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- [00:00]
A
Hello everybody. This is Marshall Po. I'm the founder and editor of the New Books Network. And if you're listening to this, you know that the NBN is the largest academic podcast network in the world. We reach a worldwide audience of 2 million people. You may have a podcast or you may be thinking about starting a podcast. As you probably know, there are challenges basically of two kinds. One is technical. There are things you have to know in order to get your podcast produced and distributed. And the second is, and this is the biggest problem, you need to get an audience. Building an audience in podcasting is the hardest thing to do today. With this in mind, we at the NBM have started a service called NBN Productions. What we do is help you create a podcast, produce your podcast, distribute your podcast, and we host your podcast. Most importantly, what we do is we distribute your podcast to the NBN audience. We've done this many times with many academic podcasts and we would like to help you. If you would be interested in talking to us about how we can help you with your podcast, please contact us. Just go to the front page of the New Books Network and you will see a link to NBN Productions. Click that, fill out the form and we can talk. Welcome to the New Books Network.
- [01:07]
B
Hello and welcome to New Books in Drugs, Addiction and Recovery. I'm your host, Emily Dufton and today I want to do something a little different. Usually the people I talk to have recently published a book about drugs and we discuss what it is they wrote. Today's guest, however, recently released not a book, but a co authored report. A census of patients currently receiving treatment in certified Opioid treatment programs or OTPs in the United States and the medications they're taking as overdose deaths continue to climb and the country faces a continually shifting series of drug threats. At the moment, it's fentanyl dominating concern. This report provides one of the most complete pictures of addiction treatment in America today, both of what we do and what we don't. But the last time I spoke to today's guest, Mark Perino, president of the American association for the Treatment of Opioid Dependence, or AA atod. I also realized that the background to this report, Mark's five decades on the front lines of America's treatment system, was basically a book unto itself. And I wanted Mark to share his experience as well as the report's findings in a conversation I'm going to try to have about both. So while I apologize for not sticking to the usual format, I recognize this is New Books Network after all. I do hope Mark's insights into the field today will prove valuable along with his perspective on its influential but often little understood past. So with that caveat, Mark, welcome to the show.
- [02:52]
C
Well, thanks very much and certainly thanks for having me. The history of our treatment system really is of great interest. And it started when three doctors, Vincent Dole, Marie Niswander and Mary Jean Creek, were conducting experiments at Rockefeller university in the mid-1960s. And after a series of their experiments, they had a breakthrough. And they found by giving patients methadone maintenance, they would stabilize, not use heroin, and would form a barrier. So if they tried to use heroin, the therapeutic dose of methadone would not basically let the heroin get to the brain. And this is a major pharmacologic breakthrough and remains to this day.
- [03:52]
B
Now, prior to this point, what was treatment for opioid dependence like?
- [03:57]
C
The treatment for opioid dependence was basically an abstinence based model that it was what people would say would be either immediate cessation of using heroin, what was described as a cold turkey approach to treatment, or a more gradual reduction in the use of heroin and then other medications would be used. The medications of course, were not effective and that's. So that really wasn't much that existed that would able to stabilize the patient, which is why the Rockefeller experiments proved to be so valuable.
- [04:45]
B
Valuable, but weren't they also extremely controversial? You know, the mid-1960s America is just coming out of what's known as the classic era of narcotics narcotic control. Right. Harry Anslinger has just stepped down as director of the federal Federal Bureau of Narcotics. And you know, we're coming out of decades of a very punitive, very punishment, abstinence based system wasn't even for these three well renowned researchers, wasn't the idea of giving a daily dose of legal opiates to known people who had dependence wasn't that controversial?
- [05:21]
C
Significantly controversial. They were given a very hard time by federal enforcement authorities because that period lingered in the antipathy that federal administrators would have in the use of the medication to treat opioid use. And to them and to many others, actually, which carries over to this day, it seems counterintuitive to use an opioid to treat opioid addiction, or what's currently used the term is opioid use disorder. And so I understand that. Keep in mind that throughout the history of how medications would be used to treat opioid use disorder, there's never been a public education campaign which explains how people get into trouble when using opioids and how that can go from use to dependence to addiction. And there's never been a public education campaign that explains how the medications are useful and where they are effective. So people are left to their own consideration about how they view this. And that's part of why this is still a stigmatized treatment. It's improving. And certainly the federal authorities and a number of state authorities are trying to penetrate the stigma so that people can get the treatment that will help them and restore them to recovery.
