it up because
51:19I think there's probably questions
51:20that people would like to ask.
51:22And then if we run out of audience questions,
51:25I still have a slew more,
51:27but people probably heard enough with me.
51:28So I'm going to turn this over to Anna,
51:31who's checking the quest.
51:33You're checking the Q&amp;A because I'm certain.
51:38We look at it
51:39up there because for some reason I'm
51:40not seeing any questions on my screen.
51:44Sorry, I can't see you.
51:48Is that OK? So.
51:53So with many millions coming to states
51:56through opioid settlements, how can the
51:59harm reduction community users,
52:01providers and advocates best demand
52:02that funds be prioritized for
52:04increased harm reduction services
52:06and behavioral health services? That
52:08is absolutely critical and and I think.
52:13I don't have the precise
52:15answers about how to do that,
52:17but it absolutely must be done,
52:19and it absolutely.
52:21There are two real dangers to harm
52:24reduction from this opioid funding.
52:27And one of them is that people will take
52:30the buzzword and know nothing about harm
52:32reduction and just soak up the money.
52:34And I'm sure that's already happening
52:36and we need to prevent that happening.
52:38The other is that some harm
52:40reduction organizations are going
52:41to get funded and others aren't.
52:43And this will create, you know,
52:47conflict on and any time when you
52:50have money flowing into a field.
52:53It's really dangerous for that
52:54field as well as an opportunity.
52:57So I think you know some of the
52:59obvious things that need to be done
53:01are apply for the darn grants like
53:03get your organization out there
53:05as much as you can to to do that.
53:08And if you don't have that expertise
53:11does national harm reduction have
53:13support for people writing grants to.
53:16I think you know there's there's a
53:18couple big not you know a couple big
53:20organizations that have been putting out
53:22webinars on the opioid settlement and.
53:24Appropriate settlements in the states,
53:26so it's united different ones.
53:28OK, great. Well, so.
53:30So that that information to you.
53:32And and yeah,
53:33I mean, I think,
53:35but just also in terms of rhetorically
53:38speaking about it, you know,
53:40this is the approach we know that works.
53:43And if we,
53:44if we keep going by the people
53:47who propose the lovely policy of,
53:50oh,
53:50we're going to fix the medical
53:52opioid crisis by cutting off
53:53all the medical opioids and not
53:55doing anything to help anybody.
53:56If we keep letting those people
53:58get the money,
53:58we're going to keep not doing so well and so.
54:03And maybe you can give him some information
54:05on those those French organizations.
54:08But yeah,
54:08that's a it's a great question and
54:10hopefully we can get you some more
54:13detailed and useful information on it.
54:18And that that person also just adds
54:20it would be tragic if these funds
54:22perpetuated the stigma of criminalization,
54:23as you were saying, including more
54:25resources for law enforcement and
54:26coercive treatment and quotes.
54:28One thing I want to say about
54:29opioid settlements is, you know,
54:31we're also very nervous that
54:34there's all this, you know,
54:36all of this money coming in.
54:38It's going to go to the sort of people that,
54:41you know, might be focused on, you know,
54:44reinforcing methods that are that
54:46don't work like abstinence only.
54:48Programs but but also really that
54:52you know the a lot of these chain
54:55pharmacies that have been pulled
54:57in you know there's reports that
54:59they're they're they're they're
55:01decreasing access to life saving
55:04medications like buprenorphine you
55:06know they're those reports are coming
55:09in that there's this a continued.
55:11Uh, like, despite other regulations,
55:14you know, they're even stricter,
55:16you know,
55:16regular regulations than than the states
55:18or the OR the federal government are
55:20having and that people are not able to
55:22access their medication because of this.
55:24Their names have been out and about, right.
55:26People.
55:27An orphan is incredibly safe medication,
55:29right? It's very, very,
55:30very hard to overdose on it.
55:32It's not the same as oxycodone.
55:34But at the same time,
55:35in the public imaginary,
55:38it's they are decreasing access to opioids.
55:43I think, I think this is a really
55:45important point because I think
55:47you're talking about either Walmart
55:48or Walgreens, Walmart, Walmart.
55:50And they they had a policy where basically
55:53if you hadn't seen a doctor in person,
55:55they're going to cut off your prescription.
55:57Now, this is the stupidest possible policy
56:00in terms of buprenorphine access because
56:02buprenorphine is one of two treatments.
