tv Fentanyls Role in the Opioid Epidemic CSPAN September 23, 2019 8:32am-9:11am EDT
will be quite low and your access to apartments because of his right as gore, not because your payment history, that because of your job prospect or not how much money your bringing in, it's your credit score. >> the issue i would like to see discussed more in washington, d.c. is the importance of bipartisanship. we as americans have more in common than we probably have disagreements on. i would like to see us talk much importance of reaching across the aisle and this point we don't disagree, fine, grant goes on when we can move the nation forward is to work together. >> voices from the campaign trail, part of c-span's battleground states tour. >> with the rise of synthetic opioid in valdez, drug policy experts talk about the trend in ways to lower the number of deaths. they spoke adding that hosted by the rand corporation.
>> thank you. the yes my name is priced in the near with ball and i like to acknowledge to make additional co-authors, doctor reuter and -- both collaborated very much on several parts of this very comprehensive report. in addition to that we would like to acknowledge the fact we dedicated this work to mark the just passed away this year. one of the major mentors and drug policy shaped a lot of our dispatch into thinking innovatively about challenges when it comes to drugs and drug policy. that said, that no, yes, it is right now the driving force behind overdosed desk in the united states. today just to keep it brief take respect the work we've been doing in the last year looking at fentanyl, the main key points just from the ship or come to an page is basically nature and magnitude of the ongoing overdosed crisis brought on by synthetic opioids is really unlike a traditional drug epidemic and his more so or
better thought of as a poisoning outbreak. that said, if we just limit our policy responses to the traditional approaches, these are likely to be sufficient. to make points. this is new. unprecedented in our drug policy history and we need to think innovatively when it comes to responding to it. just keep that in mind. the road map for this, on 20 speaking to what presley is going on, fentanyl footprint in the united states, what is a company who's been impacted and what factors contribute to this crisis. it is not new. it's been around for a while and then put to trip over to blow the would-be talk about some of the possible futures of how this might unfold given what you're seeing in other countries, given the history of fentanyl, given what we know about drugs and drug markets and then he will wrap up with some ideas about what the federal government can do to respond to this.
so rand has been working diligently the last several years on opioids is been if you know. we've been putting together reports on opioid and opiate policy request to relaunch his new edition called opioids uncharted am trying to understand the ecosystem of opioids. again this not something that is i slid to a social problems or social policy. touch on healthcare, colonel justice, international affairs, trade and we are kindly to the whole dynamics around opioid policy. this book, the future fentanyl come , is the first major initiative from this project, the first cut of confidence in the analysis of we are aware of. again we look at prior fentanyl outbreaks in the trend, where else in the world is dental impacting drug markets and then thinking about what this means going forward in the future. this is the motivator have you what is with the overdosed crisis getting worse every year. the difference though is in many of you know the prescription
opioids drove all all of the overdoses, the first way. it's been spoken of at aaa phenomena. the first big prescription opioids in the changed about injured to go as we to see heroin overdose deaths increased article about 2011 or so. that was brought on in part by some policies aimed at trying to reduce access to prescription opioids, oxycontin, those types of things. may contribute to rising heroin use. then in the last six years we start to see this shift and overdose death and drug seizures involving synthetic opioids, predominantly fentanyl. that exponential rise and that is what's driving today's problem. it is an unprecedented just jump in overdoses. you can see now that synthetic the oak overdoses outnumber heroin overdoses 221. it's been it's been an unprecedented jump in the numbers, and it's come we've never seen something like this before. welcome what is that no?
a lot of people had never heard of fentanyl before the listing is. we took a poll of scholars, , dg use and just about fentanyl, very few probably would've heard of fentanyl. it's been around six years. its use everyday, hospitals across the country as an anesthetic, a successful use clinical settings. it was reappointed to treat end-of-life pain in patches and it works for end-of-life pain can it works or anesthetics. but that said what we're seeing today is not a problem of diverted fentanyl. what we're seeing is a form of endlessly imported powders principal from china, traffic from mexico that are writing to drug markets in the united states and basically poisoning users. that's the key take away, it's not a different problem. it's essentially illicit imports. as i mentioned we've had several private outbreaks of fentanyl in the united states, going back to his early as 1979, the first the first one we could document. there's a lot of difference between what happened before and what is happening now.