- [07:05]
B
Absolutely. David Courtright, the great drug historian who has very much served as my mentor for the past couple of years, he once said, you know, tell me your opinions on mat on medication assisted treatment, and I'll tell you your politics. And I think that's really quite right. People's ideas about treatment for this particular issue is so bound up with their ideas of drug use itself, specifically illicit drug use, that I think it is very difficult for people to wrap their heads around the idea of legalizing and sort of legitimizing an action that is still seen by many as incurably stigmatized. And that's tough. So people are coming across that in the mid-1960s. What happens then?
- [07:56]
C
Well, the treatment system expands, and it does not expand through the general medical community. In fact, Vince Stull would talk about this in the early years that the use of medications like methadone to treat this disorder were flatly rejected by the general medical community. And as a result of that, you see the birth of what are called at that time, methadone treatment programs, which would later be called opioid treatment programs. And there was a built in isolation as these programs would expand. Federal rulemaking started in 1972. And in those early years of 72 to 75, the federal government establishes a number of critical rulemaking policies which leads to what's called a closed panel system of treatment programs. So that the methadone treatment programs would have to be registered by two federal authorities, which would then be under the direction of the Food and Drug Administration and the Drug Enforcement Administration in order to operate. And they would be the exclusive treatment providers in using methadone as a medication.
- [09:24]
B
Not a lot of other drugs are treated this way, right?
- [09:27]
C
No, no, no. It's an extraordinary piece of history. And the there are changes that are being considered at the present time not only with methadone, but the use of buprenorphine based on recently approved legislation in late December of 2022. So the federal government and Congress have been moving to make treatment more accessible. But again, the issue is about educating not just the Public, but the treatment providers themselves. Keep in mind that the trajectory of how methadone would be used over the decades would see an expansion of treatment in the 1970s. But it would take another two decades for the first major clinical compendium, which SAMHSA, the Substance Abuse and Mental Health Services Administration, would release in its final form in 1993. And this would be the first real clinical guidance provided to all of the treatment programs in the country. So I think that was also a defining moment as treatment would expand. Now, of course, there were challenges all along the way based on the stigma. If you wanted to see a community organize, even businesses and neighbors that wouldn't even talk to one another, all you had to do was say, we're going to open up a methadone treatment program in the community. And that's when the NIMBY not in my backyard syndrome is seen, because it's a direct threat. And I have to say that when you look back in history, and certainly David Courtright, who would be an excellent mentor on this, would agree that expansion of treatment was really stymied by community opposition and sometimes by county or local regulation, such as limiting where a treatment program could be located. Some counties would have regulations that would stipulate the treatment programs could not open within 1,000ft of a school or a church. And, you know, there were other sort of zoning restrictions that would come into play. Now, I'd say In the last 10 years there have been very good court challenges to the zoning requirements, and now you have fewer townships implementing these sort of zoning restrictions. So things have been evolving gradually and for the better.
- [12:22]
B
Right. But it seems as though the effects of this increased regulatory regime on the part of the federal government and the sort of untouchability of it by traditional medicine had the effect of siloing methadone treatment in the 1970s as clinics were undergoing vast expansion in response to increased demand. Can you tell us a little bit about what this scene was like in the mid-1970s? This is about when you entered the field, Right?
- [12:51]
C
Right. I entered the field as a young clinician in 1974 working in a methadone treatment program in lower Manhattan. And the truth is, it was in. In the earliest phase. You did not have tremendous clinical structure at that time. And consider the fact that it's still relatively new in treating the disorder. So there was challenge inciting treatment programs in community based settings. And it was driven by the necessity that somewhere we had to effectively treat heroin addiction and you didn't have prescription opioids use at that Time that wouldn't show its head into the late 1990s, in the first decade of this century. So it was a strain, for sure, and treatment programs did expand gradually, but there was tremendous doubt and hostility toward the use of these treatment programs and, of course, the use of methadone.
- [14:02]
B
Right.
- [14:02]
C
I think it hit its apex in the mid-1980s when a Florida newspaper published a series called Method on the Deadly Cure. And this would come out of Broward County, Florida. And the publisher seemed to have some axe to grind about this treatment. But that was a widely disseminated series, and it was destructive and damaging. And interestingly, that would influence me in 1984 to found the. What was called then the Northeast Regional Methadone Treatment Coalition, which would serve as a precursor to the current organization, ATOD.
