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This whole season we’ve focused on how to help people with substance use disorders. We’ve talked about the importance of harm-reduction and human connection, destigmatization and education. But to at least one of our listeners—a really important one—something is missing. Why not talk about punishing the people who make and sell drugs? China, Mexico, Purdue, the Sacklers? This week, we talk to two experts—Ben Westhoff, author of Fentanyl, Inc. and David Smith, a healthcare economist—about why it’s so hard to control supply, who’s really to blame, and the potential long-term benefits of billions of dollars in settlement money.

Transcript

[00:01] Stephanie Wittels Wachs: If you consider yourself a Last Day listener, which I hope you do, Lemonada Media has some interesting crossover happening in our show content at the moment that I think will be of interest. On this week’s episode of Mouthpeace with Michael and Pele Bennett, the guest is Freeway Rick Ross, a famous reformed drug dealer. The conversation touches on some surprising and some really relevant themes about addiction as a disease, the role of incarceration, and second chances and redemption. Freeway Rick Ross’s perspective is so clearly connected to the things we’ve been talking about and exploring this season together, so please check out Mouthpeace from Lemonada Media. The episode is called Crack and Redemption. And if you like what you hear, go back and listen to the new Mouthpeace series from the start.

 

[01:00] Stefano Cordova Sr.: I think you guys are really pushing, pushing into this field that there is a solution for this addiction. This is mental sickness and so forth. There’s a couple of things that I think that still the show is missing, but that’s just my personal opinion.

 

[01:20] Stephanie Wittels Wachs: Remember this iconic voice? I mean, how could you not? This is the voice of Stefano Sr., the father of Jess, our executive producer, and Stefano Jr., who we got to know in the first half of our season. Stefano Sr. and I caught up back in November for episode 12. You can hear more of our conversation there. And like a dad, he had some suggestions at the time for how we could improve the show.

 

[01:50] Stephanie Wittels Wachs: Oh, my gosh. I want to know. I want to know, what do you think? What do you think is missing?

 

[01:54] Stefano Cordova Sr.: Well, think about it. We are playing defensive. We are trying to help people from the medical point, a system point, you know, in some case, economic point. But nobody’s doing nothing about the source. And nobody’s doing anything about who’s producing fentanyl. There is no war against production. Nobody’s talking about why is this fentanyl produced? Why is China producing 99 percent. Why 40,000 people have to die every year. And how do we stop it? And the other thing is that people sell the fentanyl. You know, what are we doing — I mean, if I go to the butcher and I buy a steak and the guy puts poison inside a steak and I die, he will be charged with homicide. Why is the person who sells fentanyl not considered a criminal? And the war on drug is always against the addicted, the people who are suffering. It has never been against the producer. And that’s a problem. I think that’s the one thing that we need to address. 

 

[03:01] Stephanie Wittels Wachs: I hear what you’re saying. Yeah. You know, we also haven’t really addressed the pharmaceutical companies, which are also at fault. So I feel like it’s almost like you take it for granted. Like there’s always going to be drugs, there’s always gonna be people selling drugs. But then I think you’re right, we need to question, why are there drugs? Why are they coming from China? You know, it’s a good question. 

 

[03:22] Stephanie Wittels Wachs: It is a good question. And even though we’ve managed to avoid it for the past 20 episodes, today we are going to address it head-on. Right here, right now, we are going to talk about production and supply, China and Mexico, Purdue, the Sacklers and the darkweb. Today, we point fingers and place blame. I’m Stephanie Wittels Wachs, and this is Last Day. 

 

[03:58] Stephanie Wittels Wachs: So let’s start with fentanyl. That super strong synthetic opioid that killed Jess’ brother Stefano. The drug that killed Emily from Episode 19, and Chris from episode 16. And basically fucking everyone nowadays. In 2017, 28,000 overdose deaths in the U.S. involved synthetic opioids. So I sat down with Ben Westhoff, who literally wrote the book on fentanyl — it’s called Fentanyl Inc. — to figure out where it’s coming from and what we can do about it. To start, I told him about Stefano Sr. and his desire to punish the bad guys. Turns out, since writing his book, Ben has heard from a lot of Stefano Sr. types, a.k.a. loving, grieving parents.

 

[04:50] Ben Westhoff: I’ve heard from so many parents and they all are pretty much spurred to action in some form or another. You know, you know this better than anyone. They want to feel like there’s purpose behind this awful thing that happened. And so I would say maybe half really feel like they want greater law and order. Often there are bills that are introduced in state legislatures that the parents get named after their deceased kid. And that’s the way people really feel like they can make a positive impact. And then there are the other half of parents who go the opposite way and think that harm reduction is the answer. You know, it sounds like you’re in the latter camp. And I certainly don’t fault anyone for feeling how they feel, but the more I learn about this, the more I tend to think the harm reduction is the answer. 

