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A Second Opinion with Anne Schuchat, MD

Welcome to A Second Opinion podcast where we are rethinking American health. I’m your host Senator Bill Frist. To make sense of all the dynamic perspectives in healthcare, you need a trusted source engaging at the intersection of policy, medicine, and innovation. You need A Second Opinion, a podcast where it all comes together. In A Second Opinion, we engage with the leading minds in healthcare at the nexus of medicine, policy and innovation. In the current series of four episodes, we’re hearing from four leading women in healthcare.

In today’s episode, I’m excited to have Dr. Anne Schuchat of the Centers of Disease Control and Prevention with us. For over four years Anne Schuchat has served as a principal deputy director of the CDC. She’s played key roles in CDC emergency responses including the 2009 H1N1 pandemic influenza response. And during my own years in the Senate in Washington, the 2003 SARS outbreak in Beijing and the 2001 bio terrorist anthrax response. Globally, she’s worked on meningitis, pneumonia and Ebola vaccine trials in West Africa and conducted surveillance and prevention projects in South Africa. In our conversation, we take a deep dive on the devastating vaping crisis that’s affecting our youth and communities nationwide and hear how the CDC is addressing the problem. And now please join me and our guest for a second opinion. Dr.

Bill Frist:           Dr. Anne Schuchat, let’s talk about vaping. Let’s talk about opioids and let’s talk about detectives.

Anne Schuchat:            Perfect.

Bill Frist:                       Let’s sort of see where this goes. But listen, we’re really honored to have you with us today. The number one social issue that is affecting us today in terms of our attention and appropriately so is vaping. And for our listeners and for me, I want to be sort of start with the basics coming in. But Jewel, which everybody has heard about, was started by two Stanford students whose intentions, I don’t know the real story, but I understand the intentions were basically to get a product that would help public health, that would hopefully get thousands, if not hundreds of thousands or millions of people off cigarettes, which I do think is the biggest in terms of causing health public issue that challenges out there. But it went awry and badly awry. And we’re right in the middle of it. So let’s start with that. First of all, vaping, what is it?

Anne Schuchat:            Yeah. So electronic cigarettes are devices that use a battery to heat substances and let people inhale the substance deep into the lungs. And so the initial group of them were for nicotine. And Jewel is an example of one of these electronic devices that delivers nicotine. More and more substances are being used with that same electronic product.

Anne Schuchat, MD Headshot

Bill Frist:                       And why electronic? So why … so the first e-cigarettes, well e is electronic cigarettes, but talk to me about the delivery, how it works. You have a device, you have a heater, you have a capsule, you have a thumb drive. Now paint the picture.

Anne Schuchat:            Yeah, there’s been several generations of e-cigarettes or vaping devices. And they started out looking like cigarettes with a little battery powered component and they were disposable. And then they became non-disposable. And then they got bigger. So there was a larger container that could hold the nicotine or the other substances. And then they became smaller. And so the fourth generation has a device that is not disposable. And cartridges, like your coffee cartridges, cartridges that can be replaced. And this fourth-generation, which Jewel is one of, has a very small device that’s very discrete. It can look just like a USB drive-

Bill Frist:                       Right. Little thumb drive.

Anne Schuchat:            Or like a thumb drive. It could be in your pocket. The aerosol that’s produced doesn’t have a smell, so it can be very discrete to vape or to use the e-cigarette product. In fact, kids are doing it in class and the teacher can’t even see that they’re doing it because there’s not an aroma and their device looks like a normal thing that’s okay to have in class.

Bill Frist:                       So the thumb drive has the whatever the chemicals, the nicotine in it, and then the little unit itself heats it up.

Anne Schuchat:            Yeah. The cartridge has the substance that whether it’s nicotine or marijuana or flavored oils. But the battery part, the electronic part produces the energy that leads to the high heat that heats up the substance and produces an aerosol, not a vapor, but an aerosol. And initially as you said, people thought, well, it’s the all the chemicals and all the products of cigarettes. There’s like 7,000 different chemicals that come out from smoking a combustible cigarette. And the thought was that the electronic nicotine delivery systems might be more controlled, pure, cleaner, and the thought was maybe they’re safer.