56:05It's buprenorphine and methadone that
56:07amongst all the treatments we have,
56:10including abstinence.
56:11Only buprenorphine and methadone and
56:13probably heroin, but we don't have that.
56:16But only people in methadone
56:17are proven to cut the death rate
56:19by 50% or more in the long run.
56:20So basically what you're doing is if
56:22you're cutting off that prescription,
56:23you're doubling that person's
56:25chances of dying.
56:26And I actually am trying to get to
56:31write about this or get somebody to
56:33write about this because I think once
56:35media attention focused on how stupid
56:37this is because the thing with the
56:39pharmacies and the thing with the doctors.
56:42Is that like?
56:44I was mentioning earlier this idea
56:46of the comfort of someone with
56:48addiction and you're not allowed
56:49to prescribe an opioid for that.
56:51Now, buprenorphine and methadone are
56:53these very rare exceptions to that.
56:56And so historically, if you, you know,
57:01it's, they've been framed as well,
57:03not really opioids,
57:04but of course they are opioids.
57:06And you know, but like since the 19,
57:11you know, teens and 20s,
57:12there's been this idea that maintenance.
57:14Treatment or giving opioids to people who
57:17have misused opioids is just like not OK.
57:20And so we had the exception of
57:22methadone and these horrible
57:23ghettoized literally clinics.
57:25And you've been working with
57:27approved in with less strict but
57:29still somewhat strict rules and you
57:32have the DEA overseeing methadone
57:34and buprenorphine and all opioids
57:36which they should have no role in.
57:39It should be the FDA.
57:40But right now what this means is that.
57:45All of the,
57:46the best treatments we have for
57:48the opioid problem are opioids.
57:50And we're still cracking down on
57:52opioids and we are therefore very much
57:55limiting our ability to fix the problem.
57:58But I do want to say something hopeful here,
58:01which is that surprisingly enough,
58:03the Supreme Court recently decided
58:069 to 0 that if a doctor is going
58:10to be convicted of drug dealing.
58:14That doctor must have intent to drug deal.
58:17So because previously doctors could be
58:20convicted basically for prescribing
58:22more than the CDC guidelines,
58:23and that's basically malpractice, right?
58:25That's criminalizing malpractice because,
58:27you know,
58:28like if you're killing somebody
58:30on the operating table,
58:31it's going to be malpractice unless
58:33you're doing it deliberately.
58:34So you have to have intent, right.
58:37And so similarly with prescribing opioids,
58:40if you are, if you have this patient,
58:43this patient. Um has a fast metabolism.
58:46They need an enormous dose of opioids.
58:48You have documented this on.
58:51If you then get busted,
58:53you need to have the Supreme
58:55Court just ruled that
58:56you must be given the opportunity to
58:59prevent to present a good faith defense.
59:01And you can't just get convicted of.
59:03The DEA doesn't like doses over X amount.
59:06And so that's huge.
59:07And there's just been some really
59:09awful media coverage of this.
59:11But I think it was Kaiser News
59:12and they were like, Oh my God.
59:14Like, you know,
59:16pill mill doctors are going to get off
59:18because the Supreme Court did this decision.
59:20There's not a single quote in there
59:23from a patient or a doctor or anybody
59:26who thinks anything other than like,
59:28Gee, you know, maybe some.
59:30It's always a good idea to
59:32increase policing of medicine.
59:33Hello, abortion.
59:38OK, great. So let me toss out
59:40this question from Jeanette Tetro.
59:42What are your recommendations to
59:44health professional trainees?
59:46Across the training spectrum,
59:48students, residents,
59:49fellows on how to effectively
59:51use their voice to advocate
59:52for patients who use drugs,
59:54it can be challenging at times and
59:56with the reach of social media,
59:57being careful is vital.
01:00:02I would say that I am enormously
01:00:05impressed with a lot of young doctors
01:00:08and residents and medical students
01:00:11who are doing this and you know.
01:00:14Back in the day. And I think,
01:00:16I'm sure I know this is true in
01:00:17some hospitals still. You know,
01:00:19the idea is these are scummy drug seekers.
01:00:23You know, let's laugh at the person
01:00:26who's asking for pain medication.
01:00:28You know, I I had a horrible story recently
01:00:31of a former nurse who relapsed in his
01:00:35addiction and had been injecting drugs,
01:00:38and he was paralyzed.
01:00:39And he went to the ER and they didn't
01:00:42believe him, that he was paralyzed.
