Fresh Approaches to the Overdose Crisis
2022-02-21 · Guest: Dr. Jeffrey Singer (Senior Fellow at the Cato Institute) · 52:30
Government interference and the opioid overdose crisis
Bob Zadek interviews Dr. Jeffrey Singer about the root causes of the overdose crisis, debunking the myth that doctor prescriptions are the primary driver of addiction. They explore the history of drug prohibition, the distinction between physical dependence and addiction, and how government interference in the doctor-patient relationship has exacerbated the crisis by pushing users toward more potent illicit substances like fentanyl.
Topics: Opioid Crisis, Drug Prohibition, Fentanyl, CDC Guidelines, Medical Freedom, War on Drugs, Public Health Policy, Chronic Pain
Speakers:
- Bob Zadek: Host
- Dr. Jeffrey Singer: General Surgeon and Senior Fellow at the Cato Institute
Introduction to the Opioid Discussion [00:17]
Bob Zadek: Good morning, everyone. Welcome to the Bob Zadek Show, the longest-running live libertarian talk radio show in all of radio. This Sunday and always, the show of ideas, never once the show of attitude. Thank you so much for joining me this Sunday morning.
It seems that no matter what section of the news media you turn to, to read or to listen to—whether it’s health, or public affairs, or law, or government, or federal versus state government—no matter what section of the news you care about, no matter what topic you look for, you can’t avoid an article, a discussion, an op-ed piece about opioids.
And as I have this conversation with friends and those who I happen to be standing in front of or behind at the supermarket checkout line, and the conversation drifts to opioids, I am astonished at how little core understanding there is over this issue, which is in the news every single day.
And I’m delighted to welcome back to the show this morning, Dr. Jeff Singer. Jeff is a dear friend of mine, somebody that I met many years ago at a libertarian function and have seen at every other libertarian function that I go to. One of the highlights is Jeff is always there. Jeff is a practicing general surgeon in Phoenix, Arizona. He is a senior fellow at the Cato Institute, and he works in Cato’s Department of Health Policy Studies. He’s president emeritus and founder of the Valley Surgical Clinics in Phoenix, which is the largest and oldest private surgical practice in Arizona. He’s also a visiting fellow at the Goldwater Institute in Phoenix, a member of the Board of Scientific Advisors of the American Council on Science and Health. He is immersed in the medical, in the political, in the sociological issues and interaction between the practice of medicine and the scope of government. Who better to help us understand government’s intrusion into individual decision-making, government’s intrusion into the sacred—and yes, I mean sacred—relationship between doctor and patient, and intruding into bare economic policy of businesses in America, in this case, Big Pharma or pharmaceutical manufacturers, who have contributed immeasurably to improving the quality of life in this country, but the government through the court is now intruding into the business affairs of drug companies and the products they manufacture and the products they sell.
It is, in short, a mess. It is my ambitious hope that during the course of the next hour, I will at least be able to, with Jeff’s essential help, at least be able to blow away some of the smoke, some of the confusion, so that when you, my friends out there, follow what is going on in the media, you will at least be able to follow it on an informed basis. Jeff, ambitious agenda this morning. Welcome to the show.
Dr. Jeffrey Singer: Hi, Bob. Happy to be here again. Great to talk to you.
Defining Opiates and Opioids [03:01]
Bob Zadek: Now Jeff, the subject broadly, the topic at the top of the pyramid is opioids. And opioids—when one talks about opioids, probably some of our listeners, they consider opioids to be OxyContin and those other drugs that Dr. House was taking on that very popular TV show. And so they—there is a negative inference with pharmacological opioids, opioids that are manufactured in factories and sold by drug companies through the prescription drug delivery system, flawed though it may be in the country. Other people, when they think about opioids, they think of illegal drug use. They somehow vaguely think of heroin and morphine and things of that nature. So introduce us, if you will, as a starting point, to the topic of opioids. When we read about opioids, what are we reading about when we see conversations or discussions about opioids?
Dr. Jeffrey Singer: Well, first of all, a lot of people use the word opiates and opioids back and forth. Opiates are drugs that are directly derived from the opium poppy plant. And by the way, going back as far as antiquity, even Homer wrote about opium and its effects on controlling pain and helping you get relaxed and sleep. So this has been around as far back as recorded history. So opiates are directly derived from the plant, like morphine is an opiate, codeine is an opiate. When you take codeine in your body, it gets broken down into two components. One of them, the active component, is morphine. So think of codeine almost as like raw cane sugar, and morphine is like the refined sugar.