 

[05:50] Stephanie Wittels Wachs: OK! End of episode. We were right. See you next week. Jkjkjk. Why? Why is harm reduction the answer? Well, because Pandora’s Box has already been opened and trying to shut it is complicated. So let’s start with a very basic question. Why does fentanyl even exist? 

 

[06:15] Ben Westhoff: It has long been, and still is, an important medical drug. It’s used for women in childbirth often for epidurals. When men get colonoscopies, they’re given fentanyl. And cancer and end-of-life patients use like a fentanyl patch or even there’s a fentanyl lollipop. And no one really worried about it too much becoming a drug of abuse. Even the DEA put out this big report in 2016 that said basically fentanyl, it’s dangerous, but it’s really too dangerous, so users don’t want it. It’s too easy to overdose. But the DEA was completely wrong. That same year, fentanyl overtook heroin and pills and started killing more Americans than any drug in history. But what’s different about fentanyl than all other drug crises is that most people don’t want fentanyl. It’s instead cut into drugs that they do want. So it’s often cut into heroin, meth, cocaine and increasingly in pills. And it’s so cheap. It’s like a fraction of the cost to make it in a lab compared to heroin or cocaine, where you have to come from a natural plant. It takes a long time to grow it in a field. It’s more easily observable by law enforcement. But fentanyl can just be made in a lab, super cheap, super potent. It’s 50 times stronger than heroin. And so the Mexican cartels in particular are switching over from heroin to fentanyl as fast as they can. And that’s the case where a lot of places what’s being sold as heroin actually as fentanyl in it. And then a lot of places it’s starting to become that fentanyl is the only thing being sold and heroin is going away. 

 

[08:00] Stephanie Wittels Wachs: So when you’re making fentanyl, you never have to touch a poppy pod? I mean, there’s no opium involved at all. 

 

[08:06] Ben Westhoff: Correct. Yeah. Heroin and fentanyl, they affect the brain in the same way and they both impact these opioid receptors, but heroin comes from the natural plant, the opium poppy, and fentanyl is just a chemical from a lab. And when it comes from China, it’s pretty pure. But the cartels start cutting it up, you know, with different things like Benadryl, even caffeine, different cutting agents. It’s mixed with heroin. It’s, you know, it’s cut further at every step of the distribution chain. So the regional distributors cut it more. The local distributors and drug dealers more. The problem is that when it gets to the end-consumer, nobody knows how strong it is. And so you could take one batch that is totally benign, and there could be the next batch, which is enough to kill you. And even, in fact, in the same batch, it’s so hard to mix up, because such a tiny amount will kill you — it’s basically two milligrams, which is like two grains of rice worth of fentanyl is enough to kill you. So if you’re trying to mix two grains of rice worth to a normal batch of heroin, it’s almost impossible to mix that properly. And so that ultimately is what’s killing so many people.

 

[09:28] Stephanie Wittels Wachs: So how fast does it take to produce fentanyl? Like if you’re going to the lab, I’m going to make a batch of fentanyl. How long does that process take? 

 

[09:37] Ben Westhoff: I don’t think it takes more than a couple of days, really. You know, there’s many different types of fentanyl. There’s different levels of purity. But basically the hard part is getting these precursor ingredients. So the same way when people make meth, you know, all these backwood crank cooks used to hear about, they needed Sudafed from the pharmacy. The people making fentanyl need the fentanyl precursors. And so that’s the hard part. 

 

[10:08] Stephanie Wittels Wachs: Think of fentanyl precursors like the ingredients in a cake recipe, but a cake that kills people. So China can say, hey, we’re not shipping lethal cakes anywhere. We’re shipping flour. And if Mexico uses that flour to bake cakes that kill people, that’s on them. Now, the U.S. could say, whoa, whoa, whoa, ok, these cakes are out of control regardless of who’s baking them, so let’s just ban flour altogether. But that doesn’t work either, because flour is just too common of an ingredient. And then every time you try to pin down a specific flour, the chemists back in China simply tweak the molecular structure and then can claim it’s a whole new ingredient. It’s not all-purpose. It is whole wheat flour or spelt flour. Perhaps the fentanyl cake metaphor is running out of steam, but you get the idea. It is crazy-making and pretty impossible. So maybe trying to ban the main ingredients is a fool’s errand, but surely we can at least ban fentanyl itself. 

 

[11:13] Ben Westhoff: Well, they definitely have. And they’re trying to step up enforcement of all these packages. But the problem is there’s millions, literally millions of packages coming from China every year, you know, and tens of millions. And searching each one is impossible. Plus, it’s just such a tiny amount of fentanyl that’s needed, it’s very easy to hide it in other things. The majority tends to come over in these big shipping containers, on boats, actually. And so, you know how big one of those shipping containers is. And now, if you can fit a million doses of fentanyl in an area smaller than a briefcase, you can just imagine what a difficult task it is.

