The following is a conversation between Harry Nelson, Author of The United States of Opioids: A Prescription for Liberating a Nation in Pain, and Denver Frederick, the Host of The Business of Giving.
Denver: Harry Nelson is one of the leading healthcare legal experts in the country addressing the worsening problems on how we treat pain and addiction. In his recent book, The United States of Opioids: A Prescription for Liberating a Nation in Pain, he tells us how we got here and what we need to do as a nation to successfully address this ever-growing problem, which is only likely to be exacerbated some by the current pandemic, and he’s with us now to discuss it.
Welcome to The Business of Giving, Harry!
Harry: Great to be with you. Thanks for having me today.
Denver: So, what inspired a healthcare regulatory lawyer to write a book like this?
Harry: It was obvious it’s not the natural thing to do as a lawyer. First of all, most of the work that I do for clients is confidential, and so I’m a keeper of a lot of secrets. And second, a lot of the work that I’ve done over the years and that the lawyers like me do tends to be very technical… a lot of writing contracts and making sure people are in compliance.
But what started to happen to me is I started to find myself in the middle of responding to overdoses and disasters in addiction treatment at an unprecedented clip. And it got to a point where I felt like I simply couldn’t just keep my expertise and wait for the next disaster to happen. I felt like I needed to get out there with some messages to help people understand what was happening. And the other part of it was that I feel like, as often happens in our system, the problem of they say the blind men surrounding the elephant? Everybody sort of sees the problem from a different standpoint.
And I felt like working in some cases with doctors; working with recovery treatment programs, drug rehabs; working in some cases with drug makers and device makers, I was seeing this problem from a lot of different sides, and I thought it gave me a different perspective that would add something to the conversation. So, I took a step away from traditional lawyering to do this.
Denver: Well, it’s hard to put things in a compartment so neatly. And I think it is a real addition to the field not to have a journalist talk about it…and those have been some wonderful books… but there’s added value to get it from a lawyer’s perspective.
Harry, let’s start at the very beginning. What is an opioid, and what makes them so dangerous?
Harry: So, when we say opioids, we’re covering really two categories of things. We’re covering opiates, which are the natural plant-derived poppy chemicals, and we’re also talking about the modern synthetics that have developed over the last 80 years or so.
And so, when we look at what opioids are, we have to go back really throughout human history. They were one of the most important forms of medication that was out there. From early human society, we learned that opioids would put people to sleep, would lead to a painful death. One of the primary uses was to help people with stomach problems. They would actually settle people’s stomach and prevent diarrhea. So, for a long time, they were one of our most important medications.
And then what you start to see happen in the last several hundred years is the world starts to wake up to how addictive they are. And it’s interesting… if you look in the 1800s, the biggest story around opioids was the Opium Wars that the British empire fought literally to keep the opium trade going and to be able to sell opium into China, where as many as a quarter of all men, Chinese men, were addicted in the middle of the 19th century. And by the way, we had a serious opioid issue, a problem of addiction in the Revolutionary War, in the Civil War; that was what soldiers were given.
So around the turn of the 20th century, right in the late 1800s/early 20th century, we start to see the world organizing to criminalize some opioids, and there was a massive crackdown. At that point, if you looked in 1899, when Bayer put heroin in as an over-the-counter drug into American drug stores, we went from that position to within 15 years later, opioids being not only prescription but very heavily controlled and doctors going to jail for prescribing them.
So, if you fast forward, what we did was we basically went through a massive crackdown, and we really never addressed how you treat pain and what the sources of pain were in our society. And it’s only in the 1970s that you start to see and ’80s, you see a full cycle reversal where we start to get so concerned about pain that we start encouraging doctors to prescribe more. And one of the big issues around opioids was, of course, that the drug companies were one of the big sources asking for more pain medicine to be prescribed more liberally.
And it finally caught up with us in what we call the “opioid crisis” in the very late ’90s, when we start to see that a particular new opioid, OxyContin, put out by Purdue Pharma is killing more people year over year, and rising up the level… the charts of accidental death in one demographic group after another. So we’re in a 20-year cycle of year-over-year increasing death from opioids, even as they remain our most critical form of pain medication.
Denver: Yes, it is really interesting. It seemed like by the end of the century, we had forgotten all the crackdown of the early part of the century and a new generation of companies and physicians came along. So, going to today, how many Americans have an opioid-specific addiction? And how many die from an overdose every year?
Harry: So the numbers keep going up year over year. The number of total drug overdoses in the United States last year in 2019 was 72,000, and two-thirds of that was opioids. So, opioids have been climbing as a percentage. More and more drug overdose deaths are related to opioids.