And then opioids are chemical modifications to the opiate that make them—designed to make them function in a particular way. So for example, oxycodone and hydrocodone are—they’ve taken the basic opiate and they’ve added a couple of little molecules to it to change it and make it better for whatever its desired use is, usually for pain control. So for example, oxycodone is an opioid, hydrocodone—often called Vicodin, which is a brand name—diamorphine or diacetylmorphine is an opioid that was marketed in the early 20th century as heroin, that’s the brand name that Bayer gave it. Dilaudid is hydromorphone, it’s twice as powerful as heroin. That’s a legal opioid that’s used a lot for pain control. And fentanyl is an opioid. Now fentanyl is what they call a synthetic opioid, so it’s completely manufactured in the test tube. It doesn’t use the original opium plant at all. So there’s—it’s completely synthetic. There are other synthetic opioids like methadone. So that’s basically the category of drug.
Dependence vs. Addiction [07:51]
Bob Zadek: And what makes opioids different than non-opioid drugs? So we know they occur naturally in nature—that’s a redundancy—it’s been around forever. It’s been used by humans forever for various purposes. So what is there about opioids—how did it get such a bad rap? How did it get the attention of those in government? Because after all, much of our show will be spent on the regulation of opioids, whether it’s at the patient-doctor level or at the prescription drug level or at the manufacturing level. So we’re going to be talking about government intervention in the use of opioids. So what appeared to be special about opioids that got the government’s attention, and when did this all start?
Dr. Jeffrey Singer: Well, they’re very effective in relieving pain, and they also are narcotics. That’s again from the—it comes from the Latin word for helping you sleep, makes you sleepy. But there are other pain relievers as well, like non-steroidal anti-inflammatory agents like ibuprofen or naproxen. Opioids for the most part are more potent than those pain relievers, and they’re actually not as dangerous as those pain relievers. For example, non-steroidal anti-inflammatories like ibuprofen, they can cause kidney damage, they can cause ulcers and intestinal bleeding. Tylenol, which is a very weak pain reliever, acetaminophen, that can cause liver damage. Opioids, if you take too many of course, you could stop breathing, you could overdose. You could also overdose on any of the other pain relievers. But they really don’t have any organ damage. They don’t damage the liver, they don’t damage the kidneys, they don’t damage the brain. They do cause constipation on prolonged use, and prolonged use can maybe affect some of your gonadal hormones like your testosterone and estrogen levels, which could cause osteoporosis. But otherwise, they’re actually—I know this may sound like blasphemy, but they’re actually safer in terms of their damage to the organ.
Now, the other thing about them though is that they can create dependency. And many drugs can create dependency. A lot of people have this tendency, and doctors included have this tendency to equate dependency with addiction, and they’re two completely different things. So opioids, for example, if you take them for maybe 10 to 14 consecutive days steadily, you could physiologically adapt to their presence, and if you suddenly withdraw the opioid, you go into a withdrawal reaction. Rarely fatal when it comes to opioids, but it can feel very just miserably sick for three or four days: diarrhea, runny nose, chills, fevers, sweats—it just feels like a terrible, terrible flu and gastroenteritis.
But there are many drugs that do this. For example, anti-epileptic drugs that people take if they have a seizure disorder. Your body adjusts to them being present, and if you suddenly withdraw them, you could go into status epilepticus, where you have uncontrollable seizures. Beta-blockers that people are placed on for high blood pressure—they’re very effective for that. But if you develop a dependency on them and if you withdraw them, you could have a fatal withdrawal reaction, a heart attack or a stroke. Anti-depressants—there are numerous drugs that create dependency, and opioids are one of them. So a lot of present-day policymakers think that because you develop a dependency on long-term use of opioids, therefore you are addicted. However, they would never say that if you develop a long-term dependency on long-term beta-blockers. Nobody would say “I’m addicted to my beta-blocker that my doctor put me on for high blood pressure.” And furthermore, nobody would say, “You’ve been on this blood pressure beta-blocker for five straight years, so not only are you addicted to it, but it’s time to get you off of it because you’ve been on it for too long.” Because you would say, “Well wait, number one, I’m not addicted to it, I’m just dependent on it. And number two, it’s working, why do we have to get me off it if it’s doing its intended job?” But nevertheless, we don’t treat opioids that way.
The Racial Roots of Drug Prohibition [12:03]
Bob Zadek: Now, that bleeds into my very next question. Jeff, you and I, when we talk, you always seem to exactly and perfectly anticipate my question before I ask it. You have that knack. So with respect to opioids, you have described them as a substance—or a derivative of a substance—that exists naturally in nature. It’s been around forever. It’s been used by humans forever for various purposes. So how did—what is there about opioids, how did it get such a bad rap? How did it get the attention of those in government? Because after all, much of our show will be spent on the regulation of opioids, whether it’s at the patient-doctor level or at the prescription drug level or at the manufacturing level. So we’re going to be talking about government intervention in the use of opioids. So what appeared to be special about opioids that got the government’s attention, and when did this all start?
