A Second Opinion with Sam Quinones | Healthcare Podcast | Bill Frist

A Second Opinion with Sam Quinones

Presenting Sponsors:

Medhost - Sponsor for A Second Opinion Podcast with Senator Bill Frist. MD
Tivity Health - Sponsor for A Second Opinion Podcast with Senator Bill Frist. MD

In today’s episode I’m excited to share a recent event where award-winning author and journalist, Sam Quinones and I sat down before a live audience to discuss the massive opioid epidemic in America. Sam Quinones is a journalist, story teller and author of the enthralling book, Dreamland: the Tale of America’s Opiate Epidemic. Dreamland won a National Book’s Critics Circle Award for the best non-fiction book of 2015 and was selected as one of the best books of 2015 by Amazon.com, Slate.com, The Daily Beast, Buzzfeed, The Seattle Times, Boston Globe, St. Louis Post-Dispatch, Entertainment Weekly and Audible.

Sam lived in Mexico for ten years as a freelance writer before returning to the United States to cover immigration and drug trafficking and neighborhood stories and gangs for the L.A. Times. Wait until you hear how this crime reporter became an expert on opioids. And now please join me and our guest for A Second Opinion.

Humana - Sponsor for A Second Opinion Podcast with Senator Bill Frist. MD

Bill Frist:                       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.

Bill Frist:                       In today’s episode I’m excited to share a recent event where award-winning author and journalist, Sam Quinones and I sat down before a live audience to discuss the massive opioid epidemic in America. But before we get started I want to thank our sponsors. A Second Opinion is powered by Tivity Health, lifestyle brands that transform healthy living for adults through nutrition, fitness and social connection.

Bill Frist:                       We’re also brought to you by Humana, reminding small business owners that three out of four employees prefer health insurance over a pay raise. Good for business, good for you, learn more at humana.com/goodforbusiness.

Bill Frist:                       Now, let’s turn to the episode. Sam Quinones is a journalist, story teller and author of the enthralling book, Dreamland: the Tale of America’s Opiate Epidemic. Dreamland won a National Book’s Critics Circle Award for the best non-fiction book of 2015 and was selected as one of the best books of 2015 by Amazon.com, Slate.com, The Daily Beast, Buzzfeed, The Seattle Times, Boston Globe, St. Louis Post-Dispatch, Entertainment Weekly and Audible.

Bill Frist:                       Sam lived in Mexico for ten years as a freelance writer before returning to the United States to cover immigration and drug trafficking and neighborhood stories and gangs for the L.A. Times. Wait until you hear how this crime reporter became an expert on opioids. And now please join me and our guest for A Second Opinion.

Bill Frist:                       Let’s start there. There was a letter to the editor and that letter to the editor … and you tell the story in your book in a beautiful way. But, I think it is a good starting point for us to start. It was a nondescript letter to the editor. Some people look through them, some people don’t. But start there and let’s walk through the story.

Sam Quinones:             Sure, this letter to the editor is now known famously as the Porter Jick letter, written by Jane Porter but really, I think, written by the … the author is really Dr. Herschel Jick and he had a patient database of hospital records that he used to ask lots of questions of the data and one of them was, one day he told me, “I just decided, I think I read a story in the paper and I decided how many people of my hospital records, how many of these folks were given narcotic painkillers while in the hospital and how many grew addicted. And the first number was 11,000 plus and the second number was four.”

Sam Quinones:             Remember these are all people in hospital. Nobody’s taking bottles of the stuff home. It’s all very, very scrutinized. And he writes this 101 word letter and that gets published and he forgets all about it. It’s a letter to the editor. Why would that matter, at all? But, along the way what happens is that there’s a beginnings of this revolution in pain management started with pain specialists who believe that we need to make far greater use of these narcotic painkillers and they were probably right, that we did not use them appropriately. There were more uses for them than that were being given.

Sam Quinones:             But, in order to push docs to get over the fear of use … they began to make the argument these pills were virtually non-addictive when used to treat pain and they said, claiming science now knew this but the truth is they didn’t have any proof that that was the case.

Bill Frist:                       This is 1980s.

Sam Quinones:             The letter’s published in the 80s, in 1980, but then it’s later on in the 80s when this movements begins to kind of gain some traction. [crosstalk]

Bill Frist:                       The whole pain-

Sam Quinones:             And then into the early 90s.

Bill Frist:                       So let’s come into that a little bit. But at that point in the 80s the letter itself was accurate.