the first aspect, different in terms of location where these things happen in private outbreaks many of these were current localized to an urban market, to one or two different cities, chicago, detroit, a couple places in california. that's not the case today. there's geographic variation. this problem is not isolated to a single city or a single market. these are spreading across entire state. the duration, in private outbreaks, private outbreaks were much shorter. only one lasted longer than two years. today we're going on six used and that doesn't appear to be ended in sight. shorter duration, more localization. the cables -- the chemicals involved are different private outbreaks tradition of fentanyl with a smattering of and looks here and there. that's not the case today. fentanyl still dominates these numbers but we're seeing many more analogs including very highly potent analogs like carfentanil. carfentanil is actually potent,
designed as an elephant tranquilizer and is now showing up in drug markets in some places like ohio was hit very hard by carfentanil. that wasn't the case in prior outbreaks it basically fentanyl, a few other analogs but today it's just a hodgepodge of chemicals. the source were different as well. with the exception of one, those are all domestic productions. there was a lab somewhere in the united states that was eventually identified, discovered and ship them not the case today. it's pretty much all imported from labs in chandigarh there's also mexican drug cartel importing the precursor from china and smuggling them across the border. and then distribution is also difficult if you look at who is distributed that no, in private outbreaks it was fairly limited. these chemists could make fentanyl but they often didn't have the wherewithal to distribute it into illicit markets. that's not the case today.
basically any individual can easily obtain a substantial amount of fentanyl online just from the comfort of his or her own basement and never have to leave his home, never had to come into contact with illicit operators or criminal drug trafficking organization. you can import the product and distribute it downstream, especially in cases where oprah just isn't in the period this is something that's a new challenge for law enforcement. the distribution matters as well. even if an individual at the wherewithal to synthesize the stuff it was limited in scope because he may be did not have the wherewithal to distribute it downstream. so as i said, the problem is bad. deaths are way up, but it's still concentrator this is not an actual problems yet. if you look at, and i should note this state in great genetic good death reporting so we drop them from this analysis.
the problem here you can see is still concert in places like appalachia, , new england to the upper midwest. it's not out west yet. there are early indications from san francisco, there is some data from phoenix so there's early indications it's starting to infiltrate at west but it's not yet entrenched so the policy considerations are twofold. how do we address errors or help areas that are swamped in fentanyl? at the same time how do we prevent fentanyl from becoming entrenched in major illicit opiate markets like san francisco, seattle, portland which have major heroin markets? this problem could get worse before it gets better. just thinking about how many unexposed untapped markets there are. the key take away is today's overdosed crisis is different from your prior overdosed crisis. this is driven by suppliers were embracing fentanyl. fentanyl is much cheaper than heroin per dose, much cheaper.
users are trying to take steps to avoid come into contact with the no. that may change over time as we see in some markets. fentanyl has completely displace heroin in places like new hampshire. so over time users may become accustomed to fentanyl and seeking it out but initially they're trying to avoid it. this is different. it's the supplies for making the decision to move to fentanyl, not users. and with that i will turn it over to beau to talk about some of these futures. >> as bryce explained we have insights for why this problem has et excessively over the pat five or six years. indie book we spent a lot of time looking at how these problems had he felt in countries. we spent a lot of time trying to help the reader understand just how cheap this is. it's hard to get good information about retail prices but if we look at import prices and we make adjustments for potency, the price of your week is at least 100 times more expensive than it is for fentanyl. that's a conservative estimate.