In terms of how many people actually have a problem, we’re talking about something like 20% of the United States population having a problem on some level. That could mean just a self-perception that you’re using them; that could mean people with an active addiction. And then all the number of the people who show up at the emergency room in hospitals; for all of those people who are actually dying, you have another 10 people who either just show up at the ER and get treatment, or actually get hospitalized and survive an opioid overdose. So we’re talking about a problem that’s afflicting literally millions of Americans.
We are a consumerist society that is selling the message that you can fix all problems and that you should be able to live exactly as you want to live. And so, we have a culture, certainly– I believe of the country — of wanting to find a solution, and pills make it easy to solve problems.
Denver: You know, you said something a moment ago that really caught my attention, Harry, and that is the attitude we have in this country towards addiction, but particularly towards pain. What is our attitude towards pain?
Harry: So it’s really conflicted. We are, on one hand, a consumerist society that is selling the message that you can fix all problems and that you should be able to live exactly as you want to live. And so, we have a culture, certainly — I believe of the country — of wanting to find a solution, and pills make it easy to solve problems. So on one level, we’ve created this economy around addressing pain in that way.
And on another level, there are aspects of our pain that we are really reluctant to talk about. There are moral judgments and shame imposed on talking about pain, and particularly talking about the sources of pain, where it comes from, and also talking about trauma, which is an incredibly important driver of pain. So many people are walking around with a pain that is not merely physical but that is psychic from events in their lives, and there’s a deep shame around it. So we have this really conflicted attitude.
And you see it play out in our medical system. In the early part of my career as a healthcare lawyer, I defended a number of doctors who got in trouble for not giving patients enough medication. Patients would complain to the medical board, and doctors would get prosecuted for undertreating pain. And now, we’ve ended up in an environment where we’ve swung the pendulum to the other side, where doctors are getting in trouble for giving too much pain relief, too much pain medication.
Denver: Yes. Well, I guess, when you’re in a hospital, they still do it in a very antiquated way, and that is they ask you “on a 1 to 10 scale, tell me your pain level,” and I don’t think anybody’s ever answered below six.
Harry: Right. It’s interesting that one of the things that has actually started to go away are those pain surveys. They’re not completely gone, but they have taken a back seat because people realized that they were incredibly subjective, and nobody tells you they’re not in pain. I take that back. The only people who actually underreport their pain are kids. Children underreport their pain. Adults overreport their pain.
Denver: Yes. I’m an adult. Well, as you said in the book, there is plenty of blame to go around for this opioid crisis. So let me ask you about a few of the players in this, and why don’t we start with Big Pharma? How do you assess their role?
Harry: So I think there’s an important allocation of responsibility to Big Pharma. I think we have a problem in this country with drug companies that market aggressively. By the way, we’re one of the few countries in the world that actually permit public television advertisements for drugs, where drug companies get to peddle their drugs on TV directly to consumers.
Denver: I watch the national news, and that’s got to be a 60-over audience. It’s got to be four out of every five commercials is for some drug.
Harry: It’s crazy. It’s literally like we’re the only developed country in the world where that still is the practice. So the drug companies have one of the most powerful lobbies in Washington, D.C., and in the story of this crisis, they absolutely deserve a share of the blame.
My only hesitation, and what I say in the book is while they are certainly not good actors, and particularly Purdue Pharma, which has received so much attention for OxyContin and for the recent crisis, but at the same time, in my book, we need to look across the board at a much more structural problem, meaning the problem isn’t just that the drug makers created this problem.
Harry: In many ways, you could hold the government responsible for the way that it cracked down too hard in the early 20th century and scarred a generation of doctors against pain prescribing, and then the pendulum swing the opposite way and it was too easy. So we have government really sending the wrong messages and being too heavy- handed.
We have the insurance companies. So much of our healthcare system in the United States is defined by what people will pay for, and the reality is that the drugs are often the cheapest solution. I’ve had many cases where government, where like Medicare, for example, did not want to pay for an expensive infusion therapy that would allow somebody to be opioid-free, but was happy to pay for the pills that were going to keep somebody bedbound for a pain condition. There are lots of ways to treat pain, but pills are the cheapest way. So, the insurance companies deserve attention.
I do think we need to look at our culture and ways that culturally, we have allowed this crisis to develop. So—
Denver: Let me pick up on a couple of those things then. Let’s start with the government. We have the FDA and the DEA, the Drug Enforcement Administration. And I guess the question I have for you there is: What are they doing that has allowed fentanyl to come into this country so easily?
Harry: By the way, I think that’s something that we just have not fully reckoned with, is how much the DEA has utterly failed to protect us from the flood of fentanyl from Asia and across our borders.
