← LSE: Public lectures and events
LSE: Public lectures and events
Season 2, Episode 8: Where did the opioid epidemic come from?
00:35:45
Loading summary
Transcript73 lines
- [00:00]
A
Testing, testing. Hello.
- [00:02]
B
Testing, testing. Hello, and welcome to the Ballpark, a podcast from the US center at the London School of Economics. I'm Sophie Dunzelman.
- [00:22]
C
It's important to recognize that today we.
- [00:25]
A
Are seeing more people killed because of opioid overdose than traffic accidents.
- [00:33]
C
Effective today, my administration is officially declaring the opioid crisis a national public health emergency under federal law. And why?
- [00:44]
A
I am directing all executive agencies to.
- [00:46]
C
Use every appropriate emergency authority to fight the opioid crisis.
- [00:53]
A
Oh.
- [00:53]
B
Opioid abuse and overdose deaths have been skyrocketing since the beginning of this decade. In 2016, more Americans died from opioid overdose than the total US casualties from the wars in Vietnam and Iraq. Simply put, the death totals are staggering. And on October 26, 2017, President Trump took a direct step to really address what many have called an epidemic. But what exactly is at the root of this opioid crisis? Where are these drugs coming from, and what can the US do about it?
- [01:41]
C
Right now, it is about quelling the expansion of the epidemic. I think not nearly enough is being done around adjusting prescription patterns, prescribing patterns in the US to even start to tail that off. Maybe we've reached a peak, but we could still be on an upward slope.
- [01:58]
B
That is Dr. John Collins.
- [02:01]
C
My name is Dr. John Collins. I'm Executive Director of the International Drug Policy Unit, and I'm a fellow of the LSE US Center.
- [02:06]
B
The International Drugs Policy Unit recently became a part of our team here at the US Center. This unit brings together different approaches and disciplines and to really study and analyze drug policy around the world. I sat down with John the very day before President Trump made his announcement on the opioid crisis to discuss the causes and context of this epidemic. So, John, at what point did opioid abuse in the US really become an epidemic? When did this become a problem?
- [02:38]
C
I think it happened late 2000s was when it started to become apparent there was something wrong or something seriously wrong. There were indications, but I think there was still a sense, even as of 2012, 2013, that drug use in the United States was actually apart from things like crystal meth, which appeared to be more of the problem. Certain indicators around cocaine use and even potentially opiate use did not appear to be a cause for major, major concern. You certainly heard discussion about it, but I think it was all of a sudden, 24, 2014, 2015, 2016, this really exploded onto the political radar.
- [03:16]
B
And what are the indicators that tell us that this is a serious problem? Is it deaths? Is it just usage? Is it how we buy the product.
- [03:24]
C
Yeah. Well, look, there's a lot of headline figures recently about just prescribing rates. Right? And certainly you get these figures about prescribing rates in towns of 10,000 people and how the level of opiate prescribing there is just so astronomical relative to the population. There's one indicator that really stands out, and that's overdose deaths, or just even overdoses, even if it doesn't ultimately result in death, because that's such an incredibly difficult situation and such a problematic situation. So it is actually a reasonable proxy indicator of what's going on in drug use. And overdose deaths have absolutely skyrocketed.
- [03:58]
B
In 2013, fewer than 4,000Americans died from synthetic opioid abuse. But yet in 2016, this caused the death of over 20,000Americans.
- [04:10]
C
The figure cited in the opiate commission appointed by Trump was that we've seen a fourfold increase in opiate overdose deaths since 1999. And funnily enough, what they highlight is there's also been a fourfold increase in prescription of opiates since 2000, or not since 1999. So that's a reasonable proxy of infrastructure, indicating there's a problem.
- [04:32]
B
So you would say it's fair to really call this an epidemic.
- [04:36]
C
Yes. What we find with things like opiates is we see cycles, as in the past. Right. Europe experienced an opiate epidemic in the 1980s through the 1990s that declined precipitously thereafter. And the problems we would associate with opiate use and, you know, the visibility of public injecting things like that, which we would recognize are actually largely derived from the initial epidemic in the 1980s and 1990s. And we haven't had major new initiating populations thereafter. So we would characterize that in epidemic terms. There was a sudden increase in use, there were populations that became dependent, and then thereafter that declined. So what we're seeing in the US is there was a decline. 1960s, 1970s was certainly associated with high levels of opiate use in the US and then that subsequently declined, and now we're seeing a skyrocketing again. So I think you would characterize it as an epidemic.
- [05:31]
B
But why the decline and then why the rise?
- [05:34]
C
That's the million dollar question. The decline. Who knows, right? Things go out of fashion. Things come into fashion. We saw in the US There was a switch to stimulants. So you saw cocaine, crack cocaine, in the 1980s, 1990s. So probably it was just a sense of opiates became associated with certain sub populations which were no longer seen as. It wasn't seen as rebellious. It was seen as actually a symptom of poverty. And therefore why would you want to be associated with poverty? Right. What we've seen now, the rise in the US is an interesting story because we has as yet. We have as yet not seen this happen in Europe. Right. We haven't seen an opiate epidemic. We haven't seen indications. I know the home office wake up every morning and check the figures to make sure that, or to. To. To try to predict if there is something coming down the tracks. But thus far we haven't. And I think there's two ways of looking this. One is that the US Is an anomaly because of factors I'll come to in a moment, or else that the US is, as it has been in the past, just ahead of the curve on Europe. So that we may actually have one coming in Europe. I suspect it's the former. I suspect it's the former because the determinants of the opiate crisis in the US as I highlighted earlier, seem to be driven largely by prescription drug, the way prescription prescription drugs were happening in the 1990s through the 2000s and are frankly still happening now, that there was a far too lax approach to the prescription drug prescribing of drugs, an inappropriate prescribing based on types of pain that don't actually respond to opiates. So you saw a view that we want to eradicate pain. Right? This was something that was in the 1990s in particular. You can discuss the causes of it, whether it was pharmaceutically driven, whether it was driven just by the medical community believing that pain is something that can be eradicated. But ultimately the sense was nobody should be in pain. And we have these medicines and we have new generations of opiates, oxycontin, things like that, that ultimately mean that we should actually not be afraid to prescribe. And even in things like chronic pain, where somebody is long term going to be in pain, people were prescribed opiates. Now, chronic pain, as we've learned subsequently, is actually not very treatable via opiates. And actually all you get from treating chronic pain, pain with opiates is opiate addiction in a lot of cases, maybe not all, but in a lot. So what we saw in the US is a precipitous rise in opiate prescription, which thereby translated into huge parts of the population becoming opiate dependent. And that was kind of a slow tidal wave coming in that nobody really seemed to spot initially. And then what happened was in a lot of cases. When that was suppressed or when the federal government tried to, or states and others tried to limit prescriptions or cut down on prescriptions, people switched to street based opiates, whether it's fentanyl or heroin or whatever it is. And so really all of the kind of subsequent use around fentanyl, heroin, things like that seem in some way, the Trump commission actually alluded that 80% of the recent uptake or the later uptake in heroin was in some ways driven by initiation on prescription opiates. So it seems like this seems to be the main driver of that.
- [08:46]
B
If it is, as you say, kind of so concentrated in areas of poverty, you can theoretically be a middle class American and not be affected by this at all. So why, apart from the moral aspect of this, should we really care? Why would the country really be concerned? We're not concerned about poverty, theoretically, the way we don't spend on welfare.
- [09:07]
C
So traditional drug epidemics were associated with poverty, and the responses to those epidemics were also determined by the poverty in the communities they were seen as infecting. Right? Nobody cared about crack users, people cared about making sure the crack users were not left free to roam the streets, etc. So you saw these incredibly draconian policies imposed in the 1980s or even as early as the 1970s around things like heroin. This was the war on drugs, right? This is the quintessential idea of we just have to be tough. The using populations we're seeing now are across the income spectrum, are across the geographic spectrum. In the US you're seeing opiate epidemics, you're seeing HIV epidemics in small town America. This is completely different. We've never seen this before. And what social justice types in the US and civil rights activists and others will rightly argue and highlight is that the responses we've seen to this epidemic are unlike any in the past. And because the users are perceived as white and maybe middle class, maybe slightly lower middle class and in some cases upper class, you know, it seems to be hitting the broad spectrum of the population. So I think we've seen a far better response to this. It's not ideal, it's not, I wouldn't even say it's good. But we've seen a better response to this cry at this epidemic than we have past epidemics. Some of that is driven by the fact that we've learned a lot since the other epidemics, particularly, particularly in settings outside the US where people innovated on approaches to diseases, dealing with these, where there wasn't a Sense of just lock everybody up and let's just build more prisons. But I think a lot of it is very justifiable in saying this highlights the racial nature of drug policy, that when the median user becomes perceived as white and lower middle class or middle class, the policies become a lot softer and the desire to lock everyone up becomes a lot less interesting.
- [11:03]
B
What efforts have been taken by federal government versus state government? Are they similar? Are they so different? Do you to really address this problem?
- [11:11]
C
Yeah, I think the states have led on this because the states seem to be ground zero in this crisis. So a number of states have issued a state of emergency. I think one of them has issued a state of disaster or something like that. Just initiatives that enable them to take specific special measures to address this. The Trump Opiate Commission, I think the Obama opioid Commission made a similar call. Declare a national emergency. Trump Obey Commission pointed out that we're losing as many people, we're losing the equivalent of a 9, 11 every three weeks, I believe it is to overdoses. So it's. There is a sense of this is a national emergency. And the national response needs to in some ways acknowledge that. What we saw following the Trump commission, which frankly I thought a lot of the, I would agree with a lot of the findings, they were pretty measured, they were pretty pretty on the ball of where public health understanding is on this issue around medication assisted treatment and things like that. But their number one thing was you need to declare a national emergency for us actually to start to take sufficient action on this.
- [12:14]
B
And as of October 26, President Trump has taken this step. He directed the Department of Health and Human Services to declare the opioid crisis a public health emergency. We'll get into this in a little bit. But some have noted that he didn't declare a national emergency, which is a very important distinction in terms of the scale and the rate of resources that can be put behind this declaration.
- [12:40]
C
But effectively what his initial response was, the traditional law and order criminal justice approach. Oh, we need to enforce our border laws, which is absolutely ludicrous given what the actual determinants of this opiate crisis are. If you see a resurgence of Mexican heroin imports, it's demand driven, it's not supply driven. Right. And if it's not Mexican heroin, it's going to be checked, going to be fentanyl. I was at a meeting last week in Vienna at the UN and China got very upset that they're being labeled as the key producer of fentanyl internationally, but largely China based fentanyl. So it's supply interdiction policies, while undoubtedly will have a role in addressing this issue, are not going to solve this issue. And so I think if the federal government moves ahead with the opiate commission findings, I think that's at least a.
- [13:24]
B
Positive step and that's a positive step.
- [13:26]
C
Forward or I think a lot of their recommendations are correct. It's about expanding treatment coverage. There's none of the traditional tough on crime, criminal justice orientation. There's some, but it's certainly played in a much lower key. It's much, much more about meeting the treatment gap. Right? 1 in 10 people with a substance dependence issue in the United States has access to treatment. Forget everything else until you plug that gap. Ensuring that people have access to medication assisted treatment. This is, as the World Health Organization calls it, the gold standard of treating opiate addiction. Right? Methadone, buprenorphine, Suboxone, things like that. There is still a great stigma around using these kind of treatments because there is this traditional kind of view of abstinence and drug users have to just become abstinent. There's no, you know, anything else is just a crutch. When we know from decades of research and experience in Europe and the US and other places these medication assisted treatments work and they're extremely effective and people are much less likely to relapse or to overdose and all sorts of other things if they are well maintained on these. So I think the recommendations of the commission go as for a federal guideline, I think go as well as they possibly. Well, not as possibly, but they go very much further than they otherwise could have.
- [14:50]
B
So now that we have a public health emergency declared, what's next? What needs to be considered and addressed by lawmakers going forward?
- [15:00]
C
The problem we have is that opiate substance dependence disorders are chronic lifelong conditions. So every week we go with new initiation and the continuation of the epidemic is an increase in the chronic population that need to be managed and treated and provided healthcare services for most of the remainder of their lives. This is a generational problem that the US Will be dealing with for decades to come. So right now it is about quelling the expansion of the epidemic. I think not nearly enough is being done around adjusting prescription patterns, prescribing patterns in the US to even start to tail that off. Maybe we've reached a peak, but we could still be on an upward slope. So that's one part is that as one Stanford psychiatrist calls it, it's the difference between the stocks and the flows, right? The stocks are the existing opiate dependent people that you have and you're going to have to deal with the flows, deal with the inflow of new opiate dependent users. And so those two need to be treated separately. So great. The sooner that we can see a slowdown in the initiation and the continued flow of opiate users, that's going to lessen the problem for future generations. But we now have a generational issue on our hands which, the magnitude of which I still don't think we fully grasp how large this is in terms of the federal government dealing with this in lawmakers comprehensive treatment services. This is, you are going to need to deal with this at a national level in terms of a public health approach to this. The Affordable Care Act, Obamacare was the first real expansion of treatment coverage probably in US Government history. If they roll that back, if that gets undermined, well then you're going to have to recreate that in some way.
- [16:51]
B
And the likelihood of that of being.
- [16:53]
C
Recreated at the federal level. You know, these are Republican states that are, that are suffering under the opiate crisis that the push for the federal government to do something is probably going to continue. So I think this complicates the politics around it. I couldn't make any predictions at this point, but I think ultimately the federal government is going to have to bail out the states in paying for the treatment services that are going to be needed over the coming decades.
- [17:24]
B
I'm joined now by my co host, Denise Baron. Hey there, Denise.
- [17:28]
D
Hey Sophie.
- [17:29]
B
And I'm also joined by Alex Soderholm, a PhD candidate in the social policy department here at LSE. He's also the policy coordinator for the International Drugs Policy Unit. Thanks for joining us, Alex.
- [17:41]
A
Thank you for having me here.
- [17:42]
B
So Alex, you recently joined us here at the US center, but you've been part of the International Drugs Policy Union for quite some time now.
- [17:50]
A
Yes, that's right. Yeah. And the move to the US center really makes a lot of sense for us. Of course US Foreign policy has a large impact on drugs markets. The US has been involved in countries like Afghanistan and Colombia for a long period of time. And of course Afghanistan is a world supplier of heroin and Colombia has traditionally been a world supplier of cocaine. So US foreign policymaking and domestic policy making has a large impact on global drug policy.
- [18:15]
B
So that's really what we want to hear more about. What do you think about John's characterization of the current levels of opioid abuse as an epidemic?
- [18:24]
A
Well, if we look at some of the numbers, I think it's definitely a public health crisis and if we look at the rapid escalation of the problem, I think it's fair to call it an epidemic. Indeed. So if we talk about some of the numbers, for example, for every 1 million Americans, almost 50,000 doses of opioids are taken every day, which is four times the rate in the UK. And then we have these horror statistics from towns like Kermit, West Virginia, where there are 392 people registered as living in the town, whereas nine hydrocodone pills, which is an opioid, were prescribed over two years. So it's really a huge problem that's been long in the making in the US this is not a new problem, a new issue. It's something that has been growing over time. But I think we're really seeing the great impact of the problem now that people's reliance on these opioid prescriptions, so when their prescriptions are being taken away from them, they go towards the illicit market and start consuming heroin. Right. Example. Or as of recently, we've had the problem of fentanyl, which I guess we'll speak more about later as well, which is having a huge problem, a huge impact on things like overdoses and deaths from opioid use in the US and.
- [19:38]
D
Then obviously recently we heard about how President Trump has declared this a public health emergency rather than a national emergency. And what's your kind of understanding of the difference between those two things? Or even like, what's coming up next with this declaration of a health emergency?
- [19:57]
A
So declaring it as a health emergency does not necessarily do very much. It allows, as far as I've understood, it allows funding to be drawn from the public Health Emergency Fund, which as of current, has a balance of just over US$56,000. Now, the federal government has estimated that tackling the opioid epidemic is going to cost at least US$75 billion per year. So even though it has been declared as a public health crisis, a lot more needs to be done to actually tackle the problem.
- [20:30]
D
Right. So basically, like, Congress has to fund it in order for this declaration to have any teeth.
- [20:35]
A
That's right, yes.
- [20:36]
B
Why is it so costly? What needs to be done? Why is this huge amount of money necessary?
- [20:42]
A
So if we look at some of the causes of why this problem exists, it's a whole range of various factors. The US and the opioid epidemic in the US Is quite interesting because it's really struck working class and middle class US families very, very hard. A lot of white families in the US and it's important to remember so the racial aspect of drug policymaking have been impacted upon by the opioid crisis because they are often the targets of prescription of opioids. And at the background of that, I think, is our understanding of pain management, what we think about how to manage pain amongst people. So whereas in Europe, as one analyst was saying, if you go to a French doctor and say, well, I'm 51 years old now and my bones are aching and I used to run the marathon, but I can't do it anymore, the doctor would probably say, c' est la vie, have a glass of wine and that's life. Whereas in the us, doctors would be much more so inclined to pursue a medicalized treatment plan, including medicines like opioids to treat pain. And that is also because of a number of factors, incentives by big pharmaceutical companies, ratings of doctors based on their abilities to relieve pain, and so on and so forth. So there was an interesting study done in 2016, actually, which found that Japanese doctors, in Japan, that is treated acute pain with opioids in 47% of cases, compared to 97% of cases in the US. So there is a huge problem with the over prescription, of course, of opioids.
- [22:20]
B
It seems like there's a crazy amount of money that needs to be spent. Yes, but to the layman, to me, where does that money actually go?
- [22:27]
A
Right. So part of the problem moving forward is going to be that the people who are now become reliant, who have become reliant on prescription opioids, who are moving towards the illicit market for, for finding opioids because their prescriptions have run out. We're going to have to bring them onto some type of treatment plans. And as a bit of a paradox, they probably will have to go on medicalized forms of treatment. Opioid substitution therapy in particular. Opioid substitution therapy is quite costly. So we're talking methadone, buprenorphine, which are also opioids, but without the psychoactive effects, basically. And these types of medicines have had a huge impact worldwide amongst people dependent on opioids, basically. So that is going to be very costly. It's going to be costly to try and reform the curriculum of medical professional, I guess, I think addiction science currently as part of the medical curricula is very, very small, very minor, a minor part of what a doctor has to learn to graduate from medical school, basically, in the us, how to treat pain. So all these type of things, there's a lot of money has to be devoted to research. A lot of money is going to have to be devoted to treating the people who are currently dependent on opioids and so on and so forth. So it is a very costly problem. But I think at the same time, the US has the money and needs to devote the money because otherwise the costs are going to just keep increasing as the number of people dependent on opioids increase every day, basically.
- [24:01]
B
It does seem to me though, that in addition to having so many people addicted, you also have so many kind of skeptics who say, oh, I'm not going to pay for their problem. If a heroin addiction is like any other addiction, why don't you just quit and go cold turkey? Why is that not really an option or is that an option?
- [24:20]
A
It's not an option. And we've seen that in a number of cases. Going cold turkey, I mean, besides from the, the physical dependency and withdrawal symptoms, which can be fatal actually themselves from withdrawing cold turkey, as you say, from opioids. And there's a whole other host of issues related to opioid dependence and which is why people should care about this. If we don't care for these people, then we're going to see probably an increase in various types of crime related to acquisitioning the resources needed to buy more drugs or to buy these drugs and so on and so forth. And in terms of infectious diseases as well, when people move from ingesting prescription opioids to injection of illicit market drugs, heroin, there's going to be a huge increase in the transmission of infectious diseases. And we've seen that in other places as well. And that is indeed something that people should care about. And yes, it is an issue, I think, in comparison to the crack cocaine epidemic, for example, it wasn't seen as a, as a public health issue because the people who were affected by it were black and Hispanic. And So in the 1980s and 1990s of the US a law enforcement paradigm was chosen instead to deal with the problem. And so the people who were impacted upon by the crack cocaine epidemic back then are still in jail today. And that's cost costed the American federal government and state governments a huge amount of money. It's very costly. To keep prisoners is not the right way to deal with these things. So actually, from an economic point of view, I guess it's much more cost efficient to go down the public health route. 75 million US might seem like a large figure, but it's actually quite cheap in comparison to pursuing these people through militarized intervention methods, for example, or fueling law enforcement officials to deal with it, which then only increases the prices in the black market, which makes it more lucrative for criminalized elements to go into the market and control it. And from that you have a whole host of other problems as well that I think we've seen around the world.
- [26:28]
D
Another reason that policymakers have highlighted that this is probably a more expensive public health crisis or expensive drug abuse treatment plan is because the populations who are most affected by this live in rural communities and live in very disparate communities. And so they don't necessarily have access to doctors for diagnosis and clinics to receive the treatment itself. So when President Trump announced this, he also announced additional funds for telemedicine, which is something I had never heard about before because I usually go to a doctor, I don't call a doctor. But they want to make sure that the people affected in Appalachia and in the Rust Belt are able to get the treatment that they especially need. And that means setting up these entirely new sort of veins of treatment, these sources of information and communication.
- [27:17]
A
Yeah, no, that's an interesting point. I think one of the issues with this rapid increase in the prescription of opioids was the sort of one stop shops where you had pharmacies attached to GPs, where you could quickly get a prescription and then just walk in next doors to the pharmacy and get whatever medication you needed. So I understand that this sort of tele. What do you call it?
- [27:43]
D
Telemedicine.
- [27:43]
A
Telemedicine, right. It's probably an important intervention in terms of reaching these populations. But at the end of the day, it is going to take much more effort and money to resolve their problems. Addiction is often a lifelong plight. Plight, exactly. Thank you. Yes, exactly. Sorry. Telemedicine is not going to make that go away. It's going to be a way to probably reach out to these rural populations. But at the end of the day, if we want to prevent other types of health epidemics from arising in the future, what we really need to focus on is to expand the public health infrastructure to these local communities. Because if these communities had adequate public health infrastructure, I don't think the problem would have been of this magnitude as it is today.
- [28:28]
D
So that was one thing that some of the advocates of or some of the people who contributed to the Trump Commission study cited as a reason of declaring this a public health emergency rather than a national emergency, since national emergencies are usually focused on situations that are a little bit quicker. These are hurricanes or tornadoes or these major disasters that happen and then we're able to rebuild. And the funding that's needed for it can decrease Relatively quickly. But instead this is something that's very, very long lasting. This is something where we need to be funding it over a generation because there is going to be an entire generation of Americans who's affected for this for the rest of their life.
- [29:10]
A
Yeah.
- [29:11]
B
Which really requires a cultural change more than anything like you've hinted, Alex. Requires us to change the way we think about this. Requires just kind of new innovations, really kind of to change almost the American psyche in the way we really address these kind of problems.
- [29:27]
A
Yeah, I think so. Most definitely. We need to understand this as, I mean the magnitude of this is massive. It's a huge problem in the US I just want to quote a few other figures actually. In 2016, there were 53,332 opioid deaths in the US and this includes heroin and methadone as well.
- [29:48]
D
Can you say that number again? How much is that?
- [29:50]
A
53,332. Jesus. I can put that in some context. So we had, if we exclude heroin and methadone, we had 34,572 overdose deaths in, in the US in 2016, which is basically the same amount of people dead from overdosing on, on opioids as the amount of people who died terrorism related deaths globally in 2016. Wow. Those numbers are basically the same. It's a difference of 10 or 14 people. It's a huge problem. There really needs to be a change in the culture of relieving pain and treating illnesses in the country as a whole. Otherwise we just keep putting logs on the fire, basically.
- [30:33]
D
And that was one thing that I found really disappointing about the way that President Trump announced this. So on one hand, positive step that he made a step to do this, that a commission really led into was a rare moment of like, you know, research led policy making. But then he says towards the end that he's part of the funding for this is going to go towards a massive advertising campaign basically focused on making sure that kids don't ever start using drugs, which. Okay, great. But then he says it's really, really easy not to take them. And that's a quote, it's quote, really, really easy not to take them, not to take drugs. And this just completely reminded me of the quote, just say no campaign that Nancy Reagan launched in the 80s. And that's not necessarily the root of the problem. You know, as we've been hearing from Alex and we heard from John before, treatment and access to treatment is the best way to reduce the number of people addicted to drugs. Telling people, don't do it and blaming the people who take it doesn't seem to be working. Didn't work in the 80s, 90s, early 2000s. And it doesn't sound like that's going to be the solution that we need going forward.
- [31:40]
A
I agree entirely. We know that these just say no campaigns and even globally speaking, prevention campaigns for drug use often have very little success. So prevention campaigns are not necessarily the best in terms of money spent. We should rather spend probably our money rather than advertising campaigns and saying that all drugs are bad. We should probably spend the money on developing the infrastructure and the social safety safety net to make sure that people don't develop a substance abuse problem from having consumed drugs. We know that a lot of people do consume drugs over the course of their lives, but as important is that we have the social systems in place to take care of them should they develop an abuse to these substances, basically. And so there is a culture in the US of taking drugs for all different types of problems. Of course there's the. And then there's a huge distinction between the illicit drugs and the illicit drugs, the medicines which are actually both from a, from the, from a social science perspective, but also from perspective looking into sort of the actual active compounds on these drugs, they aren't very different from each other. The source of the channels for procuring them are very different, but actually they are pretty much the same, which is why people would move from consuming prescription opioid like oxycontin towards consuming something like heroin. Heroin in terms.
- [33:05]
B
So sorry, the difference between licit and illicit supply chains that you're talking about, can you elaborate on that? What does that really mean?
- [33:11]
A
Sure. So listed supply chains would be what we know as the global supply chains of commodities. Like we buy something of Amazon and it's being shipped from China, probably it'll make its way to us in a container along with hundreds of other consumer goods, whereas the illicit supply chain would make its way under the wall, supposedly sort of the US Mexico border or various other illicit financial enterprises.
- [33:36]
D
So the two differences would kind of be like either the mailman or a drug mule.
- [33:40]
A
Yeah, pretty much. Yes, exactly. Yeah. That's a more succinct way of probably describing the difference between the two. And of course, the spillovers from the illicit supply chain are huge. So if we go to countries closer to supply source. So if we look at Afghanistan, for example, the countries around Afghanistan, especially the communities that live along the borders, we have a much higher incidence of substance abuse, substance dependence than we have further downstream because of the availability of supply, basically, and how cheap it is. Every time you cross a border, the price and product increases multiple plentiful, basically. Which is why a kilogram of heroin at the farm in Afghanistan, let's say, might be a thousand dollars. But on the streets of Europe, that same kilogram of Heron might be worth US$145,000 or even more than that. The markup in price is huge.
- [34:36]
B
Well, that's all the time we have today. Thank you so much for joining us, Alex.
- [34:40]
A
Thank you.
- [34:44]
B
So that's it for this episode of the Ballpark. Thank you to John Collins and Alex Stutterholm for joining us. The Ballpark is produced by Denise Barron with contributions from co hosts Chris Gilson and Sophie Delsiman. That's me. And also with help from the LSE's annual fund. Our theme tune is by Ranger and the Rearrangers, a Seattle based gypsy jazz band. Look them up@rangerswings.com after dozens and dozens of of episodes, we still love them. The contents and opinions expressed in this podcast do not reflect those of the US center nor the London School of Economics. Next month at the Ballpark, it's our season finale. We'll be discussing the many, many questions surrounding fake news. Thanks for listening. Play ball. Great. Perfect.
- [35:41]
A
Yep.
- [35:43]
B
Cool. Thank you.