you can understand why supplies can white so attractive for them to get access to fit know and use that to cut the drug so they can increase their profits. ace on these factors were identified families four different scenarios for what we think the future fentanyl and synthetic or goods can look in the united states. the first will be, we've had a series of outbreaks in the united states in the past that didn't necessarily last and there's also a small outbreak in your. in theory this action is a possibility. a second option is we almost continue with the status quo or synthetic opioids are largely mixed with heroin or there used to make counterfeit pills, counterfeit oxycodone or used to make counterfeit xanax. one of issues here though is whether or not the fentanyl or the other synthetics could get mixed in to stimulants, that being cocaine and methamphetamine. some of you may be asking why
would suppliers be mixing fentanyl in into these stimulants and potentially killing opioid naïve client? that's a good question. we are seeing this in some places. in fact, there's an analysis look at all of the retail level cocaine seizures in ohio. this was in 2017. of all those seizures at least 12% of them had at least some trace of fentanyl. it's not entirely clear whether or not this was an inadvertent mixing or intentional but this is something we have to pay attention to. a third scenario is the synthetic opioids could largely replace headwind. as bryce mention that only beginning to see in new hampshire, you can buy a quote-unquote bag of heroin but oftentimes there shall heroin in that bag. it's going to be fentanyl and other powders. in estonia when they made the move from heroin to fentanyl in 2002, they ended up never going back. it's really the only mature
fentanyl market we have in the world and if some of the highest opioid overdose death rates in all of europe. a final option is coexisting harewood that goes in markets. we saw this in sweden of the bit where they had a nasal spray for fentanyl but the folks that were using that were not necessary the individuals that were using heroin. the way to think about this is we have these different scenarios and it logically depend on a number of factors. are the people are using heroin, are they going to prefer fentanyl? what's going to happen to the retail prices? policy can shape what ends up how this plays out. but looking at this and looking how things are beginning to potentially spread west of the mississippi, as bryce said come in terms of where nattering more about no in san francisco, or seizures in seattle. it really seems like this problem is probably going to get
worse before it gets better. we think of all the scenarios, slash and receive is most likely. what can the federal government to? three different areas. first of all the places that are swamped with fentanyl we have to consider new approaches for reducing exposure. number two, we need to get creative about disrupting supply and three, we need to improve monitoring and surveillance. this isn't a traditional drug epidemics we can't treat it like one. in the report we don't make specific policy recommendations or we don't do a formal cost-benefit analysis because we think the tradoc associate with some of these policies are going to differ depending on what jurisdiction talk about and what resources they have. we tried to make it clear that just providing access to narcan or naloxone, this is not going to solve the problem. when you do think critically about getting folks out of the markets and reducing the exposure to these synthetic opioids. so it offer a number of examples of this outside the box
thinking. i think there are now seven countries where they actually will prescribe pharmaceutical grade heroin to people who tried methadone, tried other treatments multiple times but are still using heroin. there then randomized controlled trials of this. the results are very good in terms of it reducing the consumption of street-based heroin. also there's suggestive evidence they can reduce crime and potentially improve health outcomes. at the federal level this is something we can only system randomized trials. even though hate it when is one drug, we can to clinical research on this. imagining some of these trials in some of the places like philly or san francisco that a been hit hard. also the federal government could make it easier for localities to begin excavating some of the other options, whether it be allowing for the fentanyl tested or supervising consumption. there's a lot of discussion in
various cities across the united states about setting up some this supervising consumption sites. people will walk into this facility, have access to clean needles and the would be a medical official there so if they do overdose can administer naloxone. philadelphia is pushing this. so san francisco and other places but the department of justice is arguing the supervising consumption sites would violate substance control it. there's a court case going on in philadelphia no. from the federal perspective there a couple things they could do legislatively. you could pass a law explicitly excluding consumption sites if you want to let localities experiment with it or you could pass the budget writer indicating that a resources could not be used to enforce the law and that's what was done with medical cannabis before. it doesn't require legislation. remember happen after washington
and colorado legalized cannabis in 2012. it was in 2013 that the department of justice released a memo saying look, this is still all illegal under federal law but also you follow certain guidelines when the going to make going after you a priority. imagine the same thing with supervised consumption sites. as long as there is a memorandum of understanding, x number feet away from schools, maybe if there's a strong research component you can imagine setting up guidelines and safety follow them will not be an enforcement priority. there are options. duty tweeted about disrupting supply, this will be important and we have to be clear we cannot get rid of supply of fentanyl anytime soon. you if we can delay the entrenct of fentanyl and other synthetic opioids west of the mississippi,