Sam Quinones:             Correct.

Bill Frist:                       But, opiates were limited to hospitals. They weren’t out like this as Sam said and therefore the headline of the letter was what? I’ve forgotten.

Sam Quinones:             Oh, Addiction Rare in Patients … Addiction Rare in Patients Treated with Narcotics, which is an unfortunate headline because it leaves out the crucial fact, while in a hospital and only in a hospital and it’s totally misinterpreted. Essentially it was misinterpreted by the people who later used it as footnotes and sited it in papers. The author, Dr. Jick, was correct. If you give narcotics only in a hospital under very strict scrutiny, and you don’t allow people to meander around with it and take bottles of it home and there’s … and multiply that by millions of people every year, yes, then that, then there will be … the lesson is, under very limited uses there will be less, almost no addiction and that’s what he found.

Sam Quinones:             But, they misinterpreted it and then it became kind of misconstrued and then, of course, this whole, is a, say occasionally this game of telephone ensued where people began to talk about it and no one’s actually read it because that would require you having to go back to the New England Journal of Medicine, 1980-

Bill Frist:                       [crosstalk 00:05:37]. We didn’t have internet just to look at-

Sam Quinones:             No, and even when they did have internet, for the first few years of the internet, that was not up. I called the New England Journal of Medicine, “when did you put the 1980 editions of … and that wasn’t until 2010. So, there were many years, even if you had the internet you wouldn’t have been able to find that.

Bill Frist:                       So, in the 80s and 90s … so we had this little nondescript letter which was accurate that ultimately got twisted again and again and again to use for evidence that these drugs were safe and non-addictive. The letter didn’t say that, basically said that if it’s appropriately used in the hospital it’s not a problem. So, then you had this explosion of pain specialists, the expectation of all of us that we should get rid of pain, totally. Just elaborate on that-

Sam Quinones:             No, I believe that that is also crucial, that doctors were … so we have the pain specialists together with pharma companies that are saying, “this is the truth, the new truth that we should have known but we now know and you’ve got to get with the program.” You’ve got to get … and that these pills are virtually non-addictive and therefore, of course, it doesn’t matter how many of the pills you prescribe.

Sam Quinones:             For instance, in pain that’s where you get all these pills like I got and many of you, I’m sure. You have routine surgery, you go home, two days of pain, three days of pain, you get 30 days of pain pills, maybe 60, maybe refills. You can go on and on. It can be endless because if they’re virtually non-addictive what does it matter how many you prescribe.

Sam Quinones:             At the same, though, I really do believe that a crucial component of all this, I did not understand this when I started the book, I came to understand this more completely, I think, as time went on. And, that is, that as Americans we kind of wanted our pain cured. And, doctors really don’t have a cure for pain. They have approaches and ways of dealing with it but when we demand that all our pain be fixed and quickly, too, and that if we don’t get it that way that there’re now patient evaluations of doctors and you can ding a doctor.

Sam Quinones:             You can say, “no, this person did not treat my pain sufficiently.” Well, why not? Well that’s not asked. There’s not a whole lot of background to it. It’s just no and docs can get dinged. Hospitals can get dinged for that. So, you have this really strong feeling from doctors that Americans are changing. I talked with one doc in Appalachia in West Virginia and he said, “when I first started our patients were stoic. They come in, and they rarely … they don’t want to seem like they’re complaining. They would just, to a fault, they really shouldn’t have been so stoic. They should have come in earlier but … and then it gradually began to change and soon it’s patients demanding pills for … antibiotics for cold symptoms. Demanding that their … and the idea was that you went to a doctor and you left without a prescription it was somehow a failed doctor’s appointment. That every appointment had to come away with that or a refill or what have you.”

Sam Quinones:             And, in time, yeah, I think this also was sold to doctors. You know, one of the crucial things in all of this, this was sold to doctors as a boon for their practice, particularly general practitioners because they were having to deal with a new managed care that meant 12, 13 minutes per patient and pain patients take up a lot of time. They’re going to be there for an hour and that’s going to totally screw up your entire day. And, so pain pills will get them out of there. Right? You write the prescription, they’re on their way. They’re happy because you gave them the pills that they wanted. You’re happy because they got the heck out of your office. Fabulous.

