There’s good news: Opioid deaths are down. The caveat: Marginalized communities aren’t seeing the benefits. Maia Szalavitz is a contributing Opinion writer for The New York Times. She joins host Krys Boyd to discuss age and race gaps in opioid death statistics, how naloxone is helping to prevent overdoses, and why people of color aren’t seeing the same results as their white peers. Her article is “Not Everyone Is Benefiting From Drops in Overdose Deaths.”
The next phase in the war on drugs
By Madelyn Walton, Think Intern
Opioid overdose deaths are declining in the United States. However, the benefits are not being seen across racial groups.
Maia Szalavitz is a contributing Opinion writer for The New York Times. This week on Think, she joined host Krys Boyd to discuss who the opioid crisis targets, where the overdose decline comes from, and which demographics are still at risk. Her article is “Not Everyone Is Benefiting From Drops in Overdose Deaths.”
The Drug Enforcement Administration claims it’s responsible for the decline in overdoses, but the drug dealers actually play a role, too. Dealers don’t want to kill their customers, and as a result have been working to make fentanyl and other drugs less lethal.
“If enforcement were having an effect, you would see higher prices and you were not really seeing that,” Szalavitz says. “You’re not seeing shortages.”
Another tool in the fight against overdoses is Naloxone, a new drug that can essentially undo an overdose.
“The only thing it does is reverse overdose,” she says. “And if somebody is physically dependent, that may cause withdrawal symptoms, but it’s a really, really safe drug.”
Addiction can stem from childhood trauma, mental illness and negative life experiences. But these days, younger kids and teenagers who grew up around addiction have seen the harm hard drugs cause and are choosing less harmful substances.
“When you look at who’s the highest-risk person, it’s somebody who has one of these predispositions to these things and was traumatized, because trauma is basically the thing that tends to turn a predisposition into an actual disorder,” she says.
But the news isn’t all good, as the declines don’t carry across all demographics. Black, Hispanic and Native Americans fall short. For example, Black Americans have less access to treatment and recovery services than other groups.
Also, Szalavitz says people of color are more likely to be incarcerated for a drug related crime.
“If you actually look at the statistics by race, Black people are something like five times more likely to be arrested for drug related crime than white people, even though white people use and sell drugs at equal rates,” she says.
Whether these trends continue remains to be seen. Szalavitz says some Republicans campaigned against harm reduction programs that provide naloxone.
“Reversing these programs and strengthening punitive measures that failed to prevent the crisis won’t extend this positive trend and save more lives; it will merely do the opposite,” Szalavitz writes in her essay.
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Transcript
Krys Boyd [00:00:00] We’ve been talking for so long about the opioid crisis growing progressively more lethal. But I will confess, I was taken by surprise when I started seeing headlines about declines in the rate of overdose deaths in this country. It is true the U.S. recorded a nearly 15% drop in the number of people who died of overdoses between the summer of 2023 and the summer of 2024 alone. That is huge and it’s great news. But it’s not the only news. From Kera in Dallas, this is Think. I’m Krys Boyd. The downward trend in overall deaths from overdoses is not happening evenly across demographic groups. The reasons why are complex and disturbing, but perhaps not insurmountable if we understand them and commit to finding solutions. Maia Szalavitz is a contributing opinion writer for the New York Times, which published her article “Not Everyone Is Benefiting From Drops in Overdose Deaths.” Maia, welcome back to Think.
Maia Szalavitz [00:00:59] Thank you so much for having me. I’m glad to be here.
Krys Boyd [00:01:01] I do want to start with the good news that overdose deaths seem to be declining in the United States. When did this trend start to look like more than just a temporary aberration in the statistics?
Maia Szalavitz [00:01:13] Basically, this summer.
Krys Boyd [00:01:16] And there are a number of possible contributors to this, right. One relates to fentanyl. Before we get into that, can you help us understand the difference between prescribed fentanyl and the version available on the street?
Maia Szalavitz [00:01:30] Sure. So prescribed fentanyl is a pharmaceutical. You know exactly what the doses it’s used every minute all over the world for anesthesia. It’s an excellent drug that is very useful to medicine. And on the other hand, street fentanyl is manufactured by cartels or underground scientists, and there’s very little quality control. You don’t know what the dose is. You don’t know what’s in it. It can vary from being a completely inert substance to something in which a couple of micrograms could kill you.