even if it's only for a couple of years, it could potentially save thousands of lives. we need to figure out how to do that. we make it clear in report a number of jurisdictions, the way they are attacking this is their increasing the sanctions for low-level sellers, these drug-induced homicide laws. there's absolutely no evidence suggesting this is going to make a difference whatsoever. a lot of the people selling at the lower levels don't even know what's in the package. this would be the opposite of creative thinking. the low hanging fruit is disrupting websites. a lot of his happening online. you can just google this. so hacking the sites, trading fake sites, doing something to wear great distrust in the market, that might help to lift some of this especially as it moves west. getting tweeted about setting up some type of prize, competition between department of homeland security, they have something like this, where they're trying to get new ideas about how they
can detect synthetic opioids in international mail. this is a type of ingenuity we need but this isn't a seven-figure problem. imagine putting much more money into this in terms of getting at ideas, you can thing that changes with other technologies come for example, are other ways when they people to neutralize fentanyl and certain powders? when you to start thinking creatively. if a a look at how much money s invested during the aids hiv crisis there was enormous. even today we're spending spending over $100 million a year on hiv/aids surveillance. what's happened in the united states is we're cutting some of the best programs that we have first and problem. we have to change directions on this. low hanging fruit is there's a
lot of labs and also medical examiners that just don't have the technologies to be able to detect the fentanyl analogs. another way to think about monitoring this problem is using wastewater testing. this has been popular in europe for quite some time. you can test the sewage and look at the metabolites and get a better understanding of what's being consumed in these areas in real-time. europe has embraced this for years. australia has started to take this on. they just released a report they were look at urban and rural areas and become between using wastewater testing become between 2017-2018 that metabolites for fentanyl and other synthetic opioids doubled over the course of the year. this is not an expensive approach at all. this would be easy to implement and it could be useful west of the mississippi took these jurisdictions that have been hit hard to allow them to get a better understanding of when these synthetics synthetic pott
their market. the of the peace of this in terms of surveillance and monitoring is we need to think about the arrestee drug abuse monitoring program. this by far was the best source of information we had about edison drug markets. this was an interview where they would focus on individuals who were in jail and so this was for research purposes but don't ask individuals about, who were in the jail about their drug market histories, how much they pay for the drugs, what drugs they were using. it had nothing to do with our cases. it provided a rich assessment of what was happening in that market. at the end of the interview they would ask if you want to take a drug test, a urine analysis animals all of the agreed. it had nothing to do with our cases and this is a rich resource to understand what drugs are being used but also you could use that to begin to get a better understanding of what is being consumed in this different jurisdictions. this is a program that ramp up in the early 2000s, 2003 there
were focused were focus on four different counties all throughout the united states. they were any doing 40,000 people. there were plans to increase it to 75 counties and 2003 it got cut. it was funded by the department of justice. it got cut. ondcp realize this is important data set not just for civilians but also essman assize at different drug markets. in 2007 over deceivers able to cobble together enough money to bring back in ten counties. funding ran out, went down to five counts and it was cut in 2013. this is not an expensive systems to bring back some version could help us get a better understanding of what's happening in these markets while people are purchasing, , also wh skin with a analysis results
soon get a better understanding of what these new synthetics are begging to get particular markets. in terms of concluding thoughts i want to be, even though her tight butt outside the thinking, new ideas, we can't abandon prevention and treatment. we should be doubling down. when the targeted prevention we will have to create any scare campaigns. fentanyl is scary enough and also with respect to treatment, treatment on demand needs to be a goal before people who want treatment they should get access but is not just about didn't people in the front door. we have to make sure we're providing the level of quality treatment that's necessary to keep people engaged and prevent relapse. if we just continue to limit our responses to the official approaches, this is not going to be sufficient and it may condemn many people to early deaths. i'm hoping as your grappling with this, please consider brand as a resource as are trying to learn about new ideas of what's
been done in other countries because we would want to appear so with that with clothes and we look forward to your questions and your comments. [applause] -- we will close. >> can you describe what heroin treatment looks like from what the study look like, not just with naloxone. >> this is a question about what does heroin assisted treatment look like. this has been something of the said it's been intimate in six or seven countries. they've had in the netherlands, switzerland now for about 20 years. this is for individuals with her when used disorder and it's typical for people who have been using heroin for quite some time. they've tried methadone, a type of treatment of multiple times but they're still injecting heroin. there have been a number of randomized controlled trials with it done studies to look at a group of people with her when