Anne Schuchat:            The reality is that safer isn’t the same as safe and that there are still a number of compounds that are emitted with that aerosol production. There’s volatile organic compounds, the device itself is metal and there could be heavy metals that are part of the aerosol. The aerosol produces ultra fine particles that can get deep into the lungs. You know, silica, asbestos, these things to get deep into our lungs, get us nervous about what kind of damage there might be. And so that variety of toxins or chemicals or heavy metals that might be produced has people wondering. The full set of studies, I don’t think people have seen yet in terms of the short and longer term effects of e-cigarettes. But the assumption at the beginning was, well, they got to be safer than cigarettes.

Bill Frist:                       Let’s go back to the beginning and talk a little bit about that. Because I remember two years ago, smoking is a huge issue. In Nashville, Tennessee, where I live, government data says 22% of all the people, of 700,000 people are smoking. And we made huge progress over time, huge progress over the last 30 years. But there are areas like Nashville where that smoking is much higher than we’d like, and it’s killing, killing thousands and probably 30 or 40,000 people lose five to six years of their life right now in Nashville Tennessee. The old British studies, basically said that e-cigarettes, I thought, and correct me, but e-cigarettes were effective in terms of taking a smoker, transitioning to them, and like you use patches and others, but e-cigarettes was an effective way to stop smoking. Is that right?

Anne Schuchat:            There’ve been a couple of different randomized controlled trials and the results have been somewhat mixed. The National Academy of Medicine kind of reviewed the literature and thought there was moderate evidence that perhaps there’s a benefit. The issue in terms of stopping smoking but not sufficient across the board. The British study that came out this past year, the randomized controlled trial there, there are some aspects that are not applicable to our population or to our cigarettes. The e-cigarette nicotine content was lower than what we have here. And the intervention was given with a lot of behavioral health counseling. And there’s pretty much agreement that counseling is an important component of helping people quit smoking.

Anne Schuchat:            So I think the idea of an off ramp for cigarette smokers is very important. Right now the FDA has a batch of different FDA reviewed approved cessation tools. And so CDC really recommends that you use an FDA approved cessation tool and that if there’s accumulating evidence for one e-cigarette company or another, that that go through the process because the idea of an off ramp for cigarette smokers is really important. It’s still a huge killer. And we know that the majority of adults who smoke want to quit.

Bill Frist:                       Yeah. Yeah. So in the Nashville health, which is a population health or that we run in Nashville, we were in the field about six months ago and we did about 2000 people were studied and we’re looking at lots of different things. But the observation that blew everybody away was a fact adolescence in terms of vaping has increased 10, 15, 20 fold over the last three to four years, far outstripped smoking cigarettes. Why is that happening?

Anne Schuchat:            Yeah. E-cigarettes have become the most common tobacco product that youth are using. In our national teen surveys, we’re finding the same thing, that we have a drop in smoking cigarettes and other combustible approaches to tobacco. But we have this huge increase in teen use of e-cigarettes. And the factors that are important will sound familiar to what happened with cigarettes and teens. There’s been advertising, blatant and not so blatant in terms of trying to appeal to youth. There are flavors that are really youth targeted. Candy, popcorn, flavors that are a lot like candy.

Anne Schuchat:            And then the latest generation of the e-cigarettes have nicotine salts, and that makes the nicotine not so harsh. If you smoke a cigarette or you have an e-cigarette without the salts, there’s a little bit of a harshness that is a turnoff. And so the salts help, are more palatable basically. And then the device is so discreet that it’s not like teenagers having a cigarette before class or at the end of class or maybe in the bathroom. But even during class, these products can be concealed and without the smell of tobacco smoke, the kids can be doing it all day long. So the average-

Bill Frist:                       I remember Hollywood also, I remember early on, and again, Jewel itself, and I keep bringing up Jewel because 2017, that was 24 months ago wasn’t a company and that’s how quickly-

Anne Schuchat:            Right. Yeah, oh, just huge.

Bill Frist:                       And so I think back, but I remember early on the advertising where Hollywood figure, sort of the cool factor and I don’t see that anymore. But I remember early on to make it sort of the cool, the hip, the modern thing to do.

Anne Schuchat:            You may not be seeing it because you’re looking at media that’s appealing to your age group. But if you were on social media as a teen or a tween, you would be seeing a lot of things that are targeting youths. So these days, social media games and so forth, some of the e-cigarette manufacturers are sort of taking the tools that were used years ago by big tobacco and trying to get social influencers, sort of role models of teens to be really demonstrating how cool it is to do the e-cigarette use. And so if you have that influence of the subtle advertising or the peer influencers, and then you have flavors that like everybody likes the taste of and there’s not a harsh turnoff that there used to be, and then you have high levels of nicotine. Nicotine is incredibly addictive.