01:00:44That, oh, look, you have these marks on you.
01:00:46You're not really power.
01:00:47Like, they just dumped them on the floor.
01:00:48Eventually,
01:00:49somehow we made it to neurosurgery
01:00:51and the neurosurgeon said if they if
01:00:54you had lied on that floor any longer,
01:00:56you would empower life from the neck
01:00:57down for the rest of your life.
01:00:59And so this attitude that.
01:01:04Drug users or that the attitude
01:01:06that addiction is the disease
01:01:08for which the cure is get out of
01:01:10my emergency room needs to go.
01:01:14It's very common and I mean I've
01:01:16heard the worst term of it,
01:01:18subhuman ***** ** **** as a sort
01:01:21of slang word, edge spas or so.
01:01:22I don't even know how to pronounce
01:01:24something like that.
01:01:25But I've heard that that is used
01:01:27in ER and hospitals about people
01:01:30who use drugs and part of it,
01:01:34I do believe,
01:01:34is the criminalization of medicine.
01:01:36Because it's like,
01:01:37these are the people that I believe
01:01:40and they are lying I can lose my
01:01:42license for and that needs to change,
01:01:45like if a person for one.
01:01:48If you in this environment
01:01:50filled with fentanyl,
01:01:51if you prescribe an opioid to
01:01:53somebody who shouldn't have
01:01:54it because they're addicted,
01:01:56you're actually probably reducing
01:01:58their hard like because their
01:02:01alternative is likely to kill them on.
01:02:04You know,
01:02:04if and I think with you know
01:02:07pharmacists and and providers on,
01:02:10one of the good things about that
01:02:12Supreme Court decision is if you want to say,
01:02:15I'm going to prescribe.
01:02:17I you know.
01:02:19I can prescribe without making
01:02:20you have a urine test or making
01:02:22you do this or jump through this.
01:02:23Who would have counseling?
01:02:25That looks like a pill to the DEA,
01:02:28and but now you should be able
01:02:32to say OK look.
01:02:34If they get puke, they ain't using fentanyl.
01:02:37Maybe they divert it,
01:02:38but then someone else isn't
01:02:40using the fentanyl,
01:02:41then someone is using the view
01:02:43and having to produce harm.
01:02:45So we need to sort of normalize those
01:02:48kinds of things and I would urge
01:02:51medical students and people who want
01:02:54to speak out and and write about this to.
01:02:59There's a group called the op-ed Project.
01:03:02It's at the op edproject.org
01:03:04and it teaches you how to like
01:03:06write a basic op-ed and they have
01:03:08seminars and stuff like this.
01:03:10Disclosure, I have a friend of
01:03:12the woman who runs it, but the.
01:03:17But the the the thing there is that it's.
01:03:22It teaches you how to write an
01:03:24op-ed that will get published if
01:03:26you follow the their structure and.
01:03:32Everybody sort of loves
01:03:34these like my doctor's story,
01:03:36stories like tell stories like that.
01:03:38Like I had this patient and this
01:03:40happened and that happened.
01:03:41That's one way of reaching the media
01:03:44and especially doing it around this
01:03:45issue when it's hot on is a good thing.
01:03:48And I personally am happy to take emails
01:03:52from any medical people who want to
01:03:57get this kind of information out there
01:04:00because we need you and we need. Uh.
01:04:03A new generation to take over from
01:04:06the old idea that these are horrible,
01:04:10bad people and the only treatment
01:04:13for them is meeting in prayer.
01:04:14And I think that advocacy can look
01:04:17like a lot of different things
01:04:19over the course of time.
01:04:20And you know, it can look,
01:04:23I think looking back, you know,
01:04:25it's it's not just social media, right.
01:04:27I mean it is it, you know,
01:04:29it can be that it can be, you know,
01:04:32like Mya said, learning how to craft.
01:04:34The argument in an op-ed it can be.
01:04:36Today at lunch I was educating a
01:04:41Council member about the Decrim DC bill,
01:04:45which would decriminalize possession
01:04:49of substances.
01:04:51People who have, you know a bag of crack,
01:04:53you know, crack, crack a rock of,
01:04:55you know,
01:04:55a couple rocks or of crack won't
01:04:58go to jail and instead fund harm
01:05:01reduction centers with, you know,
01:05:03safe consumption, drug checking.