 

[11:58] Stephanie Wittels Wachs: Has there been any decrease like in fentanyl coming into the U.S. related to China passing laws banning the sale of fentanyl products? 

 

[12:07] Ben Westhoff: There is some indication that that is happening. So that is good news. The bad news is that we’re starting to see the trade shift to India. So China has this huge chemical industry with tons of trained scientists, chemists able to do this work. And India does also. And so, you know, just last year, there was a bunch of big fentanyl busts with Indian chemists doing business with the Mexican cartels. So, you know, ultimately, we’re never going to be able to control the supply side. That’s just the sad nature of it. And so when I talk to people, I tend to emphasize the demand side. What can we do to educate people about these drugs and to try to convince them not to use them?

 

[13:01] Stephanie Wittels Wachs: Ben makes a really good point here, because if the chemicals don’t come from China, they’ll come from India. The point of origin keeps changing and always will as long as there are human people in the world. But Ben mentioned the same destination again and again: Mexico. So how do we keep the drugs from crossing the border? Is it time for a — oh my god, I can’t believe I’m going to say this — wall?

 

[13:30] Ben Westhoff: Fentanyl is most often smuggled in vehicles that go through the traditional ports of entry. And so they’re in gas tanks and fake panels in cars and sometimes there’s underground tunnels. So, you know, everything I’ve read about it suggests that a border wall would do very little to stop this. And I wouldn’t want to say that police should allow this stuff to get through, but I just think our resources could be better used in getting to the root of the problem. And, you know, so many people who die have never even heard the word fentanyl and don’t even know what it is. And that should be job one. Educating those people. 

 

[14:15] Ben Westhoff: The thing that keeps me up at night is the pills market, because a lot more people abuse pills than abuse heroin. You know, a lot of people don’t want to put a needle in their veins. They don’t even want to have anything to do with heroin. But pills, because it’s, you know, prescribed by a doctor. It seems legitimate. People don’t think it’s going to kill them, are much more widely abused. And it’s only starting — pills are only starting to be adulterated with fentanyl. And we’ve seen the deaths of Prince, Tom Petty, Mac Miller, Lil Peep, Juice Wrld — every time I talk about this, the list gets longer — all people who didn’t know they were getting fentanyl in their pills. But it’s only the tip of the iceberg. If fentanyl is truly put into the pill market across the country, the death rate will soar even more.

 

[15:09] Stephanie Wittels Wachs: Why are we putting fentanyl in pills? I don’t understand. What is even the point of putting fentanyl in pills?

 

[15:16] Ben Westhoff: It’s just so much cheaper. So these aren’t, you know, legitimate pills that come from the manufacturer. These are made on pill presses that people use in their own apartments. And these machines are so sophisticated that they can press a powdered fentanyl, or some sort of combination of fentanyl and something else, to look exactly like a prescription pill with, you know, like exactly like OxyContin or Percocet or Xanax or whatever. And so users can’t even tell the difference. 

 

[15:48] Stephanie Wittels Wachs: So this all feels like a whole new layer of nightmare. And thanks to the convenience of online shopping, government employees may be the newest dealers on the block. Because now mail carriers all over America are unknowingly delivering fentanyl right to people’s doorsteps.

 

[16:08] Ben Westhoff: The dark web is really easy way to do it, and a lot of people do. There are lots of markets, sometimes they get shut down, but then they pop back up. The most famous is the Silk Road and there’s like a new Silk Road, the third version or fourth iteration even that has nothing to do with the original one. 

 

[16:31] Stephanie Wittels Wachs: The Silk Road of today, as opposed to the ancient trading route between Asia and Europe, was the first modern dark net marketplace. It’s a lot like Amazon only instead of shower curtains and diapers, it’s where you could go to buy illegal drugs.

 

[16:47] Ben Westhoff: It’s very hard for law enforcement to stop these deliveries. And there’s even like an Amazon rating system for people to know if these different markets, these different vendors, are likely to sell them what they say they’re selling them. And there are actually some harm reduction organizations, including when I talked to in Spain, that are in favor of some of these black markets and the way that they do kind of filter out the shady street dealer element of it. And I certainly, you know, I see where they’re coming from about that, because when there’s certainly no quality control, when you’re getting pills or powders from a street dealer. And that definitely you can get bunk stuff off the dark web very easily as well. But so the thing I always tell people is that these fentanyl testing strips and drug checking kits sold by companies like the Bunk Police are really your best option if you’re going to do drugs. 

 

[17:47] Stephanie Wittels Wachs: Fentanyl test strips are a shockingly simple way to make drug use less deadly. People who work in harm reduction are all-in on fentanyl test strips. They’re able to trace even low concentrations of fentanyl in a pill or powder form, which is necessary because the internet has made it easier than ever to buy drugs. 

 

[18:09] Ben Westhoff: I didn’t realize just how crazy the internet sales were until — for the book, I actually went to China and I infiltrated a pair of organizations who sell fentanyl and fentanyl precursors off the internet. And I went to this one company in the central Chinese city of Wuhan and they had their address right on the Internet, so I pretended to be a customer and just walked right in. And they had this huge sales floor, like hundreds and hundreds of young recent college graduates sitting at cubicles in front of computers, selling fentanyl precursors on the Internet. They use like social media and all these smiley faced emojis. And a lot of them didn’t even realize what they were selling. It was just like a good job with good benefits out of college. And so the way in which it’s been sort of normalized in China — some of these companies, I found out, even get tax breaks, they get all sorts of government incentives. The level, the amount that’s being sold over the Internet is really staggering.

 

[19:20] Stephanie Wittels Wachs: This is why Ben said at the beginning of our conversation that he thinks harm reduction is a more effective solution. It’s not because he doesn’t think there are bad guys who are worthy of punishment. There definitely are. It’s just that punishing the bad guys won’t fix the problem: people dying of drugs. And that problem looks a little different in other countries, even the countries that are exporting the fentanyl that’s currently killing so many Americans. 

 

[19:49] Ben Westhoff: China has its own drug problems, like heroin and meth. And so there’s huge crackdowns on those drugs, ketamine as well. But fentanyl isn’t killing Chinese people. And so China has been slow to ban these drugs. They’ve been slow to crack down on them. And these fentanyl precursors are still legal in China. And so I talked to the CEO. I was like, “don’t you feel bad? It’s killing, you know, more than 30,000 people a year in the U.S.” He’s like, “I don’t know about all that. It’s legal in China so we can sell it.”

 

[20:22] Stephanie Wittels Wachs: How is it not gotten into China? If it’s right there and it’s cheaper, how does that happen? 

 

[20:28] Ben Westhoff: The only countries where fentanyl is a big problem is really only the U.S., Canada and the small northern European country of Estonia. And so the U.S. and Canada, what they have in common is the overprescription of the opioids. So it really is a legacy of OxyContin and the mis-marketing of it, you know, in the ‘90s and the 2000s, and people being told it wasn’t really that addictive. And so people got their prescriptions. You know this story. 

 

[21:05] Stephanie Wittels Wachs: Oh, yes, we know the story well, or at least we think we do. Ben gave us a really good breakdown of why it’s so hard to close the supply side of Pandora’s box. But when we come back, we’ll talk to a health care economist who’s got a lot to say about the real bad guys, the drug companies who got us into this mess. Stick with us.

 

[24:06] Stephanie Wittels Wachs: We’re back. It was so interesting to talk to Ben because he confirmed a lot of what we were feeling as we set out to create this season. Like, believe me, Jess and I both have healthy egos, but even we know that the two of us aren’t exactly equipped to take down the Mexican drug cartels or defeat Big Pharma. The supply chain is a huge part of the story, yes, but it’s not the place where we can actually make an impact. We basically stood at this invisible fork in the road. And on one side, there was harm reduction and grassroots advocacy. And on the other side, it was going Liam Neeson on every person affiliated with Purdue and the Sacklers We chose harm reduction. Having said all that, I would also like to say fuck Purdue and fuck the Sacklers and fuck every single greedy asshole who got rich off of pumping our loved ones full of toxic garbage that ultimately killed them and destroyed our families. And if that version of the story doesn’t work for you, here’s another one. 

 

[25:15] David Smith: They advanced a culture that came to believe opioids were not only not addictive and not dangerous, but in some ways a drug that could just be used to improve a person’s functionality. That minor pain that might be burdensome or an impediment to a person could be not only managed, but it could be just completely forgotten about.

 

[25:40] Stephanie Wittels Wachs: This is David Smith. He is a health care economist who is doing some real front-lines-type work in the fight against this crisis. And he and I dove right into what exactly pharmaceutical companies like Purdue, founded by the Sackler family, did to create it. 

 

[25:58] David Smith: There was this TV ad that was run 20 years ago or so, and it featured a woman who had lower back pain.

 

[26:07] Ad audio: Since I’ve been on this new pain medication, I have not missed one day of work. And my boss really appreciates that. Lauren is there every day. 

 

[26:14] David Smith: They’ve got her on there. She’s talking about ever since she started OxyContin, her life has been so much better. She can play with her grandkids and she can sleep at night and she can function at work and all of the challenges she had before just been gone. 