Anne Schuchat:            So if you’re not put off by that first try and it’s like kind of like eating candy, it’s hard to stop and the nicotine makes it extremely hard to stop. And I think it’s really important to say that nicotine in the developing brain is harmful. We know that nicotine is addictive, but what happens is people’s brains continue to develop til they’re about age 25. And one of the things that happens when you’re addicted at a young age, your brain’s affected and it really can increase the risk of addiction to other substances.

Bill Frist:                       I think that is so critical. So I think, that moment, I want you to repeat it or let’s repeat it or let’s explore it further. The brain itself matures at certain pace in life and the scientific literature is exactly what you said. Up to about 25 years of age, your brain is altered and once you’re addicted, you’re addicted for a longer period of time. It’s harder to ever break that habit early on. And it’s one of the reasons that a lot of states are moving to outlaw the sale of these products until the age of 21. And tobacco, same sort of thing. State like Tennessee if it’s 18, there’s a reason between 18 and 21. Because if you’re addicted when you’re 18, you’re more likely to stay addicted the rest of your life. If you can push it off to 23, 24 you are not. It will be easier to leave. And this whole maturation of the brain, if you put addiction or if you expose nicotine to a brain during all the way up to the age of 25, it has these longterm changes. A lot of people don’t realize.

Anne Schuchat:            Yeah. So we think that there’s harmful effects on learning and attention and behavior even. But there’s also that increased addiction potential. And so we really would like to get more adults off of smoking, but not at the expense of a whole generation getting addicted. And so I think when you saw the Tennessee results or we saw the national results, we’re like oh my goodness, you know overnight practically, this has gone from barely measurable to more than a quarter of high school students being current e-cigarette users and frequent users as well.

Bill Frist:                       And so I want to come back to sort of what we’d sort of be, just start recommending, but let’s cover some of the statistics emphasized how new it is, how explosive it is, how it’s still increasing right now as we speak. From a medical standpoint and from a CDC standpoint, right now we’re talking in the studio at the Centers for Disease Control and Prevention and the CDC has done a remarkable job and you’ve done a remarkable job personally as sort of a, not just a scientist but a spokesperson and a leader here. But the role of the CDC, what have we found? Because it’s been, again, in a very short period of time. Explain that to me and to our listeners in part because the CDC is just an amazing place to be doing this. But what have you found?

Anne Schuchat:            Yeah, thanks. So we’re in the midst of two big problems right now. We have this rise skyrocketing use of e-cigarettes among youth, nicotine containing e-cigarettes among youth. But separate from that, since March, April, May, we’ve seen this increase really recognized in August of acute serious lung damage in people following the use of e-cigarette or vaping products.

Bill Frist:                       So a 16 year old, otherwise healthy and everybody can envision, a healthy girl boy all of a sudden coming down with a devastating lung disease.

Anne Schuchat:            Yeah. So they present with a cough, shortness of breath, sometimes chest pain and those are symptoms of pneumonia often. They may have fever or not. About three fourths of them have a gastrointestinal set of symptoms like vomiting, nausea, sometimes abdominal pain or diarrhea and then they get really short of breath. Seek medical care sometimes a couple times urgent care, doctor’s office and then get admitted. Half of them end up in the intensive care unit. We have had fatalities, we have people being discharged who are not themselves in terms of their lung capacity and we don’t have all the information yet because it’s fairly new.

Anne Schuchat:            As of the beginning of November, we’re talking over 1800 cases, 37 deaths every state, but Alaska. And so a problem we were not thinking about a year ago is now in every state. Half of the cases are under 25 and we’re learning more. What we know right now is that the majority have a history of vaping THC containing products. So they’re using-

Bill Frist:                       And THC is-

Anne Schuchat:            THC is the active component of marijuana. So some people have no history of using THC containing products and only report nicotine containing products. But the vast majority do report THC containing products. And many of them where we have information report, informal sources, they didn’t go to a dispensary or to a brick and mortar store. They got the vaping products from friends or family or informal sources like dealers. In some states we’re hearing about online purchase. And so a leading hypothesis right now is that cutting agents are infiltrating this supply chain. That there’ve been arrests made in a couple of states of individuals who were essentially diluting THC oil with other substances that nobody’s expected to go deep into the lungs.