Dr. Jeffrey Singer: Well, a lot of it has to do with—I hate to say this, but racism. Opioids, in addition to being effective medication, they, of course, for many people provide a very pleasant form of euphoria. So a lot of people since antiquity, since the days of Homer, would enjoy using opium not necessarily as a medicine, but as something to—as a pleasure. So for example, many of your listeners could understand that a lot of people enjoy using alcohol. In fact, again since antiquity, people have enjoyed using psychoactive substances in a recreational way. And this is I think just a human—it’s not just a human, it may even be a mammalian phenomenon. You know, cats like catnip, horses like locoweed. So it may even be a phenomenon of mammals.
But anyway, in this country, for example, a lot of famous people would use opium because it gave them pleasure, and some of them developed a dependence on it. Edgar Allan Poe, an example; William Wilberforce, the great British abolitionist, was known to be a regular opium user. This didn’t become a big problem until the early 20th century. So many Chinese immigrants coming to America had set up opium dens. It was a popular way to enjoy opium, which was by smoking it. And you could, you know, the New York Times had headlines on this. You could see lots of evidence in the literature of people being very upset about “our white daughters lying side-by-side with Chinese men in opium dens.” So it became actually racially based.
So all of these drugs were legal in the United States until 1913, the Harrison Narcotics Act was passed. So people were able to purchase opium through the Sears catalog. Heroin, which is diacetylmorphine or diamorphine, that was a popular cough syrup marketed by Bayer. And then because of the motivation against opium—like for example, one of the first states to ban opium was California, which had a very large Chinese population, people coming to work on the railroads. They banned opium long before Mississippi banned opium, which didn’t have any Chinese residents. Mississippi was the last state in the United States to end alcohol prohibition. I think it was in the ’60s when they finally ended alcohol prohibition there. So that was racially based, just like many other currently illicit drugs. Cocaine was banned in 1913 as part of the Harrison Narcotics Act. Interestingly, cocaine is not a narcotic, it’s a stimulant, and it’s still medically used, so it was allowed for that. So that had a lot to do with it. And so the first war on drugs actually began in 1913 when a whole bunch of opioids and stimulants were suddenly banned, but they were permitted for medical use.
And then in 1924, diamorphine, also known as heroin, was banned in the United States because one of the heads of the drug czar of that day concluded that people who were found illegally now using diamorphine or heroin seemed to have a lower moral character—translation: they were African American. So he thought that this corrupts the moral character and asked Congress to ban it. And despite protestations from the American Medical Association saying, “Look, we only have a couple of things to help us treat pain: morphine, heroin, not much else, codeine. Please don’t take this,” and there’s no scientific basis for that assertion that it affects your morals. Nevertheless, Congress banned it in the United States. Many people may not be aware that it is on the formulary in Canada and the European Union, UK, in many countries. They just don’t refer to it by its original brand name of heroin, they refer to it as diamorphine, and it is used medicinally in those countries. It’s also used as a form of medication-assisted treatment for addiction. But in the United States, it’s banned. Even though Dilaudid, which is perfectly legal and prescribed orally and intravenously, is twice as potent as heroin and is not banned. And of course, fentanyl is legal and your doctors could prescribe fentanyl skin patches, and that’s 50 times as potent as heroin, and that’s legal. But for some arbitrary racially based reason, it was made illegal. And any economist will tell you what would next happen. So 10 years later, the most commonly illegally used opioid in the black market was heroin, because morphine you can get other ways. So if you were a drug dealer, what would you rather push? Heroin, which there’s no other way to get except through you, or morphine, where there are other ways to get it through what they call diversion, where things get kind of stolen or snuck into the black market from medicinal uses. Which is a good segue into the current opioid crisis, by the way.
Bob Zadek: Now, let me just add one little tidbit. When I was doing some research for an earlier show on drug policy, I found a New York Times article from 1913 citing a “scientific”—that’s air quotes—study that “Negroes,” as Black Americans were then called, “Negroes became much better pistol shots if they used marijuana.” And that was a scientific study. It also, the same study said that a Negro’s sexual drive was enhanced by the use of these narcotics. So that was the hysteria, the racism that preceded the war on drugs.
Dr. Jeffrey Singer: Well, in fact, the New York Times had headlines about “cocaine-crazed Negroes” who became impervious to bullets. And a lot of people in the Northeast were very—they didn’t like the fact that all of these Blacks from the South were migrating up to the Northeast where they can get jobs, because they were resentful of that because of the competition. And they were hard workers looking for work and willing to work for less. So a lot of rumors started to abound that the reason they’re working so hard and they’re willing to put in such long hours is because they’re using cocaine. So that was all part of that thing back then.