Bill Frist:                       And, this does apply to other specialty drug discussions we have today where you see an advertisement, it takes a cure, it may be very expensive but patient’s will come in and I think just listening to you, the culture in America is immediate relief, it’s expediency, it’s getting things … if I’ve got a problem give me a pill for it. Cultural, and that’s why they ultimately will come around that we all have to be engaged and the rising expectations that we can make anything go away with a pill. What was the role, and again, I’m going to back off our time line a little bit, Valium, what-

Sam Quinones:             Yeah. [crosstalk] began. A crucial thing of Valium in all this is … well, there’s several things that are interesting about Valium, but one of them is, that it was made into the first billion dollar drug for the pharmaceutical industry. This is in the early 60s, many of you might remember. One way it was done was, this was before the feminist movement and it was, therefore, the idea was that women could not get addicted because this was addressing a natural phenomenon in women which is that they’re hysterical or they get very anxious and so on. And, so you’re going to need this because you’re a woman and the addiction idea didn’t really … but the crucial thing as it relates to this, is it becomes one of those pills that you can take. It’s mother’s little helper, kind of thing, the Rolling Stones, all that stuff.

Sam Quinones:             But, the other thing is that it was promoted with a new strategy devised by Arthur Sackler, of later to be famous as one of the brothers who later purchased Purdue Pharma and I’ll get to him in a minute, very interesting guy. But, Arthur Sackler really revolutionized pharmaceutical marketing by beginning this idea that pharmaceutical sales people had to be in constant touch with doctors, post cards, something, visits, whatever it was, giving stuff away. And, he, through that, those early, early strategies that were later very much refined, years later, he turned Valium into the first billion dollar drug.

Sam Quinones:             I will say this, Arthur Sackler died nine years before OxyContin. His heirs divested from Purdue Pharma. He, I believe, had, I believe, I don’t know this because I haven’t spoken to his heirs. But, a fairly ethical guy. He was the first one to run an integrated blood bank in New York City. First, one of the early, early anti-smokers. You could not work in his office if you smoked. This was in the 50s, imagine that. He was a great psychiatrist, had had a career already as a psychiatrist before he revolutionized pharmaceutical marketing. And, he also had a rule, according to … he formed a marketing firm but would not allow that marketing firm to work for Purdue while he owned it. That was like a conflict.

Sam Quinones:             Later, when OxyContin came out he was dead nine years by then. His heirs were divested of the company and that firm later was the one who promoted OxyContin and worked, there was no conflict apparently anymore, according to current owners. So, his two brothers and their heirs continued on with Purdue Pharma. Arthur Sackler, his name is on … if you go to the mall in Washington, D.C. the Arthur Sackler, can’t remember the full name but it’s an Asian art gallery. He was one of the great Asian art collectors in the world before he died. And, the whole Sackler family is a whole saga, worthy of a soap opera.

Sam Quinones:             But, basically, he was the one … and I think Valium began … I found that very interesting because Valium began the culture of relying on pills to solve every problem.

Bill Frist:                       So we have a culture that seeks immediacy, immediate relief through a pill and that started probably in the 70s, by the 80s. Valium, obviously, through the marketing that the supply started being there. We have physicians who, basically, were taught as I went through my residency in the later 80s and then came back to Vanderbilt, the teaching became among medical professionals that the opiates are safe and that it is our ethical obligation to get rid of pain.

Sam Quinones:             Almost a mission.

Bill Frist:                       That’s exactly right and that is, yeah, it was a fifth vital sign like blood pressure or heart rate. Do you have pain? If any of those you check off, you get rid of it and so, we, as a profession, we’re told to get rid of pain. Legislators, and in Tennessee our legislators here, because of the culture, because of the science, although the science came out of this one little op-ed, the legislators in Tennessee and across the country actually legislated pain clinics to lower the threshold, to get the drugs out or get whatever modes to get rid of pain.

Bill Frist:                       And, so, in any of those categories, the culture or the pain or the legislation, what would you add to that because you’ve kind of walked through the-

Sam Quinones:             I would only add that it seemed to me too, that as Americans, we wanted … the pills fit perfectly because we were in an era where I believe we decided that our own accountability didn’t matter, personal accountability and so, therefore, you could … a doctor really ought to take most patients aside and say, “you really don’t need these pills. These pills are not necessary for your pain. What you more likely need is to do the work.” Get in shape, exercise more, of course, that’s one of the … if there’s a magic bullet to any pain, it’s exercise, even though there isn’t really a magic bullet, but that is certainly comes close.