Anne Schuchat:            There’s a big market, very lucrative market for all kinds of vaping products. And the outbreak so far is pointing in the direction of the THC containing ones. Not that we think the THC is causing the lung damage, but we think there’d be maybe a mix of other things. We haven’t ruled out the device, the metal devices. We haven’t found one single brand or one single substance or chemical. And we’re in the midst working closely with state and local public health, working closely with the FDA, with law enforcement and other authorities within the states to get to the bottom of it. We’re getting many new cases every day, hundreds each week that we’re trying to address and we’re really trying to get key information out to clinicians about what to do, key informations to the public.

Bill Frist:                       Tell me on the CDC, take me inside. We’re right now on a studio in the CDC. How does the CDC, again, we’re in Atlanta, Georgia a long way from Washington DC. We have an agency that affects every one of our lives, both here domestically as well as globally. They’re scientists, they’re clinicians, they’re public policy experts. What happened here? Did somebody come to you early on in 18 months ago and say, “I’m a doctor down in Valdosta, Georgia and or Palo Alto, California and I saw a death. I didn’t know what it was.” How does it get to the CDC?

Anne Schuchat:            Yeah. What happened in this circumstance is fairly typical. The health department in Wisconsin had heard from clinicians in Wisconsin that they’d seen a few young people with a severe respiratory illness. They thought it was pneumonia. They did all the tests to rule out infection. They didn’t see infection and they realized there was a history upon further interview of e-cigarette or vaping use. So Wisconsin alerted the CDC and we shortly thereafter heard about a similar case in Illinois, connected the Illinois and Wisconsin health departments, which started a combined investigation and we kind of put out an alert for the rest of the country.

Anne Schuchat:            Little by little, we started to hear about similar cases all across the country and we dispatched some of our disease detectives to work with the Wisconsin and Illinois health departments. And we pretty much had all hands on deck very quickly. When we have new urgent health threats like that, we will often activate our emergency operation center and bring together the assets of the agency, not just the tobacco experts or the epidemiologists or the laboratory scientists, but really bringing the assets of the full agency to bear both to help find out what’s going on and to help feed what we’re learning to the clinicians, to the public, to policy makers, and to the other countries, in fact, so that they can take steps to protect themselves or protect their populations.

Anne Schuchat:            So this is unusual in that the root cause of this isn’t a new infectious virus or a bacteria. It seems to be essentially a chemical injury. And it may be a distributed supply that’s not one company or one bad actor, maybe many. But the skills needed to respond take an agency like CDC working very closely with the public health. And most people don’t know about the public health departments in their neighborhood, the county or city health department or the state health department. Maybe when there’s an emergency you hear about them, the boiled water problem or the outbreak at the hotel down the street. But something like this vaping issue really calls on that infrastructure of public health across the country.

Bill Frist:                       And that’s why we should eat here in Atlanta. And we had the rich resources of one of the great institutions that is trusted, that we rely on, that we sometimes take for granted until there’s something just like this. But that sort of vertical going down to everybody’s neighborhood and we’re going in the hollows of moms and dads who don’t know that their fourth grader or fifth grader has got a vaping device and there’s vaping from the 18 year old or the 17 year old. Right now as we speak with a risk that we haven’t fully determined, but it’s being determined because of the great local public health reporting up all the way through to you here and the scientist here. And it’s interesting from a funding standpoint, whether it’s at the government level or support public private partnerships, people don’t fully appreciate, and I say this having been in the Senate, don’t fully appreciate the power of that infrastructure that is quality of life, but also lifesaving.

Bill Frist:                       And I think this is a great, great example. Well, just for our listeners, where are we in terms of recommendations? I know we have a lot of people listening now and say, “Well, it’s a big problem in my neighborhood.” I know it’s bigger than I realize. We’re talking about life and death. It hasn’t been fully defined yet. Our disease detectives, and we’ll come back to that, are on it and working hard and the recommendations we say now, and I do encourage because people will be listing this over the next year, year and a half, will change. So see what the recommendations are, but what are we recommending right now?