- [14:46]
B
Tell us a little bit more about ATOD, which I believe was formed in 1984 on your website. You call it a nonprofit advocacy and policy organization. What is that? AS involves, you know, opioid use, disorder treatment. And why did you feel the need to form one of these organizations? I'm assuming there had not really been one before.
- [15:09]
C
There had not been one before. And interestingly, the treatment program administrators were working in isolation, and that represented an extension of the fact that they were siloed facilities, as you put it. So in an interesting sort of twist, there didn't seem to be any tremendous motivation to organize as a treatment system based on the fact that they were such isolated practices to begin with and heavily regulated at both the federal and state level. There were a couple of motivations. The first one was the one I cited with very negative reporting about methadone treatment. It was seen as a sort of black sheep of the treatment field, and the problem, again, was reinforced by stigma. And so the point of opening up or creating this nonprofit entity was to serve as advocates for the system, for the patients and for the treatment. And at that time, we really were the sole advocates. And so I worked with counterparts in eight states in the northeastern corridor to form this organization. And at the present time, we have now 29 state chapters representing 1300 opiate treatment programs throughout the country. And so through a decade that would begin in 1984 to the present time, there has been tremendous growth, tremendous improvement, better clinical care, and certainly treating a greater number of patients. Given all the challenges that the system faced, and reflecting back over the last four decades of my involvement, it's sort of remarkable that the system continued to exist at all, because there were very dark periods in the 1980s, and I call that especially the second half, sort of the dark ages of methadone treatment in the United States. It would yield to change as the Food and Drug Administration would end its regulatory oversight and transition to the Substance Abuse and Mental Health Services Administration. Keep in mind that both of these agencies are within the structure of Health and Human services, and the DEA's involvement has remained steady throughout. And I would say that over the last decade or so, there has been a tremendous support from the DEA in expanding access to the treatment system. So I think the sort of remarkable first change that I thought was tectonic and I would never have anticipated was as doctors were prescribing greater numbers of prescription opioids to treat pain. Oxycontin, Percocet, Percodan and other opioids, it really became the beginning of the current opioid epidemic. It is not that doctors decided to create this problem. There was tremendous pressure on doctors and hospitals to treat their patients and effectively manage pain. The problem here was that there was not any effective education for the patients to better understand the risks and the benefits of managing pain through certain prescription opioids. Also, it became easier to renew these prescriptions rather than to work with the patient to determine would there be some alternative means that could be used either in addition to the opioids to treat pain or other opportunities that are being tried at the present time. But that became a real problem between 1999 and the next 20 years. It would be the foundation of the opioid epidemic. And as the case would happen, and we have a tracking system that examines changing drug characteristics as patients are admitted to opiate treatment programs. And we do this under the operational aegis of the Denver Health and Hospital Authority. We started this in 2005, and after four consecutive years of data, we found several remarkable things. First is that 45% of new patient admissions would indicate that they were entering treatment based on their addiction to prescription opioids. The more profound finding, in my opinion, is of that group, of that 45%, 30% were injecting the opioids. Now, this was a remarkable finding because at that time, you have programs that are treating about 70% of their population are middle class white patients. Meaning that for these people to switch to injecting their drugs means they really did not know the lessons that were learned in the profound dangers of injecting opioids out of the 1950s and 60s. So we paid attention to this change. And then, as I was explaining to various regulatory authorities in 2009, that the injection of prescription opioids might in fact lead to a broader use of injecting heroin based on the fact that if you begin to inject these drugs, you have moved into a different phase, your opioid addiction experience. And in fact that would happen now. What most people could not anticipate would be the expanded use and development of fentanyl, which is now the defining opioid which is killing so many of our citizens. So if you have about 108,000 opioid related deaths in a 12 month reporting period, about 70% of those deaths are attributed to the use of fentanyl. And it's a very powerful narcotic and most people who are using it don't have what's called opioid tolerance, meaning the use of fentanyl is so powerful that it overwhelms the opioid tolerance levels of, of the people using it. And that's what causes death. And that, and that issue is a driving force in how federal and state policies are evolving and that leads to the present time of how the Drug Enforcement Administration promulgated new regulations to create what are called mobile van units which would operate under the aegis of the opioid treatment programs. And they did this in the summer of 2021 and states are in fact expanding access to this. And samhsa, the Substance Abuse Mental Health Services Administration, created a wonderful opportunity by indicating to the state alcohol and drug abuse directors, in effect the administrators at the state level of all of the drug treatment cent systems that they, the states could use federal funding in order to fund the development of these mobile vans. And now it's, it's starting to swing into execution as these states are now funding the vans. Additionally, SAMHSA and most recently released regulations that are enlightened and will lead to expanded treatment opportunities. And they expect to be finalized over the next several months. They're in a current review period, review and comment period. But again, it demonstrates that this administration and its sub agencies are really moving in a direction to increase access to treatment. And because there is the reality that people do need access to care because fentanyl is not going anywhere.