The way that I look at it is… there’s a saying that “If you walk around with a hammer, every problem looks like a nail.” And so, I think the DEA got very good in the opioid crisis at cracking down on pharmacies, at cracking down on doctors and identifying them as the source of the problem. The DEA, over time, has made its way to effectively really stopping the flow of various categories of drugs.
Fentanyl was a whole new animal. First of all, it was odor-free and synthetic. Second, it was coming into the country, in many cases, just being mailed in in small quantities directly. It was only two years ago, you could go on Google and find a website from China that would send you a packet for not too much money. So I think, honestly, I think the DEA was asleep. They weren’t developing technology to identify and stop the inflow. And as is so often the case, they just focused on what they knew how to do and ignored this problem.
The big story of the opioid crisis is that it started off as a prescription drug problem in the early 2000s. It morphed into a heroin problem as we cracked down on prescription drugs. And then as we cracked down on heroin, it’s become a fentanyl problem. And that is a problem that’s just getting much, much worse.
Denver: And if we look at it as a prescription problem as it started out, those are physicians who are prescribing these opioids and OxyContin. Are they taught in med school how to deal with pain? Is that one of the core courses or not?
Harry: That’s one of the big problems is that the medical school education really doesn’t focus on treating pain and doesn’t give doctors the tools to work with these medications and to understand them. And so, I think changing how we train doctors is such a critical piece of the puzzle.
Denver: You said before that the rise in overdose deaths across all drugs has been going straight up for about 40 years now. What do you believe Harry is at the heart of this?
Harry: So that’s a great question. That’s really one of the things that I think we have gotten too focused on is just the opioid problem and losing sight of this broader problem.
The data that came out in 2018… for the first time, there was a study out of the University of Pittsburgh Medical Center that put all the various drug sub-epidemics. And by the way, around the country, you see different flare-ups. We occasionally will have a national crisis the way we did with crack and PCP at various areas, but there’s often little geographic pockets where one drug will be a problem in one part of the country. Meth will invade this part of the country; Ecstasy that part of the country.
And so, what we saw when you added up all the data, is that going back to the ’70s, something happened in American life in the ’70s where year over year, the drug overdose death totals kept going up year over year on an exponential curve. And so, what that leads me to believe is this is not just a problem of opioids. This problem predates opioids, and we’ve got to look deeper at what’s been happening.
And that’s really what drives me to ask the question of: What changed in American life? What is actually leading so many people to become addicted or to feel a sense of sufficient despair to take the risk, to either deliberately or accidentally take their risk of killing themselves with drugs?
I think that we have been experiencing that many of the features of modern life have been leading to a deeper sense of alienation, to a deeper sense of social isolation, to a real sense of anxiety about the future.
Denver: What do you think it is?
Harry: I think that we have been experiencing that many of the features of modern life have been leading to a deeper sense of alienation, to a deeper sense of social isolation, to a real sense of anxiety about the future.
To me, one of the most important books out there was Robert Putnam’s Bowling Alone in the early 2000s.
Harry: And I’m a big believer.
So a lot of people thought… Putnam is funny. He goes in and out of fashion. He went through a period where he was a genius, and then the people started to… And his whole theory is right, of course, that we had social structures that started to fall apart in American life… things like bowling leagues is his classic example, and things that were a source of community to people.
But as our sense of community really started to disintegrate… and what you start to see in the ’70s is a shift away from life lived publicly and much more communally towards a much more atomized way of living our lives. We live much more in our small families and more and more people living alone, and we really lose that sense of community that gave structure and that was a source of real health management in people’s lives… that people feel much worse about themselves and are much lonelier, much more isolated, more anxious, more depressed as a result of that change. So I think that’s part of the story.
I think it’s not one thing, by the way. I’m a big believer that technology is an accelerating source of the problem. There are so many features. If you look around, if you look at the way that our work changed, you can find lots and lots of examples of the way that life changed in this country in the last 50 years in a way that is making these problems worse.
I think when we look back on 2020, we’re going to talk about the hundreds of thousands of people who died from COVID, but we’re also going to be talking about, if not the same number, a very substantial six-figure number of people who died from the behavioral, the social effects of the pandemic.
Denver: I think back when I was a kid, all those civic and fraternal organizations– the VFW, and the Lions, and the Junior Leagues and the Rotaries, and all those different types of things people… and even bowling you would always see them at the bowling alley. There’d be these leagues, and then we went to…
Well, if this isolation and this disconnection is really at the root of a lot of this, what do you think the impact of this pandemic is going to be? Because people are certainly more isolated and disconnected than they’ve been in quite some time.