Anne Schuchat:            Yeah. And it’s really important to say that in one of these investigations we’re learning and we’re trying to share as we go. And so we’ve learned that we need to make sure that we’re making interim recommendations. That as of today, based on everything I know, here’s what I recommend. A few months from now, things might change. But today what we’re saying is that, people should not use e-cigarettes or vaping products that contain THC, especially ones bought off the street or from informal sources. Regardless of this outbreak, no youth, young adults or pregnant women should use e-cigarettes. We know that nicotine can be harmful.

Anne Schuchat:            In terms of e-cigarette devices, you shouldn’t manipulate or further change the device based on ways that are not what the manufacturer intended, that may be harmful. We don’t know. And so based on what we know right now, we also recommend that individuals consider refraining from use of e-cigarettes that contain nicotine. Not 100% of the cases in this outbreak have a history of THC containing e-cigarettes. And so until we know more, we think you may want to consider a refraining from that use. But as I said, no, we never think that tobacco products are safe and we recommend that teens, young adults, pregnant women avoid e-cigarettes. There are particular harms of nicotine in those situations. Now, there are a number of adults who are using e-cigarettes because they quit smoking. We don’t want them to go back to smoking cigarettes. There’s a variety of FDA approved nicotine cessation strategies together with counseling that are recommended. And if you are continuing to use e-cigarettes and develop any of these symptoms we’ve been talking about, you should contact your healthcare provider right away.

Bill Frist:                       Yeah, good. On this podcast we focus on the intersection of policy, innovation and science, medicine, health, those three big spheres. Innovation here, we began just a bit ago that the innovation was probably well-intended to get a device that would help people stop smoking. And it was innovation, two Stanford students and well-intended, that’s the innovation. The health I think you’ve, very dramatic with the statistics, but outlined that where we are today, a problem is growing from medicine, from science, from quality of life, a huge challenge. And then the third one that we’ll close this section on, and that is the policy. That’s like my third big circle. And I like to look at the intersection.

Bill Frist:                       The FDA from my time in the United States Senate and during that period of time was sort of the late 1990, 1999 age for the first time, we began really to look at tobacco. We’d always said, “Well, is it a device? Is it a drug?” We did devices and drugs, but we brought tobacco in and people pretty much know the settlement it took place. Subsequent to that in the late sort of 2015, 2016, again, what happened through that period of time?

Anne Schuchat:            Yeah, well, so what has happened with the FDA and tobacco is huge success of the initial regulation of tobacco as well as the public health population based comprehensive strategies that states and others were able to execute a decrease in adult tobacco smoking and quite a lot of progress. But more recently the FDA deemed e-cigarettes as under their purview for regulatory authority and has issued draft guidance about how that’s going to be implemented. They had some enforcement discretion initially and there was a postponement in 2017 of when their enforcement of the e-cigarette policy regulation would go into effect. And there was a court case that moved the time up a bit.

Anne Schuchat:            So at this point, by May 2020, the premarket approval for e-cigarette products is supposed to be required and FDA will begin enforcing their regulatory discretion. The administration announced updating guidance for the e-cigarette manufacturers and we’re expecting that to be released fairly soon. But of course the FDA is doing the regulatory guidance, not the CDC.

Bill Frist:                       They’re the ones responsible for that. Yeah.

Anne Schuchat:            I mean, I think that the key issue is that there are lots of policy implications at the state level where states may deem the age where youth may purchase tobacco products of either e-cigarette or cigarette type.

Bill Frist:                       Yeah. In Tennessee, it’s 18 years of age, but the younger fourth and fifth and sixth graders are getting them from the 18 year olds that buy them. And so there’s legislation to push it to 21 and they’re, the time I had last looked there were six states who pushed it to 21. So that’s one type of policy that’s being considered.

Anne Schuchat:            Right. Right. Yeah, there’s a number of states that are adjusting the age. There are also location restrictions of where tobacco products can be sold. And some states are adding e-cigarette restrictions to where they can be sold sometimes only to adult only venues rather than convenience stores or others. There are policies about advertising, policies about school programs. There’s-

Bill Frist:                       Flavoring.

Anne Schuchat:            We’re getting back to flavors. It’s like you can tell, I haven’t been talking about this recently. So the issue of there were policies put in place for flavoring in cigarettes and now there are policies out there for the e-cigarette liquids. And so there’s a lot of tools that state or federal government have. Now, of course, there’s also a lot of policies around marijuana and marijuana products. And so we have a number of states where THC containing products are medicinally legal or medically legal, but not recreationally legal and states where they’re recreationally legal at a certain age, and many states where they’re illegal, any use is illegal. And so this outbreak is occurring in this very patchwork nation of policies where the FDA has federal authorities, DEA has certain authorities. And then state legislators or state executives have some ability to issue policies that are a variety of nature. So it’s very interesting, but it’s also very, very challenging to address.