Sam Quinones:             So, exercise, better diet, a variety of other things that really require us to do more work and to change our behaviors, drinking, smoking, eating fried foods, eating et cetera, that kind of thing. And, so, we like the idea that we didn’t have to actually … this was easy, it was quick, and we like the idea that we … everybody else had to be accountable. Doctors had to be accountable. Cops, politicians. We did not really feel so much the need to be personally accountable in this. You know it’s weird, as I realize that this was part of the story in the middle of the book I did not understand that it was part of the story when I started the whole thing.

Sam Quinones:             I stopped. I changed my consuming, I stopped, the main thing was that I stopped, cut way down on the amount of sugar, my intake, I consumed. So I no longer drink sodas or sweet teas or any of that kind of stuff. I used to drink quite a lot of Coca-Cola and I don’t do that anymore. I just felt like this was all, we had to be a part of the change. Individual responsibility turns out to be an important part of this whole story, as well. And you multiply that by millions and millions of Americans, you get an outcome that you don’t really want. So I felt like, so that’s kind of my own way. But I do believe that overlaid on all that … all that stuff was overlaid on this idea that we, as Americans … won the Cold War, we kind of exceptional, all that stuff and so therefore we shouldn’t be asked to tolerate pain or difficulty, I guess, disappointment.

Bill Frist:                       And, this gets into how do you treat pain and we don’t have time but we can come to that in a little bit. How far do you go in getting rid of pain? How much pain should we tolerate? Should we reimburse for other modalities of pain treatment, which insurance companies don’t today. All of these are sort of coming through my mind. I hope you get to many of them. One last element is the pharmaceutical companies and the story with Sackler, I just learned a lot from that, but it still seems to me, the science of the addictive potential was suppressed. My profession is out still writing the prescriptions, obviously and we’re getting better and legislation’s getting better. The role of the pharmaceutical companies still seems to me and the motive to make money, the motive to go global, based on bad science. So, my question is, in all your reading and studying, did the pharmaceutical companies purposely mislead physicians, the medical profession and the consumer in promoting what clearly is a profit to them?

Sam Quinones:             Sure, I think that’s been shown to be the case, and I think the more … what’s interesting now that … I’m stunned by what’s gone on in the last few years, since the book came out. When I was writing the book there were three lawsuits against pharma companies, right? Chicago, Orange County and Santa Clara County in California. Now, there are, I believe, 2000 plaintiffs, right? Tribes, cities, counties, a lot of counties, attorney general, all of those groups. And, they are now … and what’s happened is, that through their subpoena power, particularly the attorney’s general, have been able to unearth all this new stuff that I guess we don’t live in an era of the United States when reporters have subpoena power. We’re getting there. I can’t wait for that to happen, actually.

Sam Quinones:             So, no more, no comment, okay? You’re just going to answer, or I’m going to put you in jail. No. [crosstalk 00:19:27]. But now, with subpoena power and all this investigative resources your own attorney general put out a 270 page document that I was like, “Oh, whoa. That’s incredible.” And the Massachusetts had done the same. New York, I think maybe there may be a couple more to follow. All of that has filled in huge, gaping holes in our knowledge that I also had of what had gone on and what has gone on in the last few years, and I think more and more that stuff comes out, we’re going to see this incidence was just, the executives, the CEOs just convicted there.

Sam Quinones:             You’re going to find these cases coming out that of outrageous … the feeling really, what dawns on me is these folks felt that no one would say no. It seems to me like there was nobody standing in their way, and they could say almost anything. Maybe because of their own hubris because of having been pill salesmen for so long in a culture that wants a pill for everything, I don’t know, I’m not sure, but certainly that seems like part of the story where you have these guys who are like, you know it’s going to be a little bit like, we’ll look back on this era a little bit like the robber barons or the leverage buyout guys of the 1980s or whatever. Michael Milken is the face of that. Ivan Boesky, now you’ve got the Sackler family.

Bill Frist:                       And now, a quick word from our sponsors that make this podcast possible. Tivity Health does health differently. It promotes a proactive approach in achieving a healthy lifestyle that embodies the leading social determinants of health, food and security, physical activity and social connection. With its family of healthy lifestyle brands including Silver Sneakers and Nutrisystem, Tivity Health is making an impact in reducing factors that lead to serious health issues and high medical costs, such as chronic conditions, obesity, inactivity, social isolation and loneliness. To learn more, go to tivityhealth.com.