The Evolution of the Overdose Crisis [20:27]
Bob Zadek: Now, so now let’s fast forward if we can, because I want to spend the rest of the show on the opioid policy, which is a subset of drug policy, because it affects drug manufacturers, it affects something important to you, Jeff, which is the interference between the patient and doctor in how they interact and what drugs the doctor prescribes. So now let’s go forward to what was identified, incorrectly perhaps again with blurred definitions, the “opioid crisis,” which kind of seemed to have popped up somewhere around the beginning of the 21st century with drug companies as the targets and prescription writing practices of physicians. So how did that all come about, and what was the government’s role in that?
Dr. Jeffrey Singer: Well, actually a lot of that is—I hate to say this, but it’s more subtle, but there’s a racial basis for that as well, and I’ll explain why in a minute. First of all, the Joint Economic Committee of Congress reported in 2019 that overdose rates started climbing in 1959, and that report is available, it’s in the public domain. By 1970, President Richard Nixon, alarmed at the overdose crisis, declared war on drugs. So that was actually drug war number two. And this time they meant business. So they created the Drug Enforcement Administration, which scheduled drugs. And Schedule I drugs are drugs that have no medical use, like marijuana—everybody out there using it right now knows it has no medical use according to the government—and diamorphine. So morphine has medical use and fentanyl has medical use, but for some reason diamorphine has no medical use, so it’s put in Schedule I. And LSD and other things. And then Schedule II is they have medical use but they’re highly addictive potential, etc., etc.
So, and according to a recent study from the University of Pittsburgh School of Public Health, the overdose rate started climbing exponentially at least since the late 1970s. The only thing that has changed over the years is which particular drug seems to be the most in vogue for non-medical black market use at any given time. So in the ’70s and ’80s, it was heroin and heroin and cocaine. And then in the 1990s, it became what they call diverted prescription pain pills like Percocet and Vicodin. And then the beginning of the 21st century, it became OxyContin, which is oxycodone, it’s just concentrated. So if you’re going to try to use some stolen or diverted prescription pain pill, instead of using oxycodone, which is like Percocet, if you use OxyContin and you crush it and either inject it or snort it, you’ll get a lot more bang for your buck because it’s just concentrated oxycodone.
So the reason why we suddenly had an overdose crisis in the early 21st century is because now what was happening was a lot of those people who were involved in this were white middle-class people. So when we had the overdose crisis that was mainly involving inner-city minority use, marginalized people in the ’70s and ’80s, it didn’t really attract a whole lot of attention. But when it started involving the rest of us, that’s when people started noticing.
Now, I’m old enough to remember—I was a medical student during President Nixon’s war on drugs, and I was indoctrinated into saying these drugs are bad, try to avoid prescribing them. And so was the rest of America. So I can remember in the ’80s when I was making post-op rounds on my surgical patients, my patients would look in horrible pain, you know, hyperventilating, sweating, pasty-looking. And I’d say, “Are you in pain?” and they’d grunt, “Yes.” And I’d say, “Well, let the nurse know because I ordered morphine for you and the nurse will bring you morphine.” “No, no, no, I don’t want to get addicted.” So this is on both sides of the table.
Oh, I gotta get back to addiction. Addiction as opposed to dependency: addiction is defined as compulsive use despite negative consequences. That’s not the same as dependency. So for example, if you’re—anybody who knows about people who are addicted to alcohol knows what I’m talking about. And it doesn’t have to be a substance, it could be gambling addiction, it could be sex addiction, it could be shopping addiction. So that even if you’ve been tapered off of the drug and you no longer have a chemical dependence on it, you are compulsively drawn to use the drug or engage in the behavior, let’s say gambling. And that’s because of underlying psychological built-in vulnerabilities you have, and also most research suggests that almost every person with this has had some sort of traumatic events in very early developmental years. But it’s a separate thing, it’s a behavioral disorder.
And even Dr. Nora Volkow, the current head of the National Institute on Drug Abuse, has written in the New England Journal of Medicine that addiction in chronic long-term opioid users and chronic pain patients is very uncommon, quote, “even in those with pre-existing vulnerabilities.” So people tend to equate opioid dependency with opioid addiction, and they’re two completely different things. So what happened is as the overdose rate started to climb, and in the early part of this century we noticed that the drug of choice being used by people who would overdose was diverted prescription pain pills, most notably OxyContin, which was manufactured by Purdue Pharma. Rather than even consider the fact that overdoses are a cause of the drug prohibition—because when you’re using something obtained in a black market, you have no idea as to whether it’s what the person who sold it to you says it is, what its dosage is, what its potency is, whether it’s mixed with something else like fentanyl—and also you’re unable to openly discuss how to use it safely. So for example, we now know about 90% of these overdoses are what they call poly-drug, like a person who overdosed from OxyContin also had in their system cocaine and alcohol and Xanax, a benzodiazepine. Normally, if you’re using this as a patient, your doctor will tell you, “Now don’t drink alcohol when you’re using this drug because it could potentiate it,” etc., and they may adjust your doses of other medicines that could potentiate it. So rather than do that, it’s much easier to blame it on the drug and particularly the manufacturer of the drug.
So they—oh, and another point is that by the early ’80s and into the ’90s, medical researchers were pointing out to us that we were undertreating pain because of this irrational and non-evidence-based fear of opioids. They even coined the term “opiophobia.” And by the late ’80s, early ’90s, we all were being told, including by the National Institute on Drug Abuse, to stop undertreating pain, take pain seriously, and don’t be afraid to prescribe opioids because they have a low addiction potential. And they still do. Like I said, like even as recently as 2016, Dr. Nora Volkow said that’s about between 1% to maybe a 5% addiction rate depending on whose studies you read. I would—but it’s closer to the 1%.
So anyway, so we started prescribing more liberally in the ’80s and ’90s. And so by the time non-medical drug users were recreationally using drugs in the late ’90s, early 2000s, you’d be at a college student at a party and somebody would say, “Hey, I got some of this stuff called OxyContin. You want to try it? If you crush it, or even if you just take it orally, it gives you a great feeling.” And by that time, people were familiar with these drugs because they’d been prescribed now, they’ve been—and the prescription pain relievers were associated with safe use. So they became more popular. And by the way, that was rational. If I had a person come up to me and say, “Doc, I am going to recreationally use a drug tonight. I have in my hand a bottle of OxyContin I stole from my mother’s medicine cabinet. I have in the other hand a bag of what some guy on the street tells me is heroin. Which should I use? I’m going to use one of them, you can’t stop me.” I would say, “Use that pill bottle with the OxyContin in it because it says exactly how many milligrams is there, we know it’s nothing but that. That bag that this person sold you, you don’t know what the potency is, you don’t know whether it’s laced with fentanyl, you know nothing about it, you can’t trust it.” So that’s why it became popular. People had no longer been afraid of it, they associated it with pharmaceutically manufactured pure compounds that had medical use. So that became popular.
When the prohibitionists decided rather than blame it on prohibition, blame it on the drug, they started forcing us doctors to prescribe less. So from the peak—opioid prescribing reached its peak in 2012. It’s down 60% since that time. And what’s happened to the overdose rate? It’s soared. Because as non-medical use of opioids continued, now because there were fewer prescription pain pills available for diversion into the black market—and incidentally in 2018 the DEA said that less than 1% of prescription pain pills now get diverted into the black market, so that’s no longer a problem—so what happened is if you wanted to use OxyContin or oxycodone or hydrocodone or whatever, it wasn’t available. So you moved over to the next thing you were going to use then: heroin. And then heroin became mixed with fentanyl, and now it’s mostly fentanyl. So in the most recent data, the 12 months ending April 2021, there were 100,000 overdose deaths. That’s a record high, never seen before. And out of that, about 70,000 were due to—were opioid-related. But opioid-related doesn’t mean prescription pain pill-related, it means opioids like we talked about in the beginning. So 83% of the opioid-related overdose deaths involved fentanyl. And again, over 90% were poly-drug use.
By the way, 22% of the overdose deaths of those 100,000 contained cocaine and 23% contained methamphetamine. Again, the notion that is trying to be promulgated is that Purdue Pharma and other evil pharmaceutical companies fooled us doctors into prescribing our opioids to our patients, and then we turned them into drug addicts. And so we’re supposed to believe that all these people who are dying on the street and injecting heroin mixed with fentanyl while they’re taking cocaine and meth, that we’re supposed to believe these are our former patients. And that’s absolutely untrue. And by now, all our patients that we hooked on opioids should be dead by now, you would think, since it’s been going up, up, up, up, up.
In fact, I published in the peer-reviewed medical literature, we did a study. The National Survey on Drug Use and Health, which is conducted by the federal government, started in 2002. And since 2002 to present, using their terminology, “past month’s non-medical use of pain relievers” by persons aged 12 and up has essentially been a straight line. And also “past year diagnosed with pain reliever use disorder,” persons 12 and up, has been essentially a straight line. From 2002 to 2012, the number of prescriptions per 100 persons doubled, and then since 2012 they’ve come down 60%. Meanwhile, those two other things I just mentioned, those two metrics, have been a straight line. So there’s no correlation between the number of prescriptions written and people getting hooked or using drugs non-medically at all. The only thing is that as the prescription numbers came down, there were fewer prescriptions available for diversion into the black market for people who wanted to use them recreationally, and so they went to the next available thing, which was heroin and fentanyl.
The Iron Law of Prohibition and Fentanyl [33:04]
Bob Zadek: So therefore, the phrase we have heard during the COVID era has always been “follow the science.” And what you have just pointed out with complete objectivity is that the opioid policy, insofar as it affects the manufacture of legal drugs by drug manufacturers and the prescribing of painkillers by a doctor to a patient in pain, there is no relationship between the writing of scripts for painkillers, the manufacturer of drugs—there’s no relationship between that and overdose deaths. And in fact, that statement is probably false. There is a relationship, but it’s the opposite. Overdose deaths have increased as limitation—legal limitation on the prescribing of prescription drugs has become stronger. The interference with the doctor-patient relationship has been a cause, not a cure, for overdose. Is that an overstatement or pretty accurate?
Dr. Jeffrey Singer: Yeah, more accurate way to say it is there’s no relationship between the number of opioids prescribed and non-medical use or addiction. There is a relationship between the number of opioids prescribed and overdoses: the fewer opioids prescribed, the greater the number of overdoses, because there are fewer prescription pain pills that become available for diversion into the black market, leaving non-medical users or recreational users with more dangerous options. Because when you buy something on the street, you don’t know—it’s not the same thing as buying something that was manufactured legally by a pharmaceutical company and dispensed in a pharmacy for medicinal use. So that’s what you could say.
Also, by the way, the National Survey on Drug Use and Health—this will be a surprise to your listeners—since they began taking the survey, the percentage of adults who have heroin addiction, alcohol addiction, and cocaine addiction and cannabis addiction has all, in all four of those categories, has been unchanged over the years. The same percentage. Now, obviously as the population has grown, then the raw number grows because 10% of 300 million is a larger number than 10% of 200 million. But the percentage of the population has not changed. We don’t know this.
So it’s much easier for people—and now, another thing is there were doctors, undoubtedly, and this fed the narrative, who were operating—who were basically drug dealers. They were using their medical degree to be drug dealers. So for example, there was a doctor arrested in Orange County for selling OxyContin prescriptions at $600 a prescription at a Starbucks. People knew where to find them. There were doctors in Florida operating these pill mills, and drug dealers had a thing called the “Oxy Express” where they would actually pay to fly down people from New York to Florida. They’d give them instructions: “Go to this pain clinic, ask for this doctor, say these words. He will give you a prescription for 500 OxyContin. Then go to this pharmacy, make sure you get this pharmacist, he’ll fill that prescription. Then bring it to me and I’ll pay you.” And that’s the kind of thing that was happening. Now, I would argue that that’s not because prescription painkillers do their job in relieving pain; that’s because of prohibition again. If it wasn’t for prohibition, prohibition corrupts people. It corrupts doctors, it corrupts pharmacists, it corrupts policemen—I mean, anybody who’s watched any crime shows knows this—it corrupts prosecutors and it corrupts politicians. So if there’s anybody to blame for doctors selling prescriptions for $600 a pop or operating these so-called pain clinics which were really just ways of funneling prescription drugs into the illicit market, it’s prohibition, because it makes it very lucrative, and corruptible people get corrupted by that.
So again, they don’t want to point put the blame where it belongs, they’d rather blame the drug manufacturer. And so now they’ve gotten Purdue Pharma is bankrupt and they’ve extracted billions and billions of dollars out of these pharmaceutical companies in settlements. Note they’ve never gone to trial because it makes business sense for the businesses to cut their losses. And in fact, the prosecutors hope it doesn’t go to trial, it’s much easier for them to extract a settlement. So they got this tribute from these pharmaceutical companies. And how’s that working out? Overdose rates—I could expect the next report from the CDC is going to show it’s exceeded 100,000. It just keeps climbing because the reason we have an overdose crisis is because we have drug prohibition. We had the same thing when we had alcohol prohibition. People were dying from drinking alcohol, thousands of people were dying from tainted alcohol. And now hundreds of thousands of people are dying from laced illicit opioid drugs.
And another important point is people who study this talk about what’s called the Iron Law of Prohibition. Prohibition by its definition fosters the development of more potent forms of whatever it is that’s prohibited. So for example, during alcohol prohibition, they weren’t smuggling in beer or wine, they were smuggling in whiskey. And here’s a real-life example is when you’re tailgating at a football game, everybody outside in the parking lot is drinking beer and wine, but when you go into the stadium where there’s no alcohol allowed, they’re bringing in tequila or whiskey or the hard stuff in flasks. Well, the same thing happens now with these illicit drugs. So crack cocaine probably wouldn’t have come about were not for prohibition, because it fosters development of more potent forms that could be smuggled in in smaller amounts and subdivided into a greater number of packets to be sold. If you’re going to take the risk you have to take with prohibition, then that’s—makes the risk worth taking.