Bill Frist:                       And it’s complex, but the policy ultimately will take effect, like it did with tobacco I think. But as you go back and forth and you trace it, there’s a lot that probably can be improved in terms of what that policy ultimately is. Taxation. A lot of people don’t know for cigarettes where taxation in Tennessee might be 60 cents a pack. And in other states it’s $5, $6 a pack. That kind of variation is determined by state. But the vaping products where one of those little thumb drives has a pack of cigarettes worth of nicotine in it. Just one little thumb drive is not taxed at all. And so there are tools that can be used as well.

Anne Schuchat:            Yeah. Absolutely. The issue here is interesting because there’s a huge amount of evidence about policy implications for tobacco products that can be applied to the e-cigarette story. And so I think we learned a lot over the past 15 years or so about effective ways to reduce cigarette smoking, at the state level with a policy at the program level with comprehensive approaches. And much of that can be applied to e-cigarettes, but of of course a lot of it is state decision-making.

Bill Frist:                       But we know from the cigarette sort of from the nicotine cigarette what tools are effective and how they can be used. But again, it comes back to the CDC and why your job, what you do in this organization, this building that we’re in is so important. You have to build that science base for that.

Anne Schuchat:            Absolutely. Yeah we try to be … Our director, Dr. Redford loves to say, “We are not an opinion organization, we are a data driven organization, science-based, mission-driven. And our job is really to pull together the best evidence there is and make it accessible to policy makers where there’ll be different values that they bring to the table.”

Bill Frist:                       Exactly. And again, having been on the policy making side of the United States Senate, I’ll just have to say I relied so heavily, immensely on the science and on the rigor and the robustness of people like you in making that policy. Let’s shift gears again briefly. The vaping is so current that I really appreciate you. We’re starting with our simple definition and walking through the science and the policy and the innovation end of it. The opioid crisis is the other big crisis. And again, we’ll just spend a few minutes on that, but I’ll be leaving here and going to South West Virginia. And there you see a young person, middle aged person or an old person and two out of three, the opioid crisis has just about destroyed their life. And it’s not just in Southwest Virginia that’s happened to where I’m going. It’s in Tennessee. It’s in every state, sort of current in terms of our listeners right now, what are sort of the developments in terms of the whole world of opioids, whether it’s in the policy or science or innovation world?

Anne Schuchat:            Yeah. I mean this epidemic is really tragic and it has affected the whole country pretty much every community, many families, in many different age groups. We think there’ve been a few different phases and we’re entering phase four. So the first phase really was an explosion of prescription opioid use that physicians like you and I might’ve been misled about treating pain. We weren’t taught that much about treating pain and then it seemed like we should be treating it more aggressively. And some of the ways that we were treating chronic pain turned out to be extremely addictive and sort of harmful in many cases. The wave of drug overdose fatalities that was associated with prescription drugs was soon surpassed by heroin related deaths when there was very inexpensive, very potent heroin when that came onto the market in some parts of the country.

Anne Schuchat:            And then a third wave came in with fentanyl, another painkiller and its analogs that was essentially illicitly manufactured, extremely potent, and became both direct and indirectly linked with a lot of overdose deaths. This fourth wave that we’re in right now, we’re seeing an increase, not just a continued lots of deaths associated with fentanyl use, but often in association with stimulants, with methamphetamine or cocaine. And those are really difficult to deal with. The government, the private sector, and pretty much every state has really taken action and CDC is keenly involved in trying to turn the tide on this epidemic. It’s been bad enough that it’s affected life expectancy. We used to think that every generation is getting better and better-

Bill Frist:                       Yeah. The American dream. We’re going to live longer than our parents. But they don’t.

Anne Schuchat:            Yeah. And we’re having young people die. When young people die, life expectancy at birth starts to change. And so some people call it deaths of despair, middle aged and younger people dying from drug overdose or from a few other causes, suicide, et cetera. But what we’re doing trying to address that prescription issue where in 2016 CDC issued guidelines for clinicians, primary care clinicians about treatment of chronic pain to try to address the pain in a way that was safe and careful. And really for clinicians who kind of were taught, it’s fine to use these long acting opioids. No problem. If a person really has pain, it’ll be okay, to realize think twice before you start an opioid. If you do start one, start low and go slow in terms of increasing and check back frequently because the harms can be substantial.