 

[26:30] Ad audio: It’s amazing just to be able to keep up with them and not have to always constantly tell them grandma can’t play now, grandma’s hurting. 

 

[26:40] David Smith: And it’s this rosy picture of the life-enhancing capabilities of opioids. Well, that became our ethos. That became the ethos of physicians, became the ethos of E.D. docs, became the ethos of a sales force that was incentivized by Purdue significantly to go drive volume of the drug. It was essentially Purdue is complicit for number one, not responsibly measuring any evidence about the dangers of opioid use or opioid dependence. Number two, they recklessly and wantonly threw millions of dollars in resources and accelerating a process through the FDA. They got the drug cleared in eleven and a half months. So the FDA abdicated its responsibility to adequately assess the dangers of the drug. Because they did that, they created this demand — like I said earlier, if opioids are used in a particular clinical way, they’re really valuable. That’s just not a big market. You don’t have a huge market of Stage 4 cancer patients, but you have a huge market of people with lower back pain, or some other kind of discomfort. Well, they expanded that market and they did it completely overlooking the evidence about the dangers. And they made a significant amount of money for it. And when they created that demand, everybody else in the system that can make money became motivated to make money. 

 

[28:20] David Smith: Prescribers, pharmacies, distributors, you have that much volume of a drug moving through a system, everybody’s making a lot of money. And that’s the environment they created and why it perpetuated for as long as it did and it did the damage that it did.

 

[28:37] Stephanie Wittels Wachs: So is there evidence that they knew the harms and did it anyway?

 

[28:45] David Smith: I think there’s going to probably be clarity on that question in a couple of years, because what we’re seeing play out right now across the country, of course, is litigation that is unearthing treasure troves of documents and emails and meeting notes that are painting a picture to what was known and what wasn’t known, what was nefarious and what wasn’t nefarious. At best, this was a wholesale abandonment of responsible drug design, drug approval, drug manufacturing and drug distribution. And I say that because there’s an incumbent on all of the different actors and their regulatory and manufacturing chains to understand the implications and the dangers of a substance. Especially a substance with the molecular root of opioids that go into a person’s body. And we didn’t do that diligence. So in the best case scenario, it was willful neglect by having not done that diligence and not taken it seriously. And as the epidemic began to spread and people began to die, an overlooking, a disregard in some ways for the complicity they held. So that’s like that’s the best-case scenario. 

 

[30:10] David Smith: The worst-case scenario is that through the litigation processes going on throughout the country, that you’ll continue to find not just relics of willful abandonment of those principles, but a more direct, maybe even nefarious drive to capitalize on that moment and that opportunity. I suspect, Stephanie, that most of the people at Purdue, the sales people and the marketers and others, probably bought into a line in the business that there were probably people that went home every day feeling like their work mattered. And that they were they were doing things that were helping people because they were in a culture that reinforced that message.

 

[30:58] Stephanie Wittels Wachs: And this is why the finger-pointing is so tricky and frankly, imprecise. There are so many people to blame: the drug companies, the FDA, the doctors, the marketing teams, the pharmaceutical reps. So can you point to one thing and say this is why we’re in this mess? And this is who needs to pay?

 

[31:24] David Smith: One of the most humans things we try to do in the face of loss and tragedy is we try to find a reason. And we really do want to shift or point our finger at something or somebody that was that was the link that did something that created the conditions that ultimately led to that tragedy. And the way I’ve come out of this, I’m going to give you kind of a highfalutin’ answer and then I’m going to give you my health care economist answer. The highfalutin’ answer is that the thing to blame is human nature. 

 

[32:00] Stephanie Wittels Wachs: OK. Let’s just pause here for a moment, because this is truly one of the most profound things that I’ve heard all season. In fact, let’s play it again. 

[32:15] David Smith: I think that the thing to blame is human nature. Addiction is the most common human defect I think we have. It is timeless. It is boundless. It is something that we have never really understood as a species until the last 20 years. And even now, we don’t really fully understand the pathology of it. So opioids is just the latest wave of things that have tapped into that addictive characteristic of who we are as human beings. But history is replete with these same kinds of crises and traumas and urgencies that all just hail from addiction. In this particular crisis, there is not really anybody that’s blameless. It’s very easy to look at the Sackler family and Purdue Pharmaceuticals for the way that they marketed and pushed opioids onto an unwitting public. It’s very easy to look at the federal government for promulgating thoughts and conclusions that essentially said opioids were safe. And were not a cause for addiction. It’s easy to look at the New England Journal of Medicine that posted an innocuous non-evidence based blog post that said opioids can be an effective means for managing pain and that there’s not addictive properties. 