01:05:05You know, on site people norfin wound care,
01:05:08you know all of these other amazing
01:05:10things that that they're already
01:05:11doing 24 hour harm reduction center.
01:05:13So I was doing that over my lunch,
01:05:15you know,
01:05:16so that your advocacy could be
01:05:18partnering with your local farmer and
01:05:19I would say reach out to your local.
01:05:22Harm reduction group and don't presume,
01:05:25volunteer, learn from them.
01:05:28You know doctor, Doctor Tetral brings,
01:05:31you know patients,
01:05:33you know bringing the partnering
01:05:34with patients to Co write something
01:05:37is something that I've been wanting
01:05:39to do for a long time and you know,
01:05:41helping my, you know, craft,
01:05:43you know,
01:05:44come together with this interesting
01:05:46narrative.
01:05:46Podcasts are a great way to do that.
01:05:49I interviewed a patient from a
01:05:51certain service program.
01:05:52So used to be homeless and you know
01:05:55was sleeping on the six train and now
01:05:57is you know housed and you know all
01:05:59of these other you know so all of it.
01:06:02So really letting her use her own voice
01:06:04to explain what harm reduction means to her.
01:06:06So it can mean going to the state
01:06:09and advocating for bills you know,
01:06:11California for you know harm reduction
01:06:13centers or you know different,
01:06:16you know New York State or a variety
01:06:18of different ways you can get involved
01:06:20and and it changes over time. So just being.
01:06:23Being open to what might come.
01:06:25Yeah.
01:06:25And just,
01:06:25you know,
01:06:26talking to your colleagues really like
01:06:29so much changing your hospital policy,
01:06:31you know, your floor policy,
01:06:33you know, or working on things
01:06:34at that level, too. Yeah.
01:06:35So can I chime in to .1 of the questions?
01:06:39I can I see them because Doctor Phelan says,
01:06:42isn't most of medicine harm reduction?
01:06:45And I think you can both talk about,
01:06:46we think harm reduction,
01:06:47needle exchange, we think drug addiction.
01:06:50But there's also COVID.
01:06:51There's also exercise. There's also.
01:06:55So can you just, I mean, here,
01:06:57you wrote this whole book on the history,
01:06:58but you're not.
01:06:59And the book does talk a lot about drugs.
01:07:01But yeah. So I mean, yes, I mean,
01:07:04back to her property first,
01:07:05do no harm that at that time.
01:07:07And still in some instances the treatment
01:07:09is going to do more harm than the disease.
01:07:12So we better not do that ideally.
01:07:16So yes, it is an ancient idea and it is,
01:07:21you know, throughout philosophy.
01:07:23Or whatever like where you want to just
01:07:28minimize harm and maximize benefit the.
01:07:34The what I see is unique about it
01:07:37that comes out of the drug world is
01:07:40the social movement and also the idea
01:07:42that human beings are going to engage
01:07:45in unhealthy and risky behaviors.
01:07:47And they're going to do so
01:07:49for a variety of reasons.
01:07:51Some of them that we think are OK and
01:07:53some of them that we think are not OK,
01:07:55regardless of our values around that.
01:07:58We want to. Not maximize harm.
01:08:02We want to not do things like, OK,
01:08:05we're going to make needles illegal so
01:08:09that that will deter people somehow.
01:08:11And therefore basically what we're
01:08:13doing is spreading blood borne disease.
01:08:16You have to analyze like what
01:08:18harm reduction is,
01:08:19is about analyzing what you're doing in
01:08:24a larger context so you know if if you
01:08:28have a list of every patient at a pill mill.
01:08:31And you don't know if they
01:08:32have addiction or pain or what.
01:08:34And how about not just shutting
01:08:36the pill mill?
01:08:36How about, like,
01:08:37getting that list of names and
01:08:39getting care for all those people and
01:08:42figuring out what that should be on?
01:08:44You know, that harm reduction for COVID,
01:08:48you know,
01:08:48it's so difficult right now because
01:08:51people don't know on, you know,
01:08:53when they should be wearing masks,
01:08:54if they should be wearing masks.
01:08:55Who should be wearing masks?
01:08:57And it's become this very moralized
01:08:59politicized vaccine and vaccines.
01:09:01Saying, you know,
01:09:03ideally we want to have a message
01:09:06that is about how do you make
01:09:09the choices for yourself and for
01:09:12your community that are going to,
01:09:15you know, minimize the most harm.
01:09:19But yeah, I mean it and it can get,
01:09:22it can get really difficult.