Bill Frist:                       Humana reminds small businesses that three out of four employees prefer health insurance over a pay raise. Being a business owner is a big responsibility. At Humana, we get that. That’s why we have health insurance plans for you and your employees with flexible plans that fit your budget, too. Good for business, good for you. Learn more at Humana.com/goodforbusiness.

Bill Frist:                       And, now, back to the episode.

Bill Frist:                       Well, much of what we have talked about is, again, looking at the landscape and looking at the big picture and the problem and the why and it’s important to understand why because ultimately all of us working together are the only way we’re going to reverse it. It’s not going to be the doctors. It’s not going to be the pharmaceutical company. It will be the culture, in many ways, and most of the time we spend is sort of defining the problem and I want to ask one more question before going to real human side of this which is what the open door is all about and what we really do … and you focus on it in the book, we just haven’t so far but what it does to individuals and families but more importantly what can be done as we move ahead. Before coming to that, which is the most important part, just for clarity explain these waves because we had the heroin, we have methamphetamine, we have opioids, and then we have, what you don’t cover in the book because it’s so new, the Fentanyl explosion.

Sam Quinones:             Right.

Bill Frist:                       But just paint this as sort of a timeline and reasons and why’s so we can put that in our mind and insert all these other factors.

Sam Quinones:             Sure, I mean, well I had my first job, what I consider kind of graduate school for me, was I covered crime in the city of Stockton, California, which if you know Stockton is a wonderful place to be a crime reporter, a lot of crime in Stockton-

Audience:                    Yeah.

Sam Quinones:             I was … if there was a drug I was addicted to it was covering crime. I was running like a mad man. I loved it. Such a wild time. But that was during the crack epidemic and that’s what I had to compare this to. So, in the 70s we have the heroin problem but really it doesn’t compare to this because the heroin that we had coming in was from the Far East and it was very, very diluted and very expensive because it came from the Far East.

Bill Frist:                       What’s the difference between heroin and cocaine?

Sam Quinones:             Well, heroin is a depressant. Comes from, grown from, derived from the opium poppy. The first drug that we, as a species, ever harnessed as a drug. Going back you can read about it in the Greeks and the Romans. I mean it’s been a long time. Egypt, 2000, 3000 years before Christ, was the center of opium production in the world.

Sam Quinones:             Cocaine is a stimulant and made from the coca leaf which only grows in a few parts of the world, Bolivia and Colombia [crosstalk]

Bill Frist:                       Okay, so heroin peaked when?

Sam Quinones:             I would say by the end of the 70s, early 80s, really end of the 70s you begin to see that dropping. And, then cocaine, with all the Colombian tonnage of cocaine, huge amounts of cocaine and you see Miami’s crime rate begin to soar. They become the murder capital of the world … I’m sorry of America.

Bill Frist:                       And what years was that?

Sam Quinones:             That was early 80s, so 81, 82, 83-

Bill Frist:                       Why did cocaine replace heroin?

Sam Quinones:             There is, I’m not sure I would be the one to know. But there is, they say that we go through these cycles of depressants and stimulants and depressants and on and on from that kind of thing. I would say that there’s … so then you have-

Bill Frist:                       Heroin, cocaine, then what?

Sam Quinones:             And then crack. Somebody develops a way of making cocaine … before cocaine, in order to really get the full rush you’d have to freebase it … it was called freebasing which is you light it up with ether. Richard Pryor did this and it blew up and he got caught fire.

Bill Frist:                       Right.

Sam Quinones:             Well, crack was a way of freebasing without ether, without a flame, without this very, very dangerous method of freebasing and somebody figured out if you cooked cocaine with baking soda and water in a microwave it’ll turn hard. You crack it, rock it up and you just crack and smoke it like that and boom, it goes right to your brain. Crack revolutionized the underworld. It transformed cities. It did enormous damage. It also brought with it an enormous competition for markets that had the form of gang violence and in L.A. believe me … and Stockton, when I was there, it was all about the gangs and drive-bys and carjackings and on and on.

Sam Quinones:             It was very, very … mostly crack, in my opinion, what I remember of it, and, I remember those years pretty well, it was a drug that brought with it lots of violence, unlike other drugs. This seemed to breed competition for turf and that seemed to breed a lot of other things. And, of course, the money allowed for a lot of weaponry. We went through a phase where that began to decline there.

Bill Frist:                       When was that? When did that start to decline?

Sam Quinones:             I would say, it kind of depends but I would think-

Bill Frist:                       What do you think?