So fentanyl that we talk about today, this is not medicinal fentanyl that we use all the time in anesthesia, in intensive care units, in critically ill patients or in chronic pain patients as skin patches. This is what they call illicit fentanyl. The DEA even says that. It’s made in labs just like meth is made in labs in a powdered form. It’s smuggled into this country. Dealers use pill presses to press them into counterfeit prescription pain pills so that unsuspecting people think they’re buying a safe oxycodone pill and instead they’re buying fentanyl, which is about 100 times the strength of it, so they overdose.
And during COVID, one of the reasons why—well, first of all, it’s been mixed in with heroin to increase its potency so you could smuggle in heroin in smaller amounts. It’s been mixed—people who like to use cocaine and methamphetamine often like to do a thing that’s called “speedballing” where they mix it with an opioid, usually heroin, because they like the feeling of when they come down from their high from the stimulant, the heroin kind of smooths out the landing, so to speak. And that’s called speedballing. But recently, fentanyl has been substituted for heroin. And then the COVID pandemic made it even worse because just like supply chains have been disrupted for everything else, they’ve been disrupted for heroin. Heroin has to be grown, processed, and smuggled. But fentanyl is much easier to make in a lab. So fentanyl has substituted for a lot of what had been heroin being smuggled into this country for non-medical users. Most non-medical users of heroin will tell you that they don’t like fentanyl, they view it as a contaminant. They prefer the feeling they get from heroin, which is a different feeling than they get from fentanyl. So it’s not like they’re choosing fentanyl, they’re finding that everything they get now has fentanyl mixed in with it. And a lot of that is driven by supply chain issues. So these are important facts, but at the bottom, it’s all prohibition that does this.
CDC Guidelines and Junk Science [47:17]
Bob Zadek: Now Jeff, the science is so clear that there is no link between the manufacture, prescribing, sale, and use of drug company-manufactured painkillers. They perform an important medical function in society. They are controlled through the system we have, flawed though it may be, of the writing of prescription drugs. But the science is bell-clear as you have explained. Now you do a lot of your work—great work by the way, great work—in testifying and educating legislators, mostly in Congress, but also at the state level. And if we assume that legislators are by and large, let’s give them the benefit of the doubt, trying to do the right thing, they hold hearings so they can learn from experts such as you. And you go in there and you explain to the legislative audience just as you’re doing this morning what the science is, what the indisputable data is. So why doesn’t the law change? Putting it another way, Jeff, because you have this experience, since there is science in support of your position, where does the other side—how does the other side, those who favor prohibition, make their case? And why are they so far carrying the day, if they are, at the legislature? Doesn’t the legislature at its core, assuming no corruption, want to do the right thing? And what is the argument against your science-based position? Why do we still have over-regulation of prescription drugs for pain relief?
Dr. Jeffrey Singer: Well, first of all, like I say, all of us are victims of this indoctrination that’s been going on since particularly since the ’70s. So while legislators want to do the right thing, they’ve been told, you know, that opioids are very dangerous and highly addictive, etc. Then there are groups of doctors who are benefiting greatly as expert witnesses in these lawsuits against the pharmaceutical companies. There’s one organization called Physicians for Responsible Opioid Prescribing, and it’s led by some notable doctors, academics at Stanford and Brandeis and other places. And they’re going around saying the opposite of what I just said, even though the science, like I said, refutes that.
So for example, many of them counseled the CDC, which in 2016 in response to the overdose crisis issued prescribing guidelines with the goal of getting doctors to prescribe fewer opioids. Those guidelines came under tremendous amount of criticism from pharmacologists, biochemists. For example, they said that you shouldn’t exceed more than 90 morphine milligram equivalents per day in a prescription to a patient of opioids. And they came up with these conversion tables of how to convert, let’s say, oxycodone into the equivalent in morphine talk, morphine dose. Now, true they stipulated this is just a general guideline, and they said it’s based on Type 4 evidence, which is the weakest possible evidence and subject to being found wrong.
Nevertheless, once that came out, almost reflexively 36 states pretty much put those things into law. So that if doctors were found—and then every state set up these prescription drug monitoring programs where every single controlled substance that’s prescribed is now being monitored and tabulated by the state. So if doctors are found to exceed that number, which was now put into statute—even though the CDC said this is just meant to be a rough guideline, it became the statute because that’s the way politicians normally react to rough guidelines is they simplistically say, “Well, let’s make that the law.” And so doctors found to be prescribing in excess of that 90 morphine milligram equivalent were getting arrested for being these pill mill operators. And they weren’t pill mill operators, they were rationally prescribing what they thought was necessary to their patients.
