Lauren and Dr. Josiah Rich continue their conversation about the current state of medical education and the opioid epidemic and touch on the history of the crisis, the challenges faced in addressing addiction treatment, and the need for improvements in medical school curriculums. Dr. Rich also highlights the dangers of contaminated illegal drugs, the importance of providing treatment for opioid use disorder, and the need to reduce stigma surrounding addiction.

Lauren Lavin:

Hello, everybody. Welcome to From the Front Row. This week is the second episode in our two-part series talking to Dr. Josiah Rich on the opioid epidemic in the US.

This is the second episode in a two-part episode series on the opioid epidemic. If you haven’t listened to last week’s episode, I highly recommend clicking back and listening to the first episode in this series so you can get all the necessary background on both Dr. Rich and the first part of this conversation. Today we’re going to be talking more about the waves of the opioid epidemic, as well as a little bit more about treatment and stigma around opioid users.

I hope you enjoy the podcast today. If it’s your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health, and how they are relevant to anyone both in and outside the field of public health. Now let’s get back to the show.

You just touched on what my next question would be, what the current state of medical education is. Because if we need providers and doctors to treat individuals with opioid use disorders, how are we preparing doctors to be able to do that? You said we’re getting a D-minus. Then my question is, in return, what kind of improvements or changes would you suggest for medical school curriculums for better education? How would you suggest that they address addiction treatment going forward?

Josiah Rich:

Clinicians and providers are also members of our society, so they have the same exposure to stigma about this disease. We have to reeducate people.

It’s very hard. If you go through your medical training and you’re told that, “Oh, those aren’t the real patients. Those are just bad people. They don’t really care about their health. They don’t deserve our time or our care. They’re really difficult to deal with. They push all our buttons. Do whatever you can to avoid even interacting with those people.” Then you get out into practice, it’s very hard to convince clinicians to say, “Oh, okay. Let me actually change my tune and start treating these people like like.”

We do have a greater opportunity because of the magnitude of this current crisis. Because now, it’s not just those people, it’s my neighbor’s kid. It’s my own kid. Or my own family member. In Rhode Island, we’ve been more heavily hit than most states. It’s hard to find somebody who doesn’t have some personal connection to this.

A lot of the things, political answers that we need, policy changes that we need, funding that we need, I wouldn’t say they’re easy, but they’re less difficult than they had been in the past. I think we should not limit ourselves to public health interventions that we’ve had in the past. I think the public will is changing. For the most part, this has stayed a nonpartisan issue, and I hope that continues because it really is a nonpartisan issue.

Lauren Lavin:

Right.

Josiah Rich:

Blue states, and red states, and purple states have all been hammered. It’s devastating. It’s horrible. The deaths are the tip of the iceberg. The people that are struggling day in and day out are the families, because this doesn’t just affect one person in the family. It really impacts everybody. I think we really need focus.

Now I think I should probably digress a little for a moment. How did we get here?

Lauren Lavin:

Yeah.

Josiah Rich:

It’s pretty simple. We are currently in the fourth wave of this crisis. The first wave was prescriptions. That came about just purely from greed. The Sackler family and the Purdue Pharma just sold it as a bill of goods. They went and did focus groups with doctors and said, “Hey, we have this new prescription medication to treat people with pain. What do you think about it? It’s great. It’ll take care of anybody’s pain for anything.”

Lauren Lavin:

Yeah.

Josiah Rich:

The doctors said, “Are you crazy? We’re not going to do that. People will get addicted.” They said, “Ah, but what if we told you it was not addictive?” They said, “Oh. Well, okay. Then I would do it. Of course.”

Lauren Lavin:

That’s right.

Josiah Rich:

“I don’t want my patients to have pain.” That’s basically what they did. They used our own tools, the profession of medicine’s tools. Publishing papers, coming up with guidelines. Creating a fake pain committee. A real pain committee, but stacking them with a bunch of liars, and then falsified data. They took us to the cleaners.

If we, as clinicians and physicians, had not been so separated from this disease, we would have realized much earlier on that, “Wait a minute. Not every patient I’ve prescribed is getting into trouble, but a lot of them are.” We would have recognized it far sooner. But because we’ve never been trained on addiction, and how to recognize it, and how to treat it, we got taken to the cleaners.

The first phase was these prescriptions. The patients would go to one doctor, and they would get an injury in their knee, and they’d get prescribed a big bottle of pills, and they’d take it. I ask a lot of people with this disease, “Do you remember the first time you took an opiate?” I get a variety of answers. But one of them is like, “Oh, yeah. This makes me feel whole. This is what I’ve been looking for my whole life. This is really different, this is really good.” That person has probably the right genetics, or the wrong genetics, and maybe they’re in the wrong situation. And then they’re off to the races.