Sam Quinones:             Like the mid-90s, late 90s, really.

Bill Frist:                       Okay, and then what?

Sam Quinones:             And then you get methamphetamine, which is another stimulant, not made from a plant, made from chemicals.

Bill Frist:                       And, where’d that come from? Methamphetamines, where’d it come from?

Sam Quinones:             Initially, well, in the drug world of America basically it starts with a very complicated method of making it that’s mainly done by Hells Angels and biker gangs. They do it out in the desert because this method is very complicated and smelly. You can smell … but then somebody rediscovers the recipe for making methamphetamine that the Nazis invented. There’s a company during the Third Reich invented methamphetamine. They called it Torvanol? I can’t remember what they called it. It was the brand name for it. The entire country was basically on methamphetamine, most of the soldiers.

Sam Quinones:             And, that recipe got lost but it uses ephedrine from Sudafed and all those … and that got rediscovered and I remember that being … I would say that was roughly, I was a crime reporter then, it was roughly about 1990 or 91 or 92, right in there when you began to see these new ways. And, that allows for methamphetamine to be made in the bathroom down hall. And, so you don’t have to be out in the desert. But, that also allows for Mexican drug traffickers. They eventually take it so it goes from being a low income white drug to being also later on you began to see this in L.A. for sure, a basically a Latino drug and run by Mexican guys who learn to make it from the biker gang folks.

Sam Quinones:             And, as that is developing and progressing-

Bill Frist:                       Just so people will know, he’s talking about L.A. and gangs and all, Tennessee was the number three methamphetamine in the United States of America. So, when you hear it from somebody and all that remember we’re the worst of the worst here in Tennessee and it’s amazing because you look at Nashville, and middle Tennessee and you look at the prosperity and all, just recognize that this is us. But keep talking. So methamphetamine-

Sam Quinones:             The idea though … was the reason that happened was because of the ephedrine method. You cannot make mass quantities of speed, whether it was called speed or crank or whatever, meth, back then, crystal meth, using the P2, the Hells Angels method. It’s just too expensive and too smelly and too difficult and so the ephedrine method revolutionized it and made it everybody could make it and you can also make it the shake and bake, the Mountain Dew bottles you know where you’re making the little bits of meth. That’s how you make it. You’re not using these older methods and so that again, these methods of making drugs revolutionized the world or the country, certainly.

Sam Quinones:             And, then as all that’s progressing, we have, for the first time, a new scourge developing in a … for the first time in a new way. No longer Mafias, no longer street dealers, no longer gangs and so on, it’s doctors and that’s about the time when as meth is diverting our attention and crack was and now meth and all that stuff, meanwhile, from a new source, the supply’s coming from a new source and that is doctors and pharma companies and this whole thing that we’ve just described and that’s a new explosion of a depressant.

Bill Frist:                       So. Everything that we have now is 100 times worse than any of these others in the past?

Sam Quinones:             Yes. There are far more deaths. There’s no doubt about that and partially that’s because … and there’s far more widespread heroin use and when we awaken the heroin sub-culture in Mexico, then later on, many years later, discovers that Fentanyl, why continue to loan land and grown plants when we just have a heroin substitute that’s so much easier and quicker and more potent-

Bill Frist:                       What do you … explain this a little bit because I’m just beginning to understand it. You have these waves and the book and what we’re talking about today is addiction and just like open door it’s not just opiate addiction. Now this last wave, since the book, is Fentanyl. And why Fentanyl and why is it so much worse than even the opiates of five years ago?

Sam Quinones:             Actually, that’s the topic of my next book. That’s why I’m working on now.

Bill Frist:                       Give us a preview.

Sam Quinones:             Okay, I will. Basically, that in the drug world it is far, far … you have to always think, of course, about drugs as a business, that’s the main thing. And, without soul, without morals, without ethics, right? And so, obviously, it’s a better business decision to make your drugs in a warehouse than to own land, employ peasant farmers to harvest the plants there, wait for the season to be right, on and on and on and all this stuff that makes it a very laborious process.

Sam Quinones:             Now, they learned that with methamphetamine. Mexican cartels learn and drug trafficking groups learned how to make their own drugs. They don’t like the Colombians. They don’t want to rely on the Colombians for cocaine so they figure out, “gee, it’s a much better idea to make methamphetamine and you get the precursors and it’s not a problem. You get that from China, you get that from Chile, you get that from India. Fentanyl was like another version of that. It’s like the synthetic version of heroin. It’s much cheaper to make. Much cheaper to smuggle. It’s almost impossible to stop it from being smuggled. No wall is going stop that, ever.