01:09:24I mean one of the things that I've
01:09:27been hearing now about the way fentanyl
01:09:29is being used is like a lot of people are.
01:09:32Reaching to slow gate now,
01:09:33in the short term that is
01:09:35going to be way less dangerous.
01:09:37It should reduce overdose risk.
01:09:39I don't think we have proof of this yet, but.
01:09:43I think there's some data
01:09:44suggesting that this is the case.
01:09:47I think users are saying that
01:09:49it lasts longer this way,
01:09:50that the high lasts longer,
01:09:52so that might reduce harm in the sense
01:09:54of that they would be doing less.
01:09:56Of course, in the long term,
01:09:58smoking weird chemicals is
01:09:59probably not exactly good for you.
01:10:02So the you know, again,
01:10:06like if you have to think about it
01:10:09in in context and use the idea of.
01:10:13You know, it could be anything from like,
01:10:16how do we reduce harm to the environment?
01:10:19You know, how do we, you know,
01:10:20save the planet and, like, not.
01:10:24You know,
01:10:25destroyed and and also realize that
01:10:27like people are still going to want
01:10:30to do things like take vacations.
01:10:32And, you know,
01:10:34how do we get that balance and
01:10:38instead of like trying to sort of
01:10:42shame people for their normal desires
01:10:45on find ways that we can, you know?
01:10:50Uh, minimize harm, recognizing that
01:10:53we cannot always eliminate it.
01:10:57Yeah. And I mean, I think,
01:10:58I think that much of medicine, you know,
01:11:01has the philosophy and the intent of,
01:11:04of harm reduction.
01:11:07You know someone is taking a
01:11:10blood pressure medication, right.
01:11:12That's to decrease their risk over
01:11:14time of a catastrophic event. Right.
01:11:16And but at the same time and you know,
01:11:19This is why I think reading
01:11:20my book is very interesting.
01:11:21It's like this term is part of a
01:11:23social movement from people who use
01:11:25drugs and people who do sex work that
01:11:28is very specific and very you know,
01:11:30and so and so I do think like
01:11:33it can if taken it missing.
01:11:35You know I'm I'm very.
01:11:37Interested in we're keeping that
01:11:39history alive and then, you know,
01:11:41I know you are too, but thanks for the book.
01:11:43You know, thanks for writing the book.
01:11:44And and there is, you know,
01:11:46a way in which as we we can apply
01:11:49the term and adopt it to our, to our,
01:11:52our principles and you know any,
01:11:54any aspect of medicine, right?
01:11:56Not even addiction medicine.
01:11:57You know, you can have that philosophy
01:12:00on this person centered that, you know,
01:12:02treats people with compassion,
01:12:04dignity and respect and I hope that,
01:12:06you know,
01:12:06my orthopedic surgeon colleagues are doing.
01:12:08You know, and all of these things, right.
01:12:10But I also want there to be,
01:12:13I want people to know that history of
01:12:15that movement, if that makes sense.
01:12:16So, you know,
01:12:17I don't want it to be so watered
01:12:19down that people are just like,
01:12:20you know,
01:12:21talk about it without recognizing the
01:12:24the the richness and the complexity.
01:12:27Yeah.
01:12:27And I think, you know,
01:12:30pain management now is doing a lot
01:12:32of harm production in terms of like,
01:12:35oh, farm production.
01:12:36Yes,
01:12:36I said.
01:12:40Yeah, in in the sense of that like, oh,
01:12:42let's do opioid free surgery because you
01:12:45might get addicted while you're asleep.
01:12:48No, there may be reasons to use
01:12:51protocol instead of fentanyl,
01:12:54but that is not one of them because
01:12:57that is not how addiction develops.
01:12:59You know, the idea that, like,
01:13:00you're going to give opioids to somebody
01:13:02in the hospital without giving,
01:13:04without even giving them a
01:13:06prescription and that that's going to.
01:13:08Activate an addiction and they're
01:13:10suddenly going to be able to instantly
01:13:12find a drug dealer and go for it.
01:13:14Like, this just isn't how addiction works.
01:13:17And so, like, all of these efforts to,
01:13:20like, you know,
01:13:21reduce risk are just ending up leaving
01:13:24people in pain for no good reason.
01:13:26And this is especially true in
01:13:28the pain treatment of people in
01:13:30recovery because the idea is like,
01:13:32Oh my God,
01:13:33you're going to expose them to
01:13:34the dog and they're going to turn
01:13:35into a zombie and and relapse.