- [24:37]
B
Right? Right.
- [24:39]
D
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- [25:06]
B
Experian. So it seems like I like, I like that you, I like how you put that. You're calling fentanyl the defining opioid of the era. It certainly feels that way and certainly sounds that way when you listen to people talking about it, especially at levels of sort of government officials. And it sounds like things are starting to change, but it also sounds like some things have stayed the same over the past 50 years since this system first started being constructed. This census that you released in September 2022, just a couple of months ago in its report, you call it a snapshot in time. So this is a time when the government is starting to maybe improve things, but we're also still encountering over 100,000 overdose opioid related overdose deaths a year. What was the snapshot in time that your census found and what did it help you learn?
- [26:04]
C
Well, I use that terminology for a reason, because I'm anticipating a significant expansion to treatment access through community based settings through the expanded use of these mobile vans, which extends the reach of the OTPs into suburban and rural communities which are significantly underserved. But it opens the door also to treatment facilities that do not have access to these medications, nor do they have an interest in dealing with that. And these vans can reach out to those facilities as well. Also, I'm expecting an expansion of medications in the justice system, particularly in correctional settings. And as an example, the New York State assembly in January of 2021 passed a law that requires all the correctional facilities that operate in New York State to in fact, work with treatment providers so their inmates will have access to medication assisted treatment for their disorder. And the three federally approved medications that fit this panel are methadone, buprenorphine and naltrexone. So I believe that we are going to see a very significant expansion of treatment. The point in time issue relates to the fact that I wanted to capture in the treatment system how many programs existed under SAMHSA's authority and how many patients were being treated and in fact, what were the medications the patients were using. And I wanted to get a sense as of January 1, 2021, this is what we know. And there were about 1837 programs operating in the United States. So that's an interesting finding. It has expanded from the last four years. But keep in mind, we're talking as of January 1, 2021, 1800 programs. We're not Talking about thousands of sites, less than 2,000. And at the present time we have moved, as of the last couple of months, we're getting close to 2,000 opiate treatment programs. So the system is gradually expanding. Now, what we found in this census is that there were about 513,000 patients in treatment. Now, keep in mind that that represents an 85% response rate to the survey that state authorities sent out to all of the OTPs. 15% of the OTPs did not respond to the survey. So while we captured about 513,000 patients, we know that there were more patients in treatment that were encountered. However, an 85% response rate to any survey is actually quite favorable. What we did find also is the majority of Those patients, about 480,000, are using methadone as the medication of choice in these OTPs. And that is driven by the fact that the majority of patients in treatment are using fentanyl or were using fentanyl before they were admitted to treatment. And the reason here is that fentanyl use is so powerful, you need a medication like methadone, which is termed as a full agonist, meaning the effect it has neurologically is to be able to block the continued feeling of using fentanyl.
- [30:09]
B
It's also true, though, that the results might have been more heavily toward methadone because OTPs are the only places in the United States allowed to distribute this drug. But buprenorphine can also be prescribed by private physicians. And now with the removal of the X waiver by, by anybody who, who applies to be in the system. Correct?
- [30:30]
C
That is correct. I mean, this is the new. This was part of the omnibus bill, it was called Data 2000, the Drug Abuse Treatment act of 2000, which would give doctors the opportunity, outside of the operating sphere of the opiate treatment programs, the opportunity to use buprenorphine in order to treat opioid use disorder. SAMHSA up until this date has approved 130,000 practitioners to have a waiver, which is now no longer necessary based on this new legislation. And the interesting problem is that throughout the 20 year history of data 2000 and buprenorphine use in private settings, you never have more than 50% of active prescribers treating patients with buprenorphine. So it remains to be seen how many more practitioners will begin to utilize this. The legislation also eliminated the eight hour training. However, there was a companion legislation also approved by Congress called the MATE act, which now requires every practitioner who wants to prescribe an opioid with some exits for board certified practitioners. But every one of them has to get an eight hour training in order to get the appropriate DEA certification to prescribe opioids.
- [32:08]
B
So the X waiver was removed, but the eight hour training was now applied to everyone.
- [32:13]
C
That's it. That's exactly it. So in a very interesting switch, I guess, of, of how you look at this from a regulatory perspective, we supported the MAT act because we think that physicians do need to be trained and medical practitioners. That's the lesson learned from prescribing so many opioids in the 1990s and 2000s. I mean, the problem that came up was that doctors also started prescribing more methadone to treat pain. And that created a major problem. And the federal government had to publish five federal reports on this topic related to reports of methadone mortality, which at that time were about 6,000 methadone specific deaths per annum.
- [33:09]
B
And when was this? In the 1980s. I'm sorry, when was this happening? When methadone was being prescribed for pain.
- [33:15]
C
You start seeing that in 1999 and it runs through 2015 in that decade. And then you start seeing a gradual decrease in prescribing a methadone to treat pain, resulting in fewer methadone specific mortalities. So methadone has an interesting distinction. You actually have to know what you're doing when you are using the medication. As one of my more well known pain management colleagues would say, even about 20 years ago, methadone is an extremely effective medication when used properly, but it's an unforgiving medication when it's used improperly. And that's absolutely true. So you really have to know what you're doing in this particular area. So we think training, not just medical practitioners, but all clinical personnel, if you're going to work in treatment programs or in these private practice settings, you really have to know what you're doing or you inadvertently create a new problem.
- [34:31]
B
One of the really interesting things that jumped out to me in your report was that there was a major increase in people enrolled in nation's OTPs even between 2020 and 2021. So the numbers I have here from your report say that about 347,000, a little over that, were enrolled in OTPS in 2020. That jumped up to over 512,000 enrolled in 2021. How can you explain?
- [34:59]
C
Well, I think you're seeing the rise of fentanyl use. You're seeing more third party payers providing reimbursement to treatment programs.
- [35:12]
B
Can you define a third party payer for us? I'M sorry, can you define that term? A third party payer?
- [35:18]
C
A third party payer is either Medicare used for people who are 65 or older, generally, and then Medicaid, which is a state run program. So Medicare is a federally operated program and generally it's easier to deal with when compared to either Medicaid or private insurers, whether that's UnitedHealthcare, Blue Cross, Blue Shield, Aetna or other proprietary insurance providers. So this expansion is also driven by the fact that more people are using dangerous opioids like fentanyl and then they're accessing care and the treatment system is absorbing the patients. So there are more. There are treatment programs that are admitting more patients and there are new treatment programs that are opening at the same time. So in the last, let's say five years, about 400 new treatment programs opened in the country.
- [36:26]
B
Wow. So if I wanted to open an opioid treatment program, what would I do?
- [36:31]
C
Well, you have to start by talking to the state regulatory authority, generally referred to as the state opioid treatment authority, and then you submit an application through websites, both that SAMHSA and the dea. And you need all three parties to agree that you should be given the license to operate. You have to meet certain inspection standards for the dea, you need to have the appropriate security, whether it's alarm systems or safe or dispensing stations. For with samhsa, you have to meet basic standards of care. And also at the state regulatory level as well. Keep in mind, at the state regulatory level, there are more stringent requirements in operating an otp. There you have more staffing requirements, in some cases, staffing to patient ratios. As an example, you would have to have one counselor for every 50 patients in the treatment program. Or you have to have nurses working at a certain capacity based on the number of patients that are in treatment and also hours of physician involvement in the treatment system. So that's generally at the state regulatory level, but it's a tedious sort of experience to go through. But obviously given the success of program expansion over the course of the past five years, it's not prohibitive, but you have to have your ducks lined up, you have to know what you're doing. And then of course you have to have the appropriate level of staff.
- [38:26]
B
Right, Right. So it sounds like there's a lot of demands placed upon this on people who are interested in actually entering this field. And yet it continues to grow. You said 400 new OTPs have opened in recent years. What do you think is drawing people to opening OTPs and working in treatment right now?
- [38:46]
C
Well, I think it's the reality that opiate addiction is increasing, driven by fentanyl, that it is a treatable illness and it is an illness. I think from the treatment provider perspective, there's a growing awareness away from stigma that indicates we want to treat this patient population. And there are better clinical standards in place at the present time, which was not the case in the treatment programs of the 1970s. So there really has been a greater professionalism in the system, a greater awareness of how to treat the patients more effectively. And now, through these new proposed federal regulations, there will be better clinical flexibilities in treating the patients. And I think with these changes, and patient advocacy groups seem to say this as well, this will improve patient retention and care. It will loosen the prior restrictions on how much medication the patient could take out of the program. So I'm actually very optimistic about the trajectory of where we're going. We have a very supportive administration and that's reflected in the regulatory changes that I talked about.
- [40:25]
B
Right.
- [40:26]
C
So I think in the next several years, we do need more of a public education that will help people understand when they're getting into trouble in using opioids. I think that the training for doctors in the country can only help so that we don't go back into an era of excessive prescribing of opioids without proper medical follow through.
- [40:54]
B
Right.
- [40:54]
C
And I also think that you're going to see a major expansion in treating inmates in correctional settings who do have opioid use disorder. They will now get access to care. This is not like an electric switch. It's not going to turn on the village overnight. It's going to take time, but it is heading in a proper direction in my judgment. And, you know, longevity in the system will help you. After 40 years of involvement in this work, you get an idea of what works and what doesn't work.
- [41:33]
B
Right.
- [41:34]
C
And you, and you tend to to be thoughtful in your recommendations rather than being reactive or otherwise histrionic in how you create policy.
- [41:48]
B
Right. And that's why I was so interested in talking to you again and also ensuring that your insights are shared to a wider audience, because not a lot of people have 40 years involvement with this field and who have had that sort of front row witnessing account of how many changes and sort of peaks and valleys it's gone through. I think to me, the most interesting thing about kind of the long history of opioid agonist, but of course, you know, antagonists are involved, but Sort of opioid treatment in the United States is how it seems to exist just outside of so many circles. Right. As you were saying, it exists and was very purposefully siloed outside of traditional medicine. Because when the field was forming in its early years in the 60s and 70s, most probably private physicians wanted nothing to do with it. So it became this sort of sub genre within the larger, more traditional field of medicine itself. But it also exists outside of public services. Right. What started like the nationalization of methadone system started with the Nixon administration and CEODAP in 1971, but now it's kind of outside. It's not a public service exactly, although it receives these third party payments, but it's also not quite a private business. It's so strange to me, like the Venn diagram of places where methadone intersects. I feel like there's a lot of circles there, but it's not quite a part of any of them. Where do you situate the field? What do you see it as?
- [43:23]
C
I think it will gradually change. Keep in mind that when the Nixon administration expanded access to treatment through funding, and it did, Dr. Jerry Jaffe, then the head of CEODAP, really understood what methadone maintenance was. And he obviously was a close colleague of Vincent Dole, Marie Niswander and Mary Jean Creek. And he was a remarkable person. He still exists. He's alive today outside of Baltimore. But he really did remarkable things at that time. The Nixon administration's primary reason, the methadone treatment expansion was related to the criminal justice system.
- [44:10]
B
Right?
- [44:10]
C
Because criminal justice researchers would find that as people enter treatment, they then discontinued committing crimes. Not just drug related crimes, but all crimes. And so that was the reason. I mean, part of the remarkable history of methadone treatment, in spite of much criticism, much skepticism and stigma, is that it has proven its worth. I remembered speaking at a national conference about, I'd say, 25 years ago, and a leading state regulator commented after one of my presentations that she felt that she had just been sold a used car. And my response at that time was perhaps, but this is a used car that will keep going with great mileage, will not need much in the terms of repair, and will get you from one place to the other with regularity.
- [45:26]
B
It's one of those big boxy volvos from the 80s, right?