used disorder who want to stop it have been will be a sign to the heroin assisted treatment which involves going into a facility two or three times a day and ejecting under medical supervision. thatcher treatment condition. your control condition is methadone. the strong evidence suggesting those the site to heroin assisted treatment, there is evidence of reduces crime and improves health outcomes. if you think about it this makes sense. there are a lot of people who have been using heroin for fora long time and once you get to that point you'll spend a lot of your time trying to obtain money to get the drugs. not everyone but sometimes those individuals are putting themselves in situations where they could be more likely to be victimized. what this does is it stabilizes their lives. they go in, they don't have to be hustling to get the money, and it's interesting. in some of these places some
individuals, they want to stand heroin forever. in other cases individuals who were in this after the divisive and stabilize, some of them say maybe what you tried methadone. we published a whole different report they came out december december 2018. but actually what apt we did that there's a report that came out of zurich switzerland. a fetish for quite some time and the study look at everyone was receiving some type of medication for the heroin used disorder. the vast majority receiving methadone. some also receiving slow-release morphine. only 12% of them received hair witnesses permitted if you offer this is not as if everyone sit. we've seen this all rights in other places. that said it could be very different in a world with fentanyl. the evidence is very solid but whether not we would see the same results here in the trinity, it's a different
question. in those places where their lives are stabilized and makes it easier for them to take offense of theirs resources. most of these places have universal healthcare. in parts of the trend we don't have that safety net. there's not as tongues is not entirely clear to me whether you see the same benefits. on the other fentanyl wasn't an issue so i think given the evidence we should be trying to do some of his randomized controlled trials in at least a few places so we can assess the costs and benefits and see this makes sense. this isn't a silver bullet. this is a first or second line of defense and some of these places were fentanyl is entrenched, if you could possibly move some these individuals out of that we could be sending some lives. >> i'm just curious about your opinion on the history of addiction in this country. if we look at the data that suggest addiction to opioids and non-marijuana illicit drugs in general have been stable since about 2002. i know some people have some issues with those of data that
if we look at germany, they have increased opioid prescribing and during that time for capital they saw a reduction in death rates. i'm curious about your opinion on the relationship between death rates in this country and addiction, whether prescribing has led to that and whether allowing more access to prescription great opioids to possibly undercut the demand for black market drugs and fentanyl exposure likes .. >> i know work with numbers,
and those numbers are a little shaky, so i'll let you-- >> no, give me an opportunity to get on my soap box here. and this is what they're doing for quite some time and this comes back to the issue of monitoring and surveillance. we cut this program not only monitoring used in different places, but this is what was actually used by dcp to estimate the total size of the different markets. so we would actually understand, you know, we'd have good information about the number of people who were using, what substances they were using and so about-- so every year they administer the national administration on drug use and health. in terms of substance use, it's a really good source of information if you want to learn about alcohol consumption, cannabis consumpti
consumption, when you talk about heroin and cocaine it's not useful. we did the work for adcp for the obama administration and this administration as well to help them come up with the numbers. and if you were to use the national drug use and health for the total number of people who use heroin on a daily or near daily bases in 2010. that would suggest 60,000 people and the real number was closer to a million. so, this is important, too, and this is something, that peter has been doing great work on this and that you're hearing people talk about, oh, in our country we have two million people who suffer from the disorder. to the extent that they're missing the heavy heroin users, we talk about this in the report, we think this is at least three million. so if we want a better assessment what's happening in terms of trends in addiction and heavy use and recreational use, we've got to move beyond, the national drug use is
helpful, but bringing back this program or something like it would help us get better information. >> yeah, so, i heard you mention manufacturers-- at the beginning of the panel, but from what a lot of people are observing, a lot of overdose deaths are related to people who try substances that maybe come with fentanyl and when they relapse, specifically, when a lot of people are losing their lives. so how would you suggest that we improve programs to help people from avoiding certain relapses associated with them that are fentanyls. a lot of people are trying to quitment when they relapse, which is very normal from people to suffer from addiction is when people are losing their lives. it's not just like they don't stop and overdose. it's precisely when they try to stop, this occur or drug
related deaths. >> that's a very good point. this should be thought of more as a poisoning phenomenon. benzo diazapines, it's a different chemical on your brain, if you're buying them off the street and they only contain fentanyl, that's a huge problem you may not have opioid tolerance at al all and you're at high risk. and test strips might be useful. if you're a drug user that wants to avoid fentanyls at all costs, and the test strip may be a way to be sure that it doesn't contain fentanyl. heroin, if everything contains fentanyl, knowing that the product contains fentanyl doesn't help, there are no tests to quantify how much fentanyl is in that drug. going back to the relapse component of your question.