01:13:37Well, the reality is.
01:13:38That's more likely to make you extremely
01:13:41stressed and think about turning to drugs,
01:13:44extreme pain,
01:13:45or feeling alright,
01:13:47I'm going to go with extreme pain.
01:13:50And I think, you know,
01:13:51while people absolutely should
01:13:53make choices for themselves,
01:13:55the idea that anybody who has any
01:13:57history of addiction should never
01:13:59get an opioid on really is inhumane
01:14:02and does not make any sense and is
01:14:04actually not doing anything other than
01:14:06saying I'm doing the right thing.
01:14:09Really,
01:14:09by not giving this horrible drug
01:14:11to this person.
01:14:12And so, you know,
01:14:13I think it needs to be considered
01:14:17on throughout medicine,
01:14:19throughout society,
01:14:22but in context of where it comes from.
01:14:25And it's funny because like there's
01:14:27harm reduction on an individual level
01:14:29and harm reduction on a social level,
01:14:32and sometimes they may conflict,
01:14:37but that's probably too.
01:14:40And we just,
01:14:41I know you have this in your book,
01:14:43and I think you've also written about it.
01:14:45Many of us who have seen recent
01:14:47documentaries might have the viewpoint
01:14:50that the whole opioid epidemic was
01:14:52started by ignorant doctors who were
01:14:55just giving out too many pills,
01:14:57and that's what started the whole thing.
01:14:59And I think you've written about that.
01:15:01Can you just sort of give us
01:15:02your little statistic? Sure.
01:15:05So.
01:15:06Not saying the drug companies are
01:15:08good at all.
01:15:09What I am saying is that 80% of
01:15:12people who misuse prescription opioids
01:15:13never had a prescription for them.
01:15:15So the first time they
01:15:17misuse prescription opioids,
01:15:17it's from grandma's cabinet.
01:15:19It's from your boyfriend's friend it is.
01:15:25And about 60 to 70% of the people
01:15:29who are misusing prescription
01:15:30opioids have previously used
01:15:32cocaine or methamphetamine,
01:15:33or psychedelics or drugs beyond just.
01:15:36Weed and booze.
01:15:37So it's not like naive,
01:15:40innocent white people are getting
01:15:42introduced to these substances and
01:15:45then turning into zombie addicts.
01:15:48Now,
01:15:48it's certainly the case that some
01:15:50people do get addicted during pain treatment,
01:15:52but 90% of all addictions start
01:15:55in the teens or early 20s.
01:15:57And so if you've gone to your 40s and 50s,
01:16:00which is the age of chronic pain generally,
01:16:03although some younger people do, you have.
01:16:06And obviously, many older people do.
01:16:08But the if you've gotten to that age
01:16:10without having an addiction, your odds
01:16:13of suddenly developing one are not high.
01:16:16Now, again, there were small percentages,
01:16:19but the reality is that most prescription
01:16:24opioid addiction is similar to the
01:16:27entire history of addiction in general.
01:16:30It's not this special thing that
01:16:32the drug companies created.
01:16:33And if you look at,
01:16:34there was a study published in science.
01:16:36I think it's Donald Burke where he found
01:16:40that overdose rates actually came began
01:16:43increasing exponentially in 1979 or 80,
01:16:47which incidentally is when inequality began.
01:16:50Economic inequality began
01:16:52expanding exponentially,
01:16:53which I think is not a coincidence,
01:16:56but the point is Purdue Farmer
01:16:59didn't introduce Oxycontin until
01:17:021995 or 96 and when the.
01:17:07We have now had a situation where so I
01:17:10believe opioid prescribing peaked in 2011,
01:17:13has fallen 60% since then,
01:17:17and overdose death has gone way up.
01:17:20So if you were going to solve the
01:17:23problem by cutting prescribing,
01:17:25that is not what happened.
01:17:26It just drove this whole group
01:17:29of people who were previously
01:17:31getting actual pharmaceutical drugs
01:17:33with known dosage and purity on.
01:17:37To getting St heroin which is
01:17:39now contaminated with fentanyl.
01:17:41Again,
01:17:41this is not to say the drug
01:17:43companies are good.
01:17:44They certainly expanded the
01:17:45market and they did marketing.
01:17:47But to me what is the biggest, well,
01:17:50one of the sickest things about
01:17:53the whole situation is that if you.