Anne Schuchat:            So we have a whole suite of implementation materials for clinicians to help with that prescription story. And we’re actually seeing some improvements. We’re seeing decreases in prescriptions and we’re seeing increases in prescription of Naloxone. The drug that blocks the opioid that can wake a person up who’s overdosed. So safer prescribing we’re seeing. A second approach is the consumer facing and really trying to help people know that even a little bit, it only takes a little to lose a lot. And that prescription painkillers can be harmful instead of they might be prescribed but be very careful. A third approach is to work with state and local government and the CDC is putting hundreds of millions of dollars into the states to go into those communities to help improve prevention and improve data.

Anne Schuchat:            A fourth approach is about data. Speeding up the information because we were kind of asleep at the wheel at the beginning. It took us a while to recognize deaths were going up, emergency department visits were going up, and which drugs were the problem. So we’re really improving that data infrastructure. And then the last of our strategies is about having public health and public safety work closely together. Because in the hotspots, in the high intensity drug trafficking areas that partnership, the public health data to drive where the law enforcement is intervening, can be so important. We’re just one part of the government’s approach to the opioid epidemic, but it’s a top priority for the whole agency.

Bill Frist:                       Yeah. And I do think of all the climate of partisanship that we’re in now in Washington DC, one of the bright spots was just a year ago, at the same time, most of the television was focused on the Kavanaugh nomination and all of that going on. People didn’t really see the split screen that Republicans and Democrats and independents came together and passed a major piece of policy, a legislation that is now law, that’s allowed States and both from a resource standpoint and from a substance in terms of content standpoint to begin addressing the issue itself. It is an issue because of it’s an addiction that does have a terrible crisis proportions now, but as people age, the chronicity of that, the cost of that, the expense of that, we can’t even estimate what that is.

Bill Frist:                       And as you pointed out, what we’re seeing now in the last couple of years is that whole concept of the American dream that you’re going to live longer than your parents did, that has reversed and it’s for lots of different reasons and it’s the diseases of despair, but this opioid crisis is from that. But again, the optimistic side is the science is improving, our government is responding, the local communities are recognizing it in a very positive way. And so we’re moving in the right direction. And again, so much of that information comes back to the science, to the evidence, to the reporting to the seamlessness way that the CDC operates.

Anne Schuchat:            Yeah. I mean, one thing to say, we didn’t get into this problem overnight and we’re not going to get out of it overnight, but there are signs of progress right now and there definitely is bipartisan concern and interest in investment. And one thing that’s kind of cross cutting in this is the role of stigma and that people who need help need, we need to, as clinicians be compassionate and address concerns and make it easier for people to present for care. We want our health system to address this in a more seamless way, that if a person comes in with a bloodborne pathogen that’s related to injecting drug use or a drug overdose from a painkiller, that we try to link them to care, to link them to services.

Anne Schuchat:            That we expand the treatment pool of evidence-based treatment that’s available for people so that the millions who are addicted to substances can get compassionate about evidence based care. And that as communities, families, faith based groups, et cetera, that we reach out because this is affecting every community costing the nation a lot. But we can do a lot about it. And so at CDC we have this public health piece, other parts of the government have pieces, the private sector is stepping up. But I think removing the stigma from addiction is going to be important to turn the tide.

Bill Frist:                       And the stigma thing is not unusual and we’ve learned how to do that, whether it’s explicit bias or implicit bias of who we think an addicted person is. Just a 35 year old female attorney who had back pain to say, but it takes a while as clinicians, as the two of us, but also as society generally. But I think we’re making headway. Go back to HIV AIDS in the 80s where the stigma was sort of the big barrier and it took 10 years to break it. But again, looking back at those tools of communication, and I’ll say once again that sort of looking at sort of the innovation in the policy, in the health and the intersection. One of the reasons we do this show is to talk about the way that you and I are talking so that people in a much broader sense, not just clinicians and not just people who are taking care of people who are addicted, but a much broader understanding which hopefully feeds into this stigmatization of what we know has to be done in order to get the appropriate care and treatment and going forward.