Krys Boyd [00:02:12] Why would the fentanyl sold by drug dealers be less potent today than a few years ago?
Maia Szalavitz [00:02:18] There’s a couple of theories for this. The DEA, of course, wants to say that their enforcement has worked and that the gangs are on the run. But that isn’t really what it looks like from the epidemiological from the people who go out and talk to people on the streets. That is not really what it looks like. If enforcement were having an effect, you would see higher prices and you were not really seeing that. You’re not seeing shortages. There was a brief period of those. But the other explanation, which kind of makes more sense is that the gangs themselves do not want to kill their customers because if you kill your customers and we also the other piece of good news is that kids are not starting to misuse prescription opioids. They are avoiding the category of drugs. The percent of new people starting is down by something like 70%. So, you know, if you’re killing 5 to 10% of your users every year and you’re not replacing them with new ones, you are not going to have a market for very long. And while they might be evil, they aren’t stupid generally.
Krys Boyd [00:03:36] So this is not a case of drug dealers developing a conscience. They’re just trying to keep their clientele alive long enough to come back for another dose.
Maia Szalavitz [00:03:44] Yeah. I mean, the thing is, as a person who had addiction and was a former drug dealer, I will say that there were plenty of drug dealers who do have a conscience and who actually, for unfortunate reasons of denial, believe that they’re doing a good thing and providing a good service. And they really would absolutely hate to see a customer killed. So this is you know, this will vary throughout the supply chain. Obviously, the people at the top, we can pretty well assume, have no conscience.
Krys Boyd [00:04:14] Can we assume that many people who are struggling with the overuse of opioids are people who were initially prescribed these medications to deal with a medical problem?
Maia Szalavitz [00:04:28] The exact opposite is true. We know from survey research that about 80% of people who misuse prescription opioids start with a prescription that was not their own. So they get it from mom’s medicine cabinet grandmas house their friends. It’s never been like maybe 20%, maybe 10% did get it directly from a doctor. Oftentimes for a root canal or a sports injury and the media has tend to focus on that group because they make the great innocent victim like they didn’t go out and start trying drugs. But the reality is that there is really no innocence or guilt in addiction. It is a medical disorder. And the way you start isn’t what determines. Whether you get in trouble, right?
Krys Boyd [00:05:24] Right. And just for folks who are not familiar, what does it feel like to be on opioids?
Maia Szalavitz [00:05:32] Well. So I was addicted to heroin and cocaine for several years. And heroin, which is an opioid, was my drug of choice. And for me, what it did was it just made me feel warm and safe and loved and connected and happy about it. Content. And so obviously that is a very attractive state for a lot of people. Interestingly, about a third of people who are given opioids absolutely hate the experience and find them really numbing. And around another third, they make them slightly nauseous. But there is a little euphoria. It’s kind of a mixed bag. And the final third are the ones like me who really like it. And that’s the high risk group.
Krys Boyd [00:06:17] It’s so interesting because it also speaks to the fact that it may not be the sort of, you know, moral fortitude of a certain group of people who try these drugs and don’t go on to develop a substance use disorder. They may just be wired differently.
Maia Szalavitz [00:06:31] No, that’s absolutely the case. And there’s a really fascinating study that just came out from the National Institute on Drug Abuse, which found that if they’re doing this huge study following teenagers, people from birth, actually, and looking at their how their brain wiring develops. And they found that the kids who started drugs really early on who were like, you know, drinking at 13 or 14 on their brains were different before they ever picked up a drink. And so, you know, we have this idea that, there’s a gateway. People find something and then they, like, get taken over by the euphoria and just chase that. The reality is way more complicated. Most people with addiction either have a history of childhood trauma or some kind of, you know, other early life negative experience, or they have a predisposition to some type of mental illness, commonly ADHD, depression, anxiety disorders, all kinds of things like this. And so when you look at, you know, who’s the highest risk person, it’s somebody who has one of these predispositions to these things and was traumatized because trauma is basically the thing that tends to turn a predisposition into an actual disorder.
Krys Boyd [00:08:00] Fentanyl sold by drug dealers is now sometimes cut or mixed with an animal tranquilizer called xylazine. Xylazine has some pretty horrific potential side effects, doesn’t it?