01:17:56Uh, I'm sorry.
01:17:58I'm losing my train of thought here.
01:17:59Give me a second on the.
01:18:03Talking about six weeks
01:18:05situation. Oh, right. Yeah.
01:18:07I mean, you could have probably
01:18:09probably fixed it earlier on by
01:18:10reducing the medical supply.
01:18:12But once you had a giant population
01:18:14of people who were already, you know,
01:18:19addicted, like just taking the drugs
01:18:22away was not going to fix that.
01:18:24And we're going to continue to see
01:18:27escalating overdose rates among the
01:18:29people who are already addicted
01:18:31because we just took the drugs.
01:18:33And oh Gee, like there is a big surprise.
01:18:36We've developed a big black
01:18:39market to supply those folks.
01:18:41And we also cut off a lot of pain patients
01:18:44who actually did benefit from the substances.
01:18:46So all around not good.
01:18:48And if we actually want to deal with
01:18:54the reality of the drug crisis we have,
01:18:57we have to look at, OK,
01:18:58so why didn't we notice this exponential
01:19:00trend starting in the 80s? Well,
01:19:02partially exponential trend to start slowly,
01:19:05but also it was happening in poor
01:19:09communities, in inner cities and we didn't.
01:19:12Pay attention because we focus on this drug,
01:19:15not that drug.
01:19:16So that was the crack crisis.
01:19:17This is the opioid crisis.
01:19:18They have nothing to do.
01:19:20Well,
01:19:20if you look at it,
01:19:21actually deindustrialization was
01:19:22hitting on black and brown people
01:19:25in inner cities in the 80s and 90s.
01:19:28Now then it began hitting white
01:19:30rural people and both of them
01:19:32developed drug epidemics and and
01:19:34we didn't connect it because it was
01:19:37like it wasn't they things are us.
01:19:41We we need to understand that drug use,
01:19:44particularly addictive drug use is
01:19:47driven by emotional pain, trauma,
01:19:49mental illness.
01:19:50It's not driven by, oh,
01:19:53I got exposed to the draw and,
01:19:56you know,
01:19:57obviously you need exposure to those
01:19:58particular thing to get addicted to it.
01:20:00But that is not the only thing
01:20:02that that causes the problem.
01:20:04And so. Yeah. Yeah, we're going.
01:20:08I'm going to ask one last question of
01:20:11both of you in terms of the future one,
01:20:14anything optimistic we can close on it?
01:20:17Also, I want you each about is it
01:20:20time to rebrand harm reduction?
01:20:22So maybe 2?
01:20:25You go and so optimism you know well.
01:20:32All my talks have been pretty grim,
01:20:34obviously,
01:20:34because my, my,
01:20:35the statistics are grim and we've
01:20:38lost our friends,
01:20:39our patients, you know,
01:20:41overdose deaths are all preventable, right?
01:20:44They're all policy failures.
01:20:45So that's a very common phrase.
01:20:47And what does that mean?
01:20:49You know, I think there's some
01:20:51promise that we are able to,
01:20:53there's interest in harm reduction
01:20:56strategies and approaches.
01:20:57We need to fund those.
01:20:59We need to put money where?
01:21:02You know, our mouths are we need to innovate,
01:21:05you know, safer supply,
01:21:08overdose prevention centers.
01:21:10These are things that we all need to
01:21:12try to stem the tide of people dying,
01:21:15you know, in their 20s,
01:21:17thirties, Forties, 50s and 60s.
01:21:19You know, people are dying prematurely,
01:21:21like and and so I'm really happy about that,
01:21:25I guess if it comes with money,
01:21:29if it comes with power to people
01:21:31who use drugs. Umm, if, you know,
01:21:33if it comes with those things, then many,
01:21:35that's our big asterisks, right.
01:21:37So I think I'm, I'm very concerned.
01:21:41I'm OK with how, you know, how it's branded.
01:21:45I do think that it's not a panacea.
01:21:47OK. Everyone on the table is like, oh,
01:21:50you do this and then they're going to blame,
01:21:52you know, in San Francisco, you know,
01:21:54their cities are going to blame it on,
01:21:56you know, harm reduction and so easy
01:21:58straw man, and it is going to expand.
01:22:02Our reach.
01:22:03I think if harm reduction is a strong actual
01:22:06pillar people will lives will be saved,
01:22:08but it is not a panacea.