They go back to the doctor, “Oh, the knee really hurts. Can I get another prescription?” This goes on and on. Finally, the doctor says, “No, you’re done,” and then shuts them off. Then they go to another doctor, and they repeat that. Then eventually, they start buying them from their friends.

If you looked in medicine cabinets, people get prescribed these huge bottles of pills. They’d take one, and then the pain goes away, so they leave it. They’ve already paid the copay, so they don’t want to throw that away. The medicine cabinets throughout the country were, and maybe to some extent still are, filled with opioids. That was the pill phase.

Then eventually, people got shut off, the doctors wised up. Then somebody said, “Hey, you know if you’d use heroin, it’s a lot cheaper. You could just snort a little bit of that.” It turns out, in fact not only can you snort it, but you can feel high, which you weren’t feeling as your tolerance had gone up so high. Then you start heroin and, “Oh, that’s great. I’m paying a lot less, it’s a lot cheaper.” But then, pretty soon your tolerance goes up, and then you’re snorting more and more. And then you’re paying just as much, eventually. Then somebody says, “Hey, instead of snorting that, if you inject it, you’re going to use just a little bit and you’re going to feel much better.”

Then they start over again. They start injecting. As soon as you start injecting, the risks of bloodborne pathogens, and infections, and HIV, and Hepatitis B and C, and local infections, and abscesses goes right up. And endocarditis. The risks, it becomes more dangerous. And your addiction accelerates too, because you’re turning on all those receptors, you want it some more. You’re increasing, and you just get deeper, and deeper, and deeper in.

Literally, millions of people transitioned to heroin, and really started to tap out the production market. Because heroin, it’s semisynthetic. You have to grow poppy plants on a hillside in some foreign on some faraway land, and then load it onto the burro, and bring it down to the place where it gets processed. And then, sneak it into Rhode Island. Well then, the fully synthetics came in and fentanyl. If I needed to sneak a cooler, two or three cubic feet of heroin into Rhode Island, I would have to figure out how to do that. A comparable amount of fentanyl would fit inside a cigarette pack.

Lauren Lavin:

Wow.

Josiah Rich:

It’s a far more easy to transport, far more powerful. And far less expensive to manufacture because you just need some chemicals and a half-witted chemist, and you get the reagents, and you’re in business.

Reuters just published, about a week ago, a study where they … Not a study. They ordered the reagents to make fentanyl online, and delivered both to North America and to Mexico. For $3000, they had $1 million of fentanyl that they could manufacture.

Lauren Lavin:

Oh my gosh.

Josiah Rich:

They could have created and sold. That’s where we’re at now. It’s out there, it’s easy enough to do.

The first wave was pills, the second wave was heroin, the third wave was fentanyl. Now, as fentanyl tore across the country, it really caused a lot of problems and a lot of deaths. It really started more on the East Coast and made it to the West Coast. Unfortunately, it made it to Oregon right as Oregon was doing what we really need to do, which was stop punishing people for being addicted. They decriminalized drugs. Just as they did that, fentanyl came through and a lot of people got much worse. There was a lot of overdose and a lot of deaths.

Of course, everybody blamed it on the decriminalized drug possession, which is unfortunate because it had nothing to do with that. A recent study, a pre-print study, it’s about to come out I think next month, documents this very clearly. But of course, the damage is already done.

Lauren Lavin:

Yeah.

Josiah Rich:

The press has been out there saying, “Decriminalize drugs and looks what’s going to happen. There’s going to be people overdosing on the streets.” Well, there’s people overdosing on the streets because of fentanyl.

But now, at this current phase, this fourth phase, is polysubstance. People are using some stimulants, cocaine and methamphetamine, and using some fentanyl. And using some other things, pills. So it’s people using all kinds of different things mixed together. It’s a very challenging time in a lot of ways. But the key thing is that the drug supply itself, the illegal drug supply is more contaminated, more dangerous than it’s ever been. And has lot of very dangerous substances in it. That’s what you get when you have an unregulated drug market.

Lauren Lavin:

Yeah.

Josiah Rich:

Clearly, the solution is not to just double-down on law enforcement because we’ve tried that and it’s just backfired completely. It makes our world less safe, not more safe. More people in prison and jails means more people coming out of prison and jails who haven’t gotten the treatment they need. If we get people treated, they’re going to be good for however long they need to be good. If we lock them up, they’re just held their temporarily. 98% of people who are incarcerated get out. They’re all coming back to us. Do we want them coming back damaged and just as addicted as before? Or do we want them come back in treatment, and be productive, and be welcomed back into society?