- [45:31]
C
Well, in a way it keeps going. It's a well constructed vehicle. But I think that it sort of betrays the issue of that sort of skepticism. But I do think in the next years of expansion, I believe that will become greater and acceptance. Look, I remember talking to an administrator of a large southeastern jail about 15 years ago, and he had a number of jail administrators in the southeastern region at that conference. And I remembered when I brought up the issue of, by the way, you have an opportunity, since so many of your inmates are using opioids, you have an opportunity to treat them before they're released back into the community. And that recommendation met with enormous skepticism. And most of the administrators said, look, we have to follow what the court tells us to do. We have to keep these inmates in a locked up environment based on what the court has mandated. We have to make sure they are fed, they have a safe place to be, and to provide access to these reins of social services for mental health and addiction is beyond our realm. And my answer was, I understand, however, you have, for lack of a better way of putting it, a captive audience. And therefore, you can do something in order to reduce recidivism if you start treatment during their period of incarceration. Now we've learned that works because now that we do have more opportunities to treat inmates with opioids disorder, whether it's New York or Rhode island or Connecticut in other states. And what have we found? As the inmate is inducted with medications during their period of confinement, and then they are referred upon release to outpatient facilities, there has been a decrease of more than 50% in post release mortality, and there's been a decrease in recidivism, meaning going back to jail, by 55%. So this is not only a major financial saving, it makes better sense, especially in the third wave of an opioid epidemic. So I think we're in an era where effective policy is now going to dovetail with treatment expansion. And I also think that there will be an increasing acceptance of how this medication or these medications will be used.
- [48:30]
B
So as we kind of wrap things up here, it sounds as though you're looking towards the future with a positive attitude and that you see a lot of room for and potential for improvement in coming years. That sounds great. Do you have any other recommendations, either for our listeners or for public figures at any level? What would you say if you had a magic wand and you could make everything better? What would your chief recommendations be?
- [49:03]
C
Well, I think the first thing is to really try to better understand what opioid use disorder is. It's a very complex illness. No one comes into treatment with a simple use of an opioid. You have patients that are using methamphetamines as an example, Patients with Long histories of depression or anxiety disorders or trauma. And it takes a real comprehensive approach in treating the individual because these patients also have hepatitis B and C or HIV infection. So I think there needs to be a better understanding of how you respond holistically to the patient. Also, I think as a culture we need to be careful about making all sorts of judgments about the human being. Now the old expression is don't judge a person until you have a chance to walk around in their shoes a bit. And then you have to be even careful. And that's where the public education comes in. I also think there needs to be an appreciation that no one really sets out as a career path to say I plan to be using opioids and I plan to get addicted to them and I plan to be in jail by the time I'm in my early 20s. It's not a career path. So we have to have a sort of broader understanding of how people do get into trouble in this area. And yes, a series of decisions are made. And yes, people pay a great price, but not just the individual drug user, their families, children and the community. I mean, that's sort of the reality here. I think people feel more isolated about this. And then I remembered listening to parents talk at a high school meeting when they said, look, yes, my kid's drinking a lot of beer, or yes, my kid's smoking a lot of marijuana, but thank God they're not using opioids. And so I think that you have, I think as a whole, you know, the recommendation to your listeners would be to think through these things for the policymakers and for elected officials. They need to be more conscious of. There are no quick fixes here. There really aren't. We're dealing with a complex phenomena. A large number of people using opioids. The fact that the Chinese government is not going to do anything to restrict fentanyl producing laboratories in their country, and certainly the Mexican cartels which are trafficking these fentanyl drugs out through the United States and Canada are not going to decrease their profit making business. So faced with those realities, we have to then prepare so that the people in our country get the treatment that they need, the help that they need, and that is an improvement financially for the health of the nation. We cannot have our citizens really using such dangerous drugs in such large numbers without providing care for them. So that's how I would suggest people think about this. And, and if I've learned anything over four decades, it's the issue of think carefully about what you are proposing in terms of policy. And you do need to think about history and context. And as I say, to a number of officials, both at the federal and state level, it's important for you to know what was tried and did not work in the past so you don't repeat that error again.
- [53:23]
B
Right. Well, thank you so much for coming on here and talking to us and giving us precisely that history and context that is so deeply required. If people want to read this report that you released recently, where would they be able to find it?
- [53:37]
C
They go right to our website. And you know what that is? It's www.atod.org.
- [53:44]
B
Okay. Super cool. We'll also put a link to that in the show notes. But I want to take a moment to thank you so much for coming on here and talking to us about all of this incredible history and the insights you have both on the foundation and formation of the treatment industry in the past and of course, your very clear insights into how it is working today and hopefully improving. Thank you so much, Mark.
- [54:07]
C
My pleasure. Thanks for having me.
- [54:15]
B
Sam.