 

[33:46] Stephanie Wittels Wachs: Fun fact: if you ever hear someone say that less than 1 percent of opioid users become addicted, they are probably, maybe without even realizing it, citing this one-paragraph letter that David is talking about. The study, if you can even call it that, I mean, it’s five sentences long. Doesn’t seem that studious to me. But it’s talking about patients who received any kind of opioid while they were in the hospital. I mean, no moderately informed person today would cite this number, but still, this 1 percent statistic became the foundation of a lot of Purdue’s claims that OxyContin was extremely safe. Here’s an OxyContin promotional video that was put out by Purdue in 1998.

 

[34:38] Promotional video: There’s no question that our best, strongest pain medicines are the opioids, but these are the same drugs that have a reputation for causing addiction and other terrible things. Now in fact, the rate of addiction amongst pain patients who are treated by doctors is much less than 1 percent. They don’t wear out. They go on working. They do not have serious medical side effects. And so these drugs, which I repeat, are our best, strongest pain medications, should be used much more than they are for patients in pain. 

 

[35:11] Stephanie Wittels Wachs: I mean, can you fucking believe that? 

 

[35:16] David Smith: We have the convergence of two really unfortunate things. We have a pharmaceutical industrial complex that expanded the application, the use application for opioids, so they could expand the market. And that converged with this void, this human void. And now that we take a step back and we want to play that playing game, we find ourselves really bereft of knowing who to blame because most of us don’t really understand the nature of addiction, even though we’ve destigmatize it, aAnd it’s become a bit more culturally accepted as a disease and as a chronic illness and not a moral failing. The truth is, if you’ve not ever really suffered under the burden of an addiction, you don’t really know exactly what that is. And so you find yourself just aimlessly looking for somebody to blame to help you to make sense of the tragedy. 

[36:14] Stephanie Wittels Wachs: And if there’s one thing David knows, it’s tragedy. He doesn’t just hold a professional stake in this game. He’s lost several — yes, several — members of his immediate family to opioids.

 

[36:29] David Smith: I was about 14 or 15 years old, my dad was diagnosed with a disease called Chronic Fatigue Syndrome, and it’s essentially a disease that’s tantamount to having like mono 24/7 forever. And so as a means of managing his pain — this was at a moment where we were telling doctors and folks in emergency department that opioids were really that addictive and that it was a great means of managing pain and improving quality of life. So there was a lot of liberty in prescribing him opioids and he became addicted. And we went through this for years and he went in and out of rehab, and in and out of his own programs, and in and out of his own denial or admission of an illness. And it began to just chip away at them and he became to kind of deteriorate right in front of us. Fast-forward a few other traumas later, my parents were divorced, and he had been separated from his new wife and was sitting in his apartment. And my little brother kind of came over to see him in Phoenix, Arizona, and he had overdosed, seemingly by accident because he was just sitting in front of his computer in his underwear, slumped over, having passed away. That little brother, his name was Joseph, was living with him in Phoenix. And right around the same time, Joseph had been diagnosed with fibromyalgia, and also was able to access these drugs at a high frequency and a high rate, and quickly found himself addicted. Fast forward for Joseph, about a year and a half later, before work one day his girlfriend came over and found him having overdosed on OxyContin.

 

[38:19] Stephanie Wittels Wachs: A few years later, David’s sister found herself on a similar path. She was dealing with health complications and had started abusing pain medication. One day she had a serious fall that led to a brain aneurysm. It essentially left her brain-dead.

 

[38:37] David Smith: And we ended up, of course, needing to make a hard decision as a family. So that that leaves a little brother that I have who lives in California, and a mother who’s since remarried, who lives in Texas. And those three are they’re all kind of buried in the same plot of land, Larkin Gardens in Sandy, Utah, about two blocks from where we grew up. Kind of like that moment where life really looked like it’d go in a different direction. 

 

[39:11] Stephanie Wittels Wachs: I mean, you’re the perfect person to have this conversation with, because — and I don’t mean that to sound insensitive. And I’m so sorry for all of that loss. I can’t even fathom that kind of loss. But it seems like opioids destroyed your family. I mean, how do you not — or do you? Did you go through a point where you were like, I want to make them pay. I would like to go to the Sackler House and set it on fire. I would like to, you know, I want to go into court. I want to — did you have that sense? I mean, do you feel that at all or no?