01:22:10So I do think, you know low barrier
01:22:13treatment would save so many lives.
01:22:15If you didn't get kicked off methadone
01:22:17for using a benzo or cocaine you,
01:22:19you would you know, you would,
01:22:21you would many more lives would be saved.
01:22:23So I think it's going to take a,
01:22:25you know, a lot of that, right.
01:22:27And understanding that it has a
01:22:29place we wanted to have a big place,
01:22:31a really, really big.
01:22:32Place, but I don't think it's tencia.
01:22:35Yes, I completely agree that's
01:22:36why it is called harm reduction,
01:22:37not harm elimination.
01:22:39And I think that is really
01:22:41important to stress.
01:22:42Speaking of the sort of,
01:22:44you know,
01:22:45blaming of harm reduction for San Francisco,
01:22:48it's like, you know,
01:22:49I dealt with that for an hour
01:22:50on Doctor Phil the other day.
01:22:52And the the thing that hasn't seemed to
01:22:55me about that framing is that crime and
01:22:59homelessness are up over the entire country.
01:23:03In places,
01:23:04if you're talking about murder rates,
01:23:07it's up more in red states that blue.
01:23:10So blaming harm reduction in
01:23:13San Francisco for, you know,
01:23:15in crazy murder rate in Jacksonville
01:23:17on where they have no harm reduction,
01:23:21it's just ridiculous, you know.
01:23:22So saying, you know,
01:23:24homelessness is a little more
01:23:26complicated because,
01:23:27you know,
01:23:28homelessness concentrates in
01:23:29places that are expensive on
01:23:31West Virginia has United States.
01:23:33Highest rate per capita of overdose deaths.
01:23:36It has very little homelessness.
01:23:38So if homelessness is
01:23:40being caused by addiction,
01:23:42then it should be the worst in West Virginia.
01:23:44But housing is cheap there,
01:23:45so complicated in terms of future and future.
01:23:522 minutes,
01:23:532 minutes after I have writing these for
01:23:55the New York Times at the moment about how,
01:23:58since I believe it is 2002,
01:24:01the rate of opioid use by
01:24:04teenagers has gone down 83%.
01:24:07Wow, we never.
01:24:09You know,
01:24:10this kind of reminds me of the
01:24:12period when there was just tons of
01:24:13crack hype and you just thought
01:24:15everybody was going to be addicted
01:24:16to crack by the end of the year
01:24:18because it was just like always going
01:24:20to be always going to get worse.
01:24:22There's a generational thing with
01:24:24drugs and people see my older
01:24:26sister died of that.
01:24:27I'm not going to mess with that.
01:24:28It doesn't mean that they're
01:24:29not going to do something.
01:24:31And the question is, can we shift it
01:24:33to something that is less harmful?
01:24:36But this is true of heroin,
01:24:38true prescription opioids,
01:24:39really dramatic declines
01:24:41in the household survey.
01:24:43So and once you start to
01:24:46see that historically,
01:24:47that means The thing is peaked.
01:24:49And now this doesn't mean that,
01:24:51you know, we're not going to still see.
01:24:52That's among people who are currently using.
01:24:54And we obviously need to deal with
01:24:57that very large and important
01:24:59population and work to keep them safe.
01:25:01But it seems like the people at the
01:25:05highest risk of addiction at this
01:25:08point are no longer seeking opioids.
01:25:11And so, you know, again, that can change.
01:25:14And it may be that they seek method.
01:25:16It gets fentanyl in it,
01:25:17but it also could be that they
01:25:19all are like psychedelics.
01:25:20Let's go for that.
01:25:22You know, since like,
01:25:23it's therapeutic, right?
01:25:24Which it is for many people,
01:25:27but another another,
01:25:29another different.
01:25:34OK. I'll just pop back on for a second.
01:25:36So thank you all so, so much
01:25:38for sticking with us for this,
01:25:40this first session and for putting
01:25:42up with the technical challenges. I
01:25:45know everybody's a little blurry,
01:25:46but hopefully you could hear
01:25:48everything that was said and
01:25:49we are making a recording.
01:25:50So if you missed any of it,
01:25:51you can get it later.
01:25:52And thank you to Kim Sue. Thank
01:25:55you, Mayor Sullivan.
01:25:55Thank you, Randy, Hutter Epstein,
01:25:57for, for this wonderful talk
01:25:59and thanks to you all for,
01:26:01for taking part and listening.