that's an important point. we need to be able to create better wrap around services so an individual that goes in and out of jail and can't get access to morphine or methadone, we have to make sure when they come out after three weeks, they haven't lost their tolerance and go back on the street and have their regular dose and overdose and that's happening in some places and we need to do a better job making sure the individuals at least are maintained on other substitutes and ipo opioid therapy. >> and that's where it's useful in jails and prisons. >> how are they in shipping containers or luggage or-- >> how is fentanyl arriving in the united states illicitly? there are two main streams how fentanyl arrives in the united states. principally from china, through the mail, containers, fedex,
and assignment carriers, they call them. a good portion is coming from the border from mexico. the drug trafficking association is transitioning away from heroin to synthetic opioids and there's tracking those over the border. we don't know how much from either stream, but if you look at the federal seizure data, you see by the bulk weight, a lot of it's coming from mexico, but it's very impure. about 5% pure. stuff coming over the border according to seizures. in contrast, product arriving direct mail through the express consignment carriers, very pure, stuff from china 95% pure. and 70% of what is seized is coming from china. a lot is coming by mail, but things might be moving to cargo. >> do you have any data on the economic impact of this?
>> we haven't-- we haven't done those estimates. there are some where they've-- not just looking at the synthetics, but you hear numbers, half a trillion and even those estimates are missing certain components. one of the things that we're doing at rand right now and bryce mentioned the initiative and trying to think of this as a whole eco system and that's going to be useful in terms of policy responses and understanding barriers, but part of this is also getting a better picture of the full costs associated with this. and when those analyses are often done, a lot of the focus is on the individual. you know? what it means in terms of pain for treatment, and health care, and labor markets. but it's important if we're thinking about the costs of opioid use disorder or any kind of substance use disorder. how it affects the families and
what it means for family structures and that's why it's harder to calculate. whatever number you see it's too low. that's one. things that we're focusing on right now, trying to get a better handle of what this actually means not only in terms of the cost of the individuals and their employers, but what it means for their families and loved ones. >> and we are going to leave this, but you can find it on-line at c-span.org, live this morning here on c-span2. we're going to be hearing from public health officials about the ungoing measles outbreak that began last fall. officials from new york city and los angeles county have been dealing with the outbreak and sharing their firsthand experiences what resources they've relied on and lessons they've learned about preventing more cases. the discussion being hosted by the american academy of pediatrics and the big cities health coalition.
>> >> so, good morning, everybody, thank you for coming. i'm the executive director of the big cities health coalition. i want to start by saying a special thank you to representative roy allard's office for securing this for us. while i know that the congresswoman couldn't be here today. i want to thank you her for being a true champion for public health and thank the american academy of pediatrics for being such a great partner to us as we started this event, planned this event. so, the big cities health coalition was founded in 2002 and is a forum for leaders of america's largest metropolitan health departments who have changed strategies and jointly address issues to promote and protect the health and safety
of their residents. we have nearly 30-- we have 30 members whose health department serve 62 million or one in five americans and we luckily have two of our member jurisdictions here today. so you all have bios in front of you so i'm not going to take up too much time, but i want to introduce the panel and then i'll turn it over to them. in the order in which they'll be presenting, dr. colleen kraft, the immediate past president of. aap. the doctor barbeau, commissioner of health. and the chief medical officer for the l.a. department of public health. two doctors came from los angeles and thank them for travelling so far. thank you for finding time to join us today and share your perspective. and i will now turn it over to dr. kraft. >> okay.