Bill Frist:                       Well, let’s close with one thing and that is your job. You know, I think you have the best job in the world. You’re sitting on the top of this organization. You wouldn’t describe it that way, but I will. You’ve been at it a long time. It is science. It is empathy. It is care, it is treatment, it is prevention. It’s a mystery. It’s a science in the sense of figuring things out that nobody’s ever figured out before. It’s got it all together. But the detective end of it, we touched upon it a little bit ago. And in my own standpoint, when I was in Washington DC, anthrax hit, we were petrified. It was in October. People started dying immediately and I was in the senate.

Bill Frist:                       As the only position, my first phone call, very first phone call was to the CDC. About six weeks later, ricin hit. Came to my office, shut down the office itself. Again, bad intent. We didn’t know if it was terrorist. We didn’t know who it was. My first phone call was to CDC. In 1983 or 1984 at Stanford, I was a cardiac surgeon. I was doing heart transplants every day and all of a sudden the Legionnaires started breaking out in our water supply. I was washing my hands with water and just two hours ago in this building, I ran into one of the detectives at that time who’d come out to figure out in a short period of time, flew out from Washington to figure out what’s in the water that people are dying from and that kind of science, that detective world. Tell me just a little bit of that. We’ll close with that because there are a lot of people saying, “What should I go into and what is this detective world about?” And say a little bit about the entity here that does that detection work.

Anne Schuchat:            Sure yeah. So as you know, I’m a physician and since I was about seven or eight, I wanted to be a doctor. Went through medical school, went through internship, residency, chief residency. And it was just at that point that I heard about the epidemic intelligence service or EIS program and I came to CDC 1988 to be a-

Bill Frist:                       And the name of the program is what-

Anne Schuchat:            It’s called the epidemic intelligence service or EIS. It’s the disease detective program. So I came in 1988 to be a disease detective. Got sent on an outbreak right away. And you did a couple of other outbreaks while I was there, but that was my entree into public health. We have a program for doctoral level individuals, a two year applied training program called the EIS. But we have a number of other programs that are kind of similar around the world, the field epidemiology training program. And we even have a camp for high school students called the Disease Detective Camp, where you actually get the steps of uncovering the mystery. How do you organize data to work up an outbreak? How do you do a fake press conference? The kids get to do that. What are the laboratory opportunities?

Anne Schuchat:            So at CDC and in public health, we really need to be ready to deal with the expected, the unexpected and frankly the unimaginable. And as a disease detective, you may find yourself in the middle of one of those unimaginable events like a mosquito bite that can cause a pregnant woman to deliver a baby with a terrible birth defect like the Zika brain problems or this new terrible pneumonia that’s affecting men attending a Legionnaire’s convention in Philadelphia. So for younger viewers or listeners, the movie Contagion talks about the disease detectives through the character that Kate Winslet plays. She came to visit the campus during the development of that movie and a couple of us got to meet with her. It was really kind of cool. But being a disease detective is a much better job than being a Hollywood actress because you both get to help solve mysteries, but also really help people and protect them, save lives. So I couldn’t have had a more exciting, fascinating career. But I think at the end of the day, it’s really the people whose lives you get to touch and help.

Bill Frist:                       Yeah. And it happens every day. And again, the American people don’t see it on the more dramatic ones do they see, but in all the little ways and whether it’s the flu or whether it’s the smallpox or polio, [inaudible 00:45:04], the HIV, the infectious diseases or things totally outside of that like vaping that we’re talking about today, it’s lifesaving. Thank you for all that you do and this organization, but in particular your leadership and thanks for sharing your wisdom. And I learned so much over the last 40 minutes. I can’t tell you how much, but to be able to share that with our listeners and our viewers means a lot. Thank you so much.

Anne Schuchat:            Well, thanks so much. A real pleasure.

Bill Frist:                       Good. Appreciate it. Thank you. This episode of A Second Opinion was produced by Todd Schlosser, the modus creative group and Snapshot Interactive. You can subscribe to A Second Opinion on Apple podcast or wherever you’re listening right now. And be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show and our guest and sponsors at asecondopinionpodcast.com, that’s one word, asecondopinionpodcast.com. Be sure to join us for our next episode with Shirley Franklin, former mayor of Atlanta and current executive chairman of the board of directors of purpose built communities. A Second Opinion broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services, where we engage at the intersection of policy, medicine, and innovation.