Maia Szalavitz [00:08:13] Xylazine is really, really awful and it can cause these grievous wounds that don’t heal. And this can happen even if you don’t inject it, although it primarily happens among people who do inject it and they don’t really know why this happens. There’s a couple of different theories, but some recent, recent research found that this drug acts on an opioid receptor that they didn’t previously realize that it acted on. And this may be why it helps. The reason they put it in there is that fentanyl is actually an anesthetic. It knocks you out and it is very short acting. And so heroin, the high lasts like 4 to 6 hours, even longer sometimes. With fentanyl, maybe you get 30, 50, a couple of minutes of euphoria at most, and then you’re unconscious and then you wake up and you are probably beginning to be in withdrawal. So you rapidly need to repeat the dose a lot more quickly. So with adding the xylazine, it keeps you sedated for a lot longer, which, you know, if you add two sedatives together in the brain, that is more likely to kill you immediately. But if it doesn’t kill you, you are now out of action for eight, ten hours or something. And so you don’t have a chance to take more. And this may be why it’s actually reducing the overdose risk.
Krys Boyd [00:09:55] People who are worried about those necrotic wounds that you described are sometimes ingesting the drug by smoking it or snorting it. Maybe that puts you less at risk of a wound that won’t heal. But it’s it doesn’t make you any safer from dying from an overdose. Is that correct?
Maia Szalavitz [00:10:13] No, it actually isn’t. Because when you inject something, you can’t get it back out. Okay. And you can sort of take half a puff of something. And so it it sort of allows you to control the dosing a little bit better. It also smoking wastes a lot of the drug and which is good if it’s too potent. So again, that is a way that it would reduce risk. And this will vary depending on the particular substance in its melting point and all kinds of complexities of pharmacology. But in general, smoking is going to deliver less drug, especially smoking the way people do on the street.
Krys Boyd [00:11:03] I’ve heard about efforts to distribute fentanyl test strips to people who regularly use this drug as a means of harm reduction. What are those strips detecting that might help users make safer choices?
Maia Szalavitz [00:11:17] So they actually do detect most fentanyls. When I first originally heard about them, I was nervous about them because I was like, well, what if it detects only, you know, straight fentanyl but not carfentanil, which is a carfentanil is like 10,000 times stronger. And so obviously that would be a bad thing. But the good thing about the test strips is that they seem to be way more prone to false positives than false negatives. And so if there’s fentanyl of any type in there, it is going to pick it up. Now, the unfortunate thing is that there are a few synthetic opioids in the supply that are not fentanyl that are called netizens, and these do not get picked up by the test strips. But those are in the United States, pretty rare. So the test strips are still if it’s if it’s positive, you don’t want to take this stuff. And the vast majority of people, for example, if you go to a dance party or something and you think you’re getting cocaine and you use one of these test strips and it says fentanyl, you’re going to throw that stuff out because you’re not an addicted person who needs to avoid withdrawal. If you are an addicted person and it test positive for fentanyl, you might still use it, but you would probably take more precautions, such as not using alone, using a much smaller dose initially, calling there’s a hotline you can call and they will call and they will just like hang out on the phone with you and call 911 if something happens. So there are ways to reduce the risk.
Krys Boyd [00:13:00] I think it’s very interesting that you bring this up and something that always stays with me when I hear interviews from with people who are using these substances. Is that sort of contrary to popular belief, people who have a substance use disorder don’t necessarily have a death wish.
Maia Szalavitz [00:13:19] No. And I mean, you know, there certainly is a good proportion of people with actual addiction who are also suicidal or are in a state where they don’t care either way. They might want to wake up. They might not. But that is not the majority by any means. And so you on most people and this is the interesting thing about fentanyl because most people who are using drugs, they don’t want to be unconscious. They want to be happier while conscious. And fentanyl just knocks you out. And so it doesn’t really do the thing that people are often looking for in opioids, which is like allowing them to function but not be overwhelmed by negative emotion.
Krys Boyd [00:14:06] Maia, how much has the availability of overdose reversal medications contributed to declining death rates?
Maia Szalavitz [00:14:14] This does seem to have had a big impact because in recent years, the amount that has the amount that is available to people who are using drugs has increased dramatically. This is one of the innovations of the harm reduction movement where a guy named Dan Big in Chicