A win in the opioid crisis

0:00The U.S. has been dealing with an opioid epidemic for a generation. It's been bad. Hundreds of thousands of deaths in America. And then it got even worse during COVID. Last year, you might recall, Sean talked to a Wall Street Journal reporter who had started carrying Narcan in her purse, just in case. It's very small. You can fit it anywhere. I have two doses of it in my purse. I carry all the time. I hope I never have to use them. But, you know, it's pretty easy to carry around. So this is how grim it had gotten. Ordinary people preparing themselves to intervene in case of an OD. But then, over the past year, something unexpected and very, very good happened.

0:45Overdose deaths started dropping fast. What on earth happened is ahead on Today Explained. We'll see you next time.

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1:36This is Today Explained. My name is Lev Fascher and I am a reporter at STAT covering substance use and the U.S. overdose crisis. Lev, the CDC released some data recently that has a lot of people feeling very optimistic. What does this data say? Essentially that drug overdoses are declining and they're declining quickly. As of mid-2023, the running 12-month death count was about 111 ,000, more than 110 ,000 people dying in every 12-month period from drug overdoses. And now that number has dropped into the mid or even low 90 ,000 range. So obviously that's nothing to brag about. That is still a horrific level of death.

2:25This is still a gigantic public health emergency, but fewer deaths is good. Okay, so what's been going on that's brought the numbers down? Well, that's the thing. It's kind of a mystery. There's no one event that happened about a year and a half ago that would explain this sudden significant decrease in drug overdose deaths. So while there's a lot of optimism in the harm reduction and addiction medicine and recovery world, it's cautious optimism because people don't really know what's happening. And some of the explanations would be good news. And counterintuitively, some of the explanations for reduced deaths might actually not be good news at all.

3:05I would say there are three main theories for why deaths might be decreasing. The first theory is just that the types of drugs that Americans are buying on the street, that people who use drugs are consuming, are less toxic than they used to be. Now, there's not amazing data to support this idea. But as most Americans know, over the course of the last five or 10 years, fentanyl became incredibly prominent. Dealers started to lace fentanyl into the drugs they were already selling, like heroin, meth, cocaine and counterfeit pills that look just like the real thing. They found rainbow fentanyl in 21 states.

3:48Milgram says it's a marketing ploy by the cartels. Fentanyl overdoses are now leading cause of death for Americans aged 18 to 49. That's according to a new analysis by The Washington Post. So one plausible theory is that fentanyl concentrations are lower. The fentanyl analogs, the specific chemical compounds in drugs, are less likely to cause overdose. But again, it's just a theory at this point.

4:18A second explanation is just that drug use behavior is getting safer, which is to say that people are using drugs more slowly maybe. There's been a shift from injecting fentanyl to smoking fentanyl. There's also been an increase in the availability of certain harm reduction services like test strips that people use to detect the presence of fentanyl or xylazine. So people doing party drugs, people doing counterfeit pills that they bought on the internet, they can actually test whatever they're using before they use it. So you don't have people unknowingly using fentanyl and dying of overdoses that way.

5:03But then the third explanation is probably the most bleak. It's a concept called the depletion of susceptibles. And that's just to say that so many people have already died of drug overdoses that there aren't as many drug users left to die. And, you know, that's not necessarily a mainstream theory. And even if it were accepted, it probably wouldn't explain the full significant sudden decrease in drug deaths. But when you think about it, when you have hundreds and hundreds of thousands of people dying of drug overdoses over the course of a pretty short span, it does make sense in some way that the population of people left to die is smaller.

5:49And that's just kind of the bleak reality we're facing. That's how bad this crisis is. The opioid crisis has gone on for a generation and Americans have come to expect our presidents to address it. Joe Biden is the outgoing president. Donald Trump is the incoming president. Donald Trump notably has served before. Did one of these two men approach this crisis better, according to experts? Yeah, of course, depends who you ask. Both presidents approached the crisis the way you would expect, given their respective parties' historic view of drug addiction and how to best combat that issue. Trump took a much more supply side approach, which is to say he focused more.

6:35He talked more about law enforcement, about drugs being smuggled in illegally via the southern border or even via the mail. Fentanyl, heroin, meth and other lethal drugs are pouring across our wide open border. The U.S. Postal Service and the Department of Homeland Security are strengthening the inspection of packages coming into our country to hold back the flood of cheap and deadly fentanyl. Unless you have the death penalty for drug dealers, you'll never get rid of the drug problem. Put that through your head, OK? Put that through your head. Biden, on the other hand, took a much more demand-side approach.

7:11We made real progress together. We passed the law on making it easy for doctors to prescribe effective treatments for opioid addiction. He focused more on treatment and even on harm reduction and was supportive of, or at the very least, not opposed to some tactics that are pretty effective, but have historically been controversial, like syringe exchange or even supervised drug consumption. Then under Biden specifically, the Biden White House was historically supportive of harm reduction interventions like syringe exchange. And they even kind of turned a blind eye to a pair of supervised consumption sites that are currently operating in Manhattan.

7:53And there's been a lot of cultural change too that happened during the past four years, though not necessarily because of the Biden White House, but a lot of cultural change toward making drug use safer. One example I would give is an organization called Never Use Alone. The concept is essentially that people overdose and die most often when they use by themselves because there's no one there to call 911. There's no one there to administer naloxone. So this is just a hotline for people who want to use mostly opioids to call and someone will sit with them on the phone as they use. And if they stop responding over the phone, that person who's listening in will call 911.

8:35So there's been a big cultural shift that I think some people credit, at least to an extent, with having helped reduce overdose deaths.

8:49But with every new administration, there's another opportunity to do it right or better. Yeah, absolutely. And President Trump has continued to talk about the opioid crisis, though, again, mostly from the perspective of illegally smuggled, imported fentanyl. But he has, I think, two very interesting figures playing prominent roles in his administration. who have talked about this issue quite a lot. One is J.D. Vance, the incoming vice president. It was definitely something I saw growing up. And I remember when, you know, addiction hit our family and I found out that mom was addicted to prescription pain pills, as we called them back then.

9:28I just didn't understand it, right? I didn't understand why anybody would be. I would actually say even more interesting is Robert F. Kennedy Jr., his nominee to serve as health secretary, also in long-term recovery and with some very, very fascinating ideas about how to combat the addiction crisis. Our country, you know, has a form of kind of chronic inflammation, spiritually, mentally, emotionally. We need to start healing ourselves. Lev Fasher of Stat News. Coming up, how do you build on this very, very real progress? Donald Trump's administration is going to get four more years to try.

10:34This is Today Explained. I'm Noelle King back with Lev Fasher. He's a reporter at Stat News who covers America's addiction crisis. He's been doing so since 2016 when one Donald J. Trump was elected president. Lev, how bad were things when Trump came into the office the first time? They were bad. The number of people killed each year in the United States from opioid overdoses is at an all-time high. Commonly abused opioids include prescription painkillers such as Vicodin, Percocet, and OxyContin. Everyone knew about how pervasive prescription painkillers had become and how in many cases those addictions led people to use illicit drugs like heroin.

11:22But they weren't nearly as bad as they are today. We had something in the range of 40 ,000, 50 ,000 people dying of overdoses every year, and now it's roughly double that. So hard as it was to imagine in 2016, things were about to get way, way worse. A deadly batch of drugs is making its way onto Chicago Street, sending more than a dozen people to the hospital in just one day. Near Route 140 and Route 97 in Westminster, a person was found unconscious after falling victim to a drug overdose. Between 10 a.m. and noon, six more would follow. According to the CDC, in 2017, there were more than 28 ,000 deaths involving synthetic opioids in the United States.

12:02which is more deaths than from any other type of opioid. The opioid epidemic. You remember that this was one of the glaring problems in pre-pandemic America. Well, it got much worse during COVID. The drug epidemic affects many families here in West Virginia, but overdose numbers especially soared in the month of May. There was a 55 percent increase in EMS responses to drug overdoses from May 29th. How did Donald Trump respond to the crisis during his first term? One of the first things Trump did was to impanel a bipartisan commission of elected leaders and subject matter experts to get to the bottom of what was happening and kind of chart a path forward.

12:45We need help from the federal government in stopping drugs like fentanyl and others from coming into our country and fighting the drug kingpins and the traffickers. But at the addiction level, we need treatment and prevention. So he had Chris Christie, the governor of New Jersey, and Roy Cooper, the governor of North Carolina. He had Bertha Madras, a Harvard expert, and Patrick Kennedy, the former congressman, RFK's cousin. This is personal for me as it is for everyone else. I also grew up in a family where addiction and alcoholism was rampant. And like today, it was something we never talked about.

13:23And they put together this document of, I believe it was over 50 recommendations for specific policies that the U.S. should implement. And this was actually really a well-received document that talked about, sure, a lot of supply-side interventions and preventing drugs from coming into the country in the first place, but also some more active prevention measures in terms of helping people not become addicted and getting them help, access to treatment, and to an extent even harm reduction services once they were using. We have been fighting this problem, and we have realized that we cannot arrest our way out of this problem, particularly at the user addiction level.

14:08The problem is that very few of these recommendations were fully implemented. Congress did pass a bill in 2018 that put some resources toward this crisis. But again, advocates would tell you that it was nowhere near what it needed to be if Washington was serious about keeping people alive. Did the Trump administration support any new treatment options, anything that previous administrations hadn't endorsed? The Trump administration was nominally supportive of medications used to treat opioid addiction, specifically methadone and buprenorphine. But it didn't do that much to expand access. And there was even an incident where Tom Price, who was Trump's first health secretary, spoke about those medications in a very derisive way and caused a whole uproar that the health secretary wasn't following the evidence in terms of what works treating opioid addiction.

15:04But no, nominally, they were supportive of access to many forms of evidence-based treatment. That's not the same thing, though, as facilitating some gigantic expansion in access. All right. So now Donald Trump gets a chance to do it all again. Have we seen him float any new proposals for combating the opioid epidemic? Him? No. But Robert F. Kennedy Jr., his incoming health secretary, yeah, absolutely. He has a lot of very interesting ideas for how to beat this crisis. And worth noting that he himself is in long-term recovery from addiction to heroin, also to alcohol. And he is a really frequent attendee of 12-step meetings, specifically Alcoholics Anonymous.

15:47I'm very active in recovery. I go to probably nine meetings a week. He is certainly a 12-step proponent, and it's going to be interesting to see how that factors into public policy. All right. So what is RFK saying? Well, his signature proposal is for a national network of wellness farms, I guess they're called, where people could go and spend time outdoors working with their hands, working with animals, etc. And there's some evidence to suggest that this could be effective, though I think there's a lot of skepticism that you could implement this at scale, given the scope of the opioid crisis.

16:29And you also wouldn't want to do it at the expense of approaches that are known to be effective from a medical perspective, like those medications I mentioned, methadone and buprenorphine. But that does seem to be RFK's big idea, these wellness farms that he has said he'd like to fund via a tax on legalized marijuana, fascinatingly. I would decriminalize marijuana. I will make safe banking laws for people who are selling it, but I will tax it federally and I will use that money to build these healing centers. He actually filmed a documentary about addiction. The documentary is called Recovering America.

17:08Talk about what a typical day is for people who have chores to do. They get up at 6.30 a.m. They have a morning meditation first thing in the morning. After that, they will do their morning chores. He has actually really endorsed the approach that Amsterdam in the Netherlands took to its drug crisis a couple decades ago, which is super fascinating because, yeah, there was an element of police involvement. There was kind of a carrot and a stick. There were consequences for people who didn't comply with Amsterdam's approach. But also the Netherlands does a lot of stuff that is seen as politically radical in the U.S.

17:47They offer supervised consumption, which is illegal under federal law. They also prescribe prescription heroin to people who are not in a position to immediately stop using. So RFK hasn't endorsed those policies specifically, but he's endorsed the Amsterdam approach writ large. And that's fascinating that he does seem to be open-minded about these various types of harm reduction interventions along with certainly having a greater police involvement. It's worth noting RFK's own recovery began after he was arrested for heroin possession in the 80s. So there does seem to be a belief that people need to hit bottom, so to speak, before they can begin their recovery.

18:32So I was arrested, which is the best thing that could have happened to me because I could have never gone into a 12-step meeting. It was just not even a place that I would consider going. But now I got busted. Everybody knew. So now I could start going to 12-step meetings. He just wants the floor, he's said, to be higher than it currently is. He doesn't want to see as many people homeless and destitute. He wants them to, I guess, hit bottom sooner so their recovery can start faster. The Trump administration has at least one other player this time around who was not there last time, and that is J.D.

19:11Vance. J.D. Vance is from Middletown, Ohio. Ohio was hit very hard, as you know, by the opioid crisis. And Vance has said he has loved ones who are opioid addicts. What have you heard from Vance over the years, and what influence do you think he might have? Yeah, Vance talks a lot about the opioid crisis, you know, in his book, on the campaign trail. He talks about his own mother's experience with addiction. And I think she is now in long-term recovery and doing very well. Our movement is about single moms like mine who struggled with money and addiction but never gave up. And I'm proud to say that tonight my mom is here, 10 years clean and sober.

19:52I love you, mom. He has also made this a signature issue. I want more of you and more of the families here in Philadelphia to get that second chance with a loved one. I want them to have another opportunity to get back on that horse and get clean. I haven't heard as many concrete policy proposals. And in fact, he had an addiction-focused nonprofit that shut down not long after being launched and was criticized for really not doing much. So it's certainly something he talks about a lot. But whether it's going to be high on his policy portfolio, I'm not sure. Do you think in light of the progress that was somehow made in the last 18 months or so, that Donald Trump and J.D.

20:44Vance and this new administration have a chance of winning the war on opioid overdoses in America? Do I think that there is a chance that over the course of the next four years, drug overdoses are going to really, really sharply drop? Yeah, absolutely. Maybe that will be a credit to them and the policies they implement. I think more likely it would be a continuation of the trend that we're currently seeing. But yeah, the good news here is everyone cares about this. Every American wants fewer of their neighbors, actually zero of their neighbors, to die of drug overdoses. And it seems like we're trending in that direction, even though, of course, death rates are still horrifically high.

21:26There are more than 90 ,000 people still dying every year of drug overdoses. But if we can sustain this momentum and if we can make progress, you know, getting the drug supply to be less toxic, getting people access to better treatment, better harm reduction. Yeah, I really do think in the next four years, there's a chance that we could find ourselves in a much better place.

22:14includes Rob Byers, Andrea Kristen's daughter, Hadi Muagdi, Victoria Chamberlain, Amanda Llewellyn, Avishai Artsy, Miles Bryan, and Peter Balanon-Rosen. Matthew Collette is a supervising editor. Miranda Kennedy is our executive producer. Sean Ramos-Firm needs a clip for the internet. We use music by Breakmaster Cylinder. Today Explained is distributed by WNYC. The show is a part of Vox. If you care to support our journalism by joining our membership program, you can do so today by going to vox.com slash members to sign up. Our archives are always free and always open to the public. We welcome your five-star reviews and your inside jokes.

22:48I'm Noelle King. It's Today Explained.

23:14Thank you.