Okay, I’m talking way too long.

Lauren Lavin:

That was really great. I just have one follow-up. When you talk about contaminated illegal drugs, can you just clarify what that means? Is there any way for that to be stopped, if that’s the big problem that we’re seeing today? Is that what is causing deaths?

Josiah Rich:

Absolutely. We have a regulated market in our supermarkets. We can buy a can of beans and we know it’s got beans in it. We have some confidence that it doesn’t have botulism in it, that it doesn’t have too much sodium. In fact, we can look and see what the contents are. That’s a regulated market. There’s regulatory agencies that tell us you can only put beans in it, you can’t put bird poop in there.

One of the big problems lately is with this polysubstance use, and the transition of fentanyl, and the proliferation of fentanyl which is so cheap, is that fentanyl is getting into other drugs. People buy cocaine, they think it’s cocaine. It’s a powder. Fentanyl comes as a powder as well. The cocaine contaminated with fentanyl. If their tolerance builds up, and up, and up, they can tolerate a lot of fentanyl. But somebody who’s using stimulants has zero tolerance for opioids. They use cocaine, which somehow either accidentally or even deliberately, has some fentanyl in it, a little bit of fentanyl is enough to kill somebody if they’re not used to taking it.

We are seeing an increase in stimulant-related deaths which are contaminated with fentanyl. When we look at the people that die, we find that quite a number of them that, to the best we can determine, they did not have opioid use disorder. They were not using opioids. They didn’t get into treatment for opioids. They didn’t get arrested with opioids. They didn’t get hospitalized, they didn’t have tox screens that showed opioids. They were using stimulants, and then they got into a fentanyl, and then died. That’s tragic. We can’t treat that. Opioid use disorder treatment is not going to help that problem.

Lauren Lavin:

Yeah.

Josiah Rich:

We can try and educate people who are using stimulants, and we need to do that, that they should check their supply. There actually are fentanyl test strips people can give out in the needle exchange program and other harm reduction programs. Check your stuff before you use it. This little test strip, you put a little drop on it, and it’ll light up just like a pregnancy test whether it’s got fentanyl in it or not. That can be helpful to protect people.

The treatment I mentioned that most clinicians and physicians aren’t educated about this disease, including the treatment. In fact, about 80 or 90 percent of people with opioid use disorder who would benefit, who would have their risk of overdose dropped by 50% immediately if they got onto treatment, are not even offered treatment, don’t get onto treatment. Imagine if 80% of the diabetics in the country just didn’t get insulin.

Lauren Lavin:

Hard.

Josiah Rich:

Imagine if 80% of the people with heart disease didn’t get any medicine for that, or cardiac catheter, or stents, or operations. That is a huge problem. That’s a workforce issue.

Lauren Lavin:

Right.

Josiah Rich:

But it’s not just on the medical side. It’s also on the public health, the public education side.

Lauren Lavin:

Exactly.

Josiah Rich:

What people need to know about this disease is that it’s treatable, that we have effective treatments. They’re not perfect. But we have them and we should use them as much as we possibly can. It’s not like you take this treatment, and you can be on it for a week, or a month, or even a year, and then you’re done. Most people need to be on it for longterm. Most people, by the time they present, they didn’t just develop this disease overnight. They’ve had it for a while. But even if they hadn’t, it still takes a while to change what’s going on in there.

Some people need to stay on these medicines for their life. Other people can taper off them and get into recovery. The Substance Abuse and Mental Health Services Administration, SAMHSA, a Federal agency dealing with substance use, they define recovery as working on four things. The first is your health, your physical health and your mental health, in a holistic way. The second is working on your home, making sure that it’s a place where you feel safe, where you feel loved, and where you support the people there and they support you. The third is your community because we all need community, everybody else that’s in your life. The fourth is your purpose. If you’re working on those four things, your health, your home, your community, and your purpose, that’s recovery.

Notice I didn’t mention methadone, or buprenorphine, or naltrexone. That’s not the goal, is to be on the medications. But those medications, they take that monster off your back. They allow you to work on your recovery. Some people work on their recovery, build up what they call recovery capital. Recovery capital is like capital, like money in the bank. It’s the support systems that you need. If you have a steady job that you go to every day that gives you structure in your life, that’s recovery. That’s part of recovery capital. If you have supportive people in your life that you can talk to and feel comfortable with, that’s recovery. Recovery capital. A lot of recovery capital got just washed away with COVID and people fell down, they relapsed. Recovery is what we need.

Now to get people into recovery, the medications are extremely helpful and should be used. People need to be not only helped to get on the medication, educated that they can get on it, and educated that their physician can prescribe it. But also, the general public needs to be educated that people need to stay on these medications for a long time. I can’t tell you how many people I’ve seen at the Department of Corrections, they come in intake, and I see them. I say, “What happened?”

“Well, Doc, I was all strung out, and I got onto methadone, or I got onto buprenorphine, suboxone, and I was doing great. My family and my wife, and everybody said you don’t need that stuff anymore, you’re good. You’re back to normal. You’re good. Just get off of that stuff.” They got off it and, “I don’t know what happened, but I’m back here, locked up again. I got a sentence of 18 months, and I lost my truck, and I lost my job. I lost my house, I lost my kids, lost my wife. I don’t know what happened.” No. No. If it’s working, stay on it, and then gradually, slowly taper off.

Lauren Lavin:

Taper off.

Josiah Rich:

If you can. If you can’t, that’s okay. People need the support of their family and their community. This is such a stigmatized disease that, if you tell your landlord you have it, you’re going to get kicked out. If you tell your employer, you’re going to get fired. If you tell your family, you’re going to be ostracized.

Lauren Lavin:

Yeah.

Josiah Rich:

You can’t tell anybody. You can’t even tell anybody that you used to have this 10 years ago. That stigma, it comes back to as a fundamental problem.

Lauren Lavin:

I think as we wrap this up, that’s something that we kept coming back to in this conversation is the stigma is a problem that needs to be remedied as we go forward. I don’t know how we do that, except for conversations like these, I think helps bring awareness to it. A lot of the stuff that you said today made me realize, one, how common this is. You talk about how many deaths there’s been. You just humanized it in a way that made it seem like it’s something that could happen to just regular people and you get trapped in it. It’s also something that’s very treatable with lots of effort, and medications, and with the help of practitioners.

I think that conversations like this is just one of the steps to reducing that stigma. Then education, that’s how I found you. The article I was talking about, how medical schools need to incorporate addiction treatment into their curriculums. That kind of thing too, would be beneficial for reducing the stigma.

Are there any other thoughts that you have on how we can reduce the stigma going forward, to wrap this up?

Josiah Rich:

Well, this is a very complicated problem.

Lauren Lavin:

Yeah.

Josiah Rich:

For every complicated problem, there is always a single, elegant, inexpensive and completely ineffective solution. That’s what people want, but it isn’t the case.

Lauren Lavin:

No.

Josiah Rich:

I, unfortunately, lost my nephew to an overdose about a decade ago. At that point, really changed my focus to focus more on opioids, and distill incarceration, distill the other aspects of this endemic, but hoping that I could make some difference in this. To this day, the more layers of this onion I peel away, the more complicated it is.

But clearly, the stigma is fundamental. The treatment is such a no-brainer, we just need to get that treatment out there yesterday, as soon as possible. There used to be this rallying cry, “Treatment on demand.” People with addiction would want treatment on demand. Absolutely not. We should not have anybody have to demand treatment for this. Somebody wants treatment for this disease, we should be thanking them. We should be welcoming them with open arms, and showing them love, and respect, and support. Instead, they’re begging for treatment on demand. They’re begging to be treated humanely.

Another word about the stigma is people are stigmatized, they’re oppressed. That’s part of humankind. People have always been oppressed to some degree or another, and people can fight against that. The worst stigma is the internalized stigma. People have been told their whole life, and treated their whole life, as if they don’t matter. They’re disposable, they’re not worthy. When I finally can get somebody to the point, “Well, you’re a person and you deserve to have happiness like anyone else. You deserve to have a good life. You deserve to have good relationships. You deserve that.” They can’t believe it, they don’t believe it. It’s really hard to get beyond that. It’s like, “I’m just worthless, so what does it matter? I’ll just go use. I’ll just feel better for the moment.” If they don’t feel so worthless, then they can actually live and be alive.

I think that’s the worst part of the stigma. It’s not so much the oppression, which is unacceptable. But it’s a lot of unacceptable things in this world.

Lauren Lavin:

Yeah.

Josiah Rich:

But it’s the internalized stuff. Thank you so much for covering this.

Lauren Lavin:

Well, thank you so for taking time out of your day.

Josiah Rich:

Thank you so much.

Lauren Lavin:

That’s it for our episode this week. Thank you to Dr. Rich for joining us for this two-part series on the opioid epidemic.

This episode was hosted and written by Lauren Lavin, and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health.