And so stories started to appear in the press of doctors getting arrested. Many of them, by the way, ended up never getting charged because they weren’t pill mill operators, but you never get the follow-up story in the press. You do see on the evening news the SWAT team showing up in a doctor’s waiting room full of patients and marching out a doctor in handcuffs. You do see that, but you don’t see what happened to them later. So what happened is doctors have been terrorized and now they’re under-prescribing medication, and chronic pain patients are being abruptly cut off pain medicine that’s been working for them for decades and allowing them to have a meaningful life. Some in desperation have been turning to the black market looking for the drug and unfortunately buying counterfeit—getting fooled with counterfeit prescription pain pills that are actually fentanyl, and they’re becoming part of those overdose statistics. Some are committing suicide. I mean, they’re organizing now into groups that are protesting. The American Medical Association protested.
And finally in 2019, the CDC, you know, a little late to the game, said, “Whoa, whoa, whoa, we never meant you to put this into law, these were just rough suggestions.” And now they’re planning this year to come out with a revised guidelines. Unfortunately, those revised guidelines, they spend from what we’ve seen from the rough draft, they spend a great deal of time emphasizing that please don’t cast this in stone, don’t take this as the gospel, these are just rough guidelines, don’t make the mistake you made before. But then they go ahead and they still use those conversion tables and things which any pharmacologist would tell you you can’t convert oxycodone to morphine equivalent because they’re metabolized by the body differently. Different people metabolize because of their genetics, metabolize the drugs at different rates. Different drugs get absorbed at different rates, they have different half-lives. Kidney function affects this, what other drugs are in your system affects this. It’s biochemically impossible to make a conversion between an oxycodone, let’s say, and morphine. Not only that, but we’ve discovered—and I wrote about this in the New York Daily News last week with a colleague of mine, Josh Bloom, from the American Council on Science and Health—it turns out that these conversion tables are based on 60-year-old single-dose subjective clinical trials where, for example, you give pain pill one to patient A, pain pill two to patient B, and then say, “Give me a pain score on one to ten, how does this relieve your pain?” And if both people said five, then you’d say, “Okay, pain pill one and pain pill two are equal.” I’m not making this up. That’s the science that went into forming the conversion tables. So it’s not only pharmacologically impossible to have a conversion table, but the conversion tables they have are based on junk science. And they’re going to come out with it again. But meanwhile, even after telling lawmakers don’t put this into law, what about the law they already put it into from 2016? We’re stuck with it. We’re stuck with junk science.
Conclusion [50:33]
Bob Zadek: And what we have, just to make it clear because that’s a crucial point you’re making, as you made in the Daily News article: we start with really as junk as junk can be, that is nobody would disagree that it’s junk science. It’s 60 years old junk science now goes along this trail of becoming a guidance, which is not a statute, which is “Hey, let’s just throw it out there, what do you guys think?” It becomes guidance in 2016. It then becomes the law in 36 states affecting tens of thousands of Americans who are in pain—millions who are in pain whose doctor wants to prescribe a painkiller which will be effective in reducing the pain, but the doctor cannot under fear of having the front door to his waiting room kicked down by a SWAT team. And there we have a government which likes to hide behind the motto of “follow the science,” and here’s where we are. Innocent Americans are living in pain because of one 60-year-old study.
Dr. Jeffrey Singer: Multiple studies, multiple studies going back 60 years, to be more accurate. Not one 60-year-old, multiple studies dating back as far as 60 years, yeah.
Bob Zadek: Jeff, we have about a minute to go. What is the prospect for the future? There has been some movement, you said CDC has reversed its 2016 ill-conceived guidance. Can we expect any relief? I know Cato is working and you are working very hard. What is the—we have about a minute left—what is the prospects for the government backing out of the doctor-patient relationship insofar as pain medication is concerned?
Dr. Jeffrey Singer: I don’t have—I’m not optimistic. First of all, they haven’t reversed it. They’re planning to later this year revise it or update it. And it looks from the draft that they’ve released for us to look at now, it looks like it’s basically the same guidelines with a very, very emphatic disclaimer saying, “These are guidelines, these are not the gospel, these are just rough things for you to use as a rule of thumb. Please don’t take these as the answer, take these as a guide and use your best medical judgment because every doctor and every patient is different.” But so it’s basically they’re just covering themselves with this disclaimer, but they haven’t—it doesn’t look like they’re going to change the guidelines.
Bob Zadek: Just sorry to interrupt, but we hope the message will be: prohibition does not work. Stay out of the physician-patient relationship. Thank you so much to Dr. Jeff Singer, senior fellow at the Cato Institute. Thank you so much, Jeff, for joining us this Sunday morning. And thank you to my friends out there for giving us an hour of your time. Have a nice balance of the weekend. Goodbye.