Sam Quinones:             And, then it tends to … it’s much more potent and so it tends to addict people and when you have addicted someone certainly to opiates the most potent kind of addiction we know, they always are your customer, all day long. There’s never, it’s not like cocaine, where you go, “I don’t think I can use any cocaine today.” Uh-uh (negative), Uh-uh (negative). You’re going to use this every day. It’s a perfect drug for the underworld because it creates a customer who must have your drug. So, Fentanyl reduces all of that cost that went into growing heroin, poppies and then harvesting and then cooking and then turning it and then trafficking it, into a few, down to a few folks. You don’t need all of that big supply chain anymore.

Sam Quinones:             And, they learned that that was the way to go from methamphetamine and then they copied that and then they have now, of course, in the recent, I would say, last two years since the summer of 2017, precisely, they have gone back … now they go back to methamphetamine. And you’re seeing this all across Tennessee and you’re seeing this in many places I’ve been. It’s a remarkable shift. Never in the history of drugs in America have we seen large numbers of opiate addicts take a right turn and start using a stimulant like within months.

Bill Frist:                       And, right now, if say 25 people will die this week of opioid and that’s just the tip of the iceberg, will half of them be on Fentanyl in the blood or all of them or-

Sam Quinones:             Yeah, and also a lot of people on meth. I talked with this guy who runs a sober living house in northern Kentucky where I’m going tomorrow and he said, “the guys, when they first came in, did a urine test, they all said, well, I’m doing meth.” Yeah, they tested positive for meth and for Fentanyl because Fentanyl’s being mixed into the cocaine, it’s being mixed into the methamphetamine and I think it’s essentially crowded out heroin. I don’t believe there’s much heroin anymore. The market for heroin in Mexico has collapsed. Just the same way that the Mexican and Colombian heroin kind of crowded out all that Far Eastern heroin in the 1980s, basically, so has Fentanyl crowded out all the what you would call organic heroin coming from the poppy.

Bill Frist:                       So, next door clearly takes us to the world of assisting, giving people hope through treatment and that sort of brings us into the individual today. If you had to come back to a root cause and there’s not a root cause but as we try to figure out how to respond to what we’ve defined as the problem, the word loneliness keeps coming up. But, that’s not the root cause but we have the internet, we have social media, we have Facebook and the average person today will be spending 58 minutes just on Facebook, that doesn’t include Instagram and YouTube. But in spite of all of that … which is an amazing statistic. But in spite of that we still have this loneliness. How prominent or how important is that in terms of where we are today and as we look to solutions should we be focusing on that?

Sam Quinones:             It’s strange, Senator. When I first started the book, I wrote a book about … I wrote a book proposal that talked about pharmaceutical marketing and Mexican heroin trafficking and that was it. I thought that was the story and the more I got into it, the more I realized actually, there was … it was this onion, I began to peel away these … and I began to realize there was all these things that were much, they were connected to this story that I couldn’t … all of a sudden I began to realize, “oh my God, this is a huge story.” Much bigger than I actually thought I was writing when I began. And I began to realize that our own isolation from each other was huge. That our own destruction of community, you can see this in a lot of places. You could see this in the Rust Belt, where those jobs … where we have treated certain areas like losers.

Sam Quinones:             Like, “well you lost in free trade, so we don’t really care. So, all your steel jobs or all your manufacturing has gone somewhere else.” Those towns lose that bulwark that protects them against these kind of social problems, and they become very … half the town leaves, very isolated, destruct … the community has been destroyed. They’ve become very vulnerable like the Indians when the Europeans brought smallpox. But you see this also in other places. In wealthy suburbs, this is a big problem in wealthy suburbs now, I think or middle class suburbs where people don’t know each other. There’s no mechanism through which we participate. We’re indoors all the time.

Sam Quinones:             I tell this story often when I’m speaking that when I was in grade school my mom was from Iowa and she, we grew up in Southern California, my mom every afternoon would go to the sidewalk. She had a farm bell from Iowa and she would ring that farm bell and that was a sign for her boys, there were four of us, to run home for dinner, every day. And, I think that was pretty much the sign for most the kids on the block were just going to run home for dinner because Sam’s mom’s ringing the bell. Now, why did she do that? Because she didn’t know where the hell we were. We could be anywhere so that bell was the only way. And, now you go … I tell you one thing she knew, a place she knew we’d never be and that’s inside the house on a sunny Southern California … that we’re never going to be there.