Harry: I think we are just beginning to get data that this is absolutely going to be the most nightmarish period, that as much as we’ve been focused on the horror of people dying from COVID-19, the number of deaths from drug overdoses, the number of suicides, and the number of people who are living and suffering with anxiety, with depression are just absolutely off the charts.
The numbers are staggering. There are communities in the United States where we’ve already seen close to a 100% increase in the overdose death rate. Syracuse, New York, for example — over 95% increase. The state of Florida — 70% year over year increase in the number of people who overdose from opioids.
So I think when we look back on 2020, we’re going to talk about the hundreds of thousands of people who died from COVID, but we’re also going to be talking about, if not the same number, a very substantial six-figure number of people who died from the behavioral, the social effects of the pandemic.
Denver: And so, when the vaccine gets out there and it works, there is going to be a long-term vestige of what this pandemic has done in terms of the way it’s harmed people and their families and their lives. How can we empower people with, I don’t know, new skills, new tools, new language to combat the crisis of addiction?
Harry: So a lot of my… in the book, I really think that part of my argument is that the sources of this crisis are so broad and so deep that we really need to think of it as a call to action across our society in two respects.
First, I think we need to think about this as a community partnership model, and we still have places where we have community. The workplace used to be, but then the pandemic, it’s gotten worse with people, everybody working at home. But the workplace, our schools, our faith communities, our civic communities are still places where we are connected to each other, where we’re seeing people and talking to each other, and we have the ability to check in with each other.
And so teaching people to not only watch for the signs but also to have the skills to identify when people are suffering and to do something about it is really powerful. I think a lot of people just simply aren’t aware unless a kind of a drug problem in a friend or family member smacks them in the face….they miss some of the signs.
We miss warning signs, like people, for example, withdrawing much more. And we miss some of the really subtle indicators. And then we also don’t know what to do about it. Just teaching people to check in with each other and say, “How are you doing? I’m concerned about you,” in a way that’s nonjudgmental, I think that’s partly where the answer lies.
And it’s not to take away from the important role that our mental health professionals and our medical community has — we need them — but I think we really need to rethink these problems as occurring on a continuum. Nobody wakes up one day and says, “Huh. I think I’m going to use fentanyl.” It is a slide. It’s an evolution. And the reality is that all of us on some level are dealing with these fundamental, underlying issues. Not everybody has the same trauma, not everybody has the same brain biochemistry, but we all are dealing, in this crisis for example, with anxiety, with worry about what’s going to happen.
And we’re all dealing with shame, but we’re afraid to talk about those things. We’re certainly not equipping our kids at a young age in schools to talk about them. I don’t think we talk about them in the workplace. Everybody just wants to project an image of being okay. And I think the change that we could make would be to actually really create an openness and start working across every path we have to give people tools and resources to actually get better at being agents of the change that we need to make.
And I think the key is really stripping away the shame and just talking about the way that we’re all dealing with this, and recognizing that it’s okay to ask for help. To me, if we had to make one change, that would be it.
Denver: Well, let me close with that then, and that is the cultural change that has to happen. We’ve seen it around drinking and driving. We’ve seen it around gay marriage. What’s going to have to really change to change our attitudes towards addiction in this country?
Harry: I think the change is happening, by the way. So, I think you can see signs. When Joe Biden, in the presidential debates, talked about his son Hunter Biden and his addiction, and spoke in a way that was recognizing that it took praising him for the effort in making it clear that this was not a moral failing, but this was a health challenge that he was struggling with. I thought that was an important marker. It’s one of the first times we’d seen that in American life. Not the first president, by the way, with a family member with a drug problem. You go back, Betty Ford deserves credit for bringing it out of the closet, so to speak.
So I think things are changing, but I think we need to move further in every setting that we find ourselves, whether it’s in our families, in our social circles, in our workplaces, in our faith communities, in our schools, about having conversations about shame. And I think the key is really stripping away the shame and just talking about the way that we’re all dealing with this, and recognizing that it’s okay to ask for help. To me, if we had to make one change, that would be it.
We still have a lot of work to do in terms of understanding, the nature of addiction. It’s funny… our health system is so advanced on so many health conditions, but we actually haven’t really done the kind of evidence-based work we need to do. And I think there is work to do, but the most… I think the biggest opportunities for change in front of us are just simple steps that every single person can take.
Denver: We’ve never been great as a country at dealing with things that we can’t see, but they’re there– just as real, and we have to address them and talk about them. The title of the book is The United States of Opioids: A Prescription for Liberating a Nation in Pain, a must-read for anyone who wants to understand how we got here and what we need to do now to change it.
I want to thank you so much, Harry, for being here. It was a real pleasure to have you on the program.
Harry: So great to be with you. Thank you for having me.
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