 

[39:49] David Smith: You know, until this very moment, Stephanie, like I’ll admit it. Even for as much as I watch this issue, and as closely as I study the litigation, and as much fault as I believe in my heart of hearts, Purdue and the Sackler family and all of these others have in setting the conditions for this. And as much as I believe they should be accountable, I’ve never instinctively gone to the place to blame them more directly for it. And I don’t know that I can totally reconcile that or even understand that. I was probably just this really dour part of me that’s an economist that just fundamentally believes we are all creatures that function in our own self-interests. And when we’re in an environment that’s not regulated and we’re left unchecked, we are going to do things that may not be in the common interests of the people around us. And there’s always gonna be another Sackler family. There’s always gonna be another Purdue. For as long as we have human interests motivating people to do things, you’re always going to have access to substances or items that would do damage that could be addictive. So if you’ve resigned that, if you accept that as a truism — and that’s not a truism a lot of people love to accept, right? Because we want to kind of fight against those evils. We want to create a society that’s bereft of those conditions. And that doesn’t mean we shouldn’t regulate. It doesn’t mean we shouldn’t criminalize. It doesn’t mean we shouldn’t hold accountable. Yes, all of those things matter. But I still think there’s an obligation to take it as a truism that we’ll have access to these things. So if that is the truism, then our fanatic focus has to be on filling that void, moving way upstream in a person’s life when a person does hit that moment of crisis, there is a system. Not just a person, not just a doctor, not just an inpatient facility, not a one-and-done. There is a system that is organized in service of that person, and that can compassionately help to lift them up and lift them out of it all. We have a culture and a stigma still around this issue that prevents us from from seeing number one, it’s a disease. Number two, it’s an enduring disease, because it’s chronic in nature. And number three, there’s no such thing, in my opinion, as rock-bottom. Where it’s pulling yourself up by your bootstraps. 

 

[42:32] David Smith: There is a moment where you’ve lost control. There’s a moment where you have clarity about the reality that you’ve lost control. And again, you reach out into the void. And if we don’t build a system that can reach 10 hands down to that one hand and pull that person up and give them the platform, give them the space, give them the tools. Then we’ve failed that perso. And we do that to our own detriment. We do it to our person’s detriment. And we do it to our society’s detriment.

 

[43:06] Stephanie Wittels Wachs: As we established in Part 1 of this season, Episode 8, to be specific, this new system is going to take lots and lots and lots of money. And lo and behold, at this very moment, American pharmaceutical companies all over the country are enmeshed in lawsuits for lots and lots and lots of money. Not just Purdue, who is facing so many suits that they have been consolidated into a couple dozen state-level cases, but Johnson and Johnson and a few others as well. David says we need a system overhaul. So are these lawsuits going to help with that? 

 

[43:52] David Smith: I think there’s one piece of this that we are looking for the culprit. We’re looking for the guilty party that we want to hold accountable. That’s a very human thing, very American thing. I do think, though, the other thing we’re trying to do is we need some reparations. There was a significant amount of money that flowed to a business on the back of spurious claims and ignored evidence. And we’ve seen whole communities devastated as a result of that. And I think there’s a need to recapture some of those economics to invest it back into our communities, for some of those communities that have eroded or have seen their own infrastructure kind of torn apart by this issue. Not only can we try to rebuild that, but there’s also, I think, this once-in-a-generation opportunity to take what could be tens or hundreds of billions of dollars and reinvestit in the things we know work.

 

[44:56] Stephanie Wittels Wachs: So is the settlement money, — it’s not symbolic, but is it really enough money to address the harms? How can we take that money and then divide it up in a way that’s going to actually help?

 

[45:11] David Smith: Yeah, well, that’s a tricky question. The first, and in you know this because of your lived experience and I know this because of my lived experience, there’s not enough money on this planet that will ever undo what’s been done. A loss of life. The tragedy, the families torn apart, children that will grow up without a parent. The intergenerational effects of this crisis are enduring. But, if we find the right way to allocate those funds, if we can rally now around the things we know now and the things we can do now, that we didn’t know five, 10 or 15 years ago, we can build an environment that thinks about this, that treats this in fundamentally different ways. There are some really amazing things that are happening in this space. We know if we pay for care differently, we’re not incentivizing relapse, but we’re incentivizing recovery. We’re paying people to keep people well. That works. And now if we can spend this capital in the right way, we can focus on those parts of the system, those parts of the infrastructure that support the science and what works. Where I’m apoplectic is we tend to stink at that as a country. We see $50 million fall out and there’s 50 million different organizations that all believe they should have some claim to that, and that their project is the best project.

 

[46:57] David Smith: And litigators, judges, governors, legislatures, anybody else that’s involved in whatever area this is happening, there’s a huge onus on them to overlook the politics, to overlook the pork, and to look hard at the evidence and the infrastructure we have to build because while we can’t replace the lives that were lost, if we get this right, we can save untold lives when the next Purdue shows its head and we’ve got to deal with the next crisis. That’s what we have to be building for.

 

[47:36] Stephanie Wittels Wachs: So there’s a big potential pile of money, but it’s hard to figure out who should decide where it goes or how it’s spent. David’s team has been researching possible solutions and they’ve identified some key areas where we should be focusing. 