Sam Quinones:             And so, now, I go back to that same street, right? Same place, lowest price housing in the town where I grew up is like that area where I grew up. And, there’s nobody on the … it’s like nobody’s around. The beautiful park around the corner, I played football, rode bikes, done basketball all day long at that park and there is never anybody in that … it’s a ghost town. It’s a very … and that is kind of what we’ve done all across this country and that’s why I get, I say this is not necessarily an economic issue. You see this in middle class and in wealthy areas too and so it’s more about isolation.

Sam Quinones:             You know that’s what makes this class of drugs, opiates, is the most isolating class of drugs we know as a species. What happens when you addicted, you just settle into your own little cocoon, right? You don’t want to talk to anybody. You certainly don’t want to talk to anybody who doesn’t know where to buy dope, how to use dope, what kind of good dope is. That kind of stuff. And, so it seems like this is the poster child kind of almost this class of drugs, opiates, pills, heroin, Fentanyl, whatever, is a poster child for our culture, almost. Like this is what we’ve created the last 30 years. This culture of isolation and people just kind of not knowing each other and then being told, also, by social media and 24 hour cable news, which are like the most toxic influences on our culture.

Sam Quinones:             That everybody else who’s not like you is somehow devious or somehow not anybody to want to know and then what’s fascinating, I’ve been talking … I’ve been traveling around this country, talking about this topic for a long time, and I have been to blue areas, and I have been to red areas, and the response is always the same. Everyone’s like, “yeah, I know. I know.” Right? And once you get to know the other person it’s actually not that big a difference between them. And, that has been my great revelation. I was like, you know what? This is a bunch of crap. We turned off … we don’t have cable TV in my house because I’m not going to be paying for garbage to be dumped in my living room every night, you know what I mean? So, I just said, “screw that. We’re getting rid of that crap.” So, 24 hour cable news, I watch it when I’m in these hotels, and I go, “bam, thank God I don’t have to watch you anymore.”

Audience:                    Whoo.

Sam Quinones:             Sad thing is, back in the early days of CNN it was actually a valid news, news station. It has become … I believe Fox News has never been. But CNN is now mimicking the worst tendencies of Fox News, and it’s impossible to watch CNN, in my opinion, now. I cannot bear to watch it. So-

Bill Frist:                       Let’s go to questions here-

Sam Quinones:             Fine.

Bill Frist:                       No.

Sam Quinones:             Enough of me preaching, I’m sorry.

Bill Frist:                       No, that’s all right. No, I love it. [crosstalk] Listen-

Sam Quinones:             Turn it all off. Through it out the window. I’m mad as hell.

Bill Frist:                       You know, the words of that, just listening, again, I hear movement and activity is important, just listening to you.

Sam Quinones:             Mm-hmm (affirmative)-

Bill Frist:                       And, getting out of the chair, getting outside, moving and the other thing I hear is just isolation, which to me is both very encouraging because that’s something that all of us can do in our lives with our kids, with our families, with our … not driving quite so much and walking into the grocery store and all of that. [crosstalk]

Sam Quinones:             Yeah, and walking out.

Bill Frist:                       And then the isolation end of it of taking exactly what the next door does, is the human touch itself and of capturing people both emotionally or affirming them or just saying hi or spending a little more time in conversation. And, that’s something we can all do and when I hear you talk, we’re not going to be able to turn off Facebook, it would be good to and I think we need to encourage that and control it but social media is here but what can push it to the side and crowd it out is the human touch.

Bill Frist:                       This episode of A Second Opinion was produced by Todd Schlosser, the Motus Creative Group team and SnapShot Interactive. You can subscribe to A Second Opinion on Apple Podcast or wherever you are listening right now and be sure to rate and review A Second Opinion, so we can continue to bring you great content.

Bill Frist:                       You can get more information about the show, its guests and sponsors at asecondopinionpodcast.com. That’s asecondopinionpodcast.com. Thank you again to our sponsors, Tivity Health and Humana. Be sure to join us for our next episode with Paul Ketchel, a former Senate staffer of mine who went on to found MDsave, the world’s first transactional healthcare marketplace. A Second Opinion broadcasts from Nashville, Tennessee, the nation’s Silicon Valley of health services where we engage at the intersection of policy, medicine, and innovation.