 

[47:52] David Smith: Number one, we have a 90 percent treatment gap in this country. Meaning that nine in 10 of us that are suffering with a substance use disorder have not sought treatment, are not getting treatment, don’t know where to find treatment. And because every door is a wrong door today, we have to build every right door we can. that’s working with law enforcement, that’s giving emergency departments the cultural and skills training and the staff and resources they need to deal with this. And paramedics, families, primary care physicians that sometimes turn an eye away from this. I think, number two, we don’t need to be thinking about more inpatient rehabs or outpatient — I mean, sure, you can invest in those things community by community where it’s needed. But we have to be able to extend our workforce in a way that allows people with lived experience in recovery, and people with clinical training, and all of the other social skill sets that exist, we have to create more individuals that can engage with persons in recovery. Not in one setting or not in just a couple of settings, but throughout the recovery continuum. Those are the key things. And the real final is can we ultimately make sure that the way we’re lining up payment for these services incentivizes recovery. We will pay people to do the things I just described and keep people well and drive long-term recovery instead of incentivizing, you know, volume for urine tests, and site visits, and IOP appointments. That’s a tougher shift to make. But that’s what’s got to be enduring. This money, it’s going to come and it’s going to go. And that’s going to be the end of it. We’re going to have money flowing through the addiction system forever. So the way we leverage that, the way we close the efficiency gap and set ourselves up to do that, well now, I think that’s the game.

 

[50:03] Stephanie Wittels Wachs: But if David were to point his finger in one specific direction, he’s very clear where that would be. 

 

[50:11] David Smith: I’ll tell you this, Stephanie, I am — if I was going to point the finger at anyone — if I’ve had a moment in my life where I’ve been the most incensed at a part of the whole system that I think failed my family, it would be the recovery system, the treatment system. It would be the fact that every time my dad would try to find a door, he’d have a moment of clarity and he would know at that moment of clarity he needed help, he needed something. And he’d reach his hand out just hoping in the void that somebody would reach back and grab his hand and pull him forward, and that system never met him there. We’re always going to have substances. We’re always gonna have people that are going to push those substances on us. Like I said addiction is as timeless as we are as humans. We have to remedy a fundamentally different — we have to have a cultural revolution the way we think about this issue. We have to build a system where there are no wrong doors. There are only right doors. And that when those people have a moment of clarity — your brother, my brother, sister, father — when they have those moments of clarity, that that system meets them where they are in a way that’s compassionate and uses the science we know works to help drive a person’s recovery. 

 

[51:44] Stephanie Wittels Wachs: So it’s all about the treatment industry. OK, then. Let’s go to there.

 

[51:53] Woman’s voice: I’ve never met an addict who didn’t have a tumultuous life. Whether you’re a drinker or you smoke meth or you shoot heroin, it doesn’t matter. Your life is a wreck. And you might be maintaining a little bit, like I did for a while there. But you’re not making your bed in the morning. You’re not paying your bills on time and you don’t have a savings account. There’s just certain things that are like pretty true for all addicts. This is like your reset. I stayed here for 16 months and I just focused on me.

 

[52:29] Stephanie Wittels Wachs: Next week, we take our show on the road. 

 

[52:38] Stephanie Wittels Wachs: Last Day is a production of Lemonada Media. Our producer is Jackie Danziger. Nicolle Galteland is our associate producer. And our assistant producer is Claire Jones. Kegan Zema is our technical director. Brian Castillo is our editor. And our executive producer is Jessica Cordova Kramer. Our music is by Hannis Brown. Special thanks to Westwood One, our ad sales and distribution partner. You can find us online @LemonadaMedia. And you can find me @wittelstephanie. If you like what you heard today, tell your family and friends to listen and subscribe. And more importantly, please give us a rating and review us on Apple, Spotify, Stitcher or wherever you get your podcasts. It really helps us to spread the word about what we are doing and we would greatly appreciate it. I’m Stephanie Wittels Wachs. See you next week.

 

[53:45] Stephanie Wittels Wachs: If you are a regular listener to Last Day, we know that you may very well have your own person. The person who drives you to listen every week. We make Last Day for you, and we have you collectively on our minds each week as we produce the latest episode. We also have a new way to connect to the Last Day concept and community, and that is through Last Day T-shirts and tote bags. Our CEO Jess often said as we were starting up, I really want nothing more than to be able to wear a pin or some kind of label that announces to the world, “I lost my person. So be kind!” On the assumption that doing so could make it easier for people to talk to her about it and get past the shame and fear and silence. And it would also help her to remember that she’s not alone. Others have been and are currently going through this, too. If that resonates with you at all, check out LemonadaMedia.com/shop. T-shirts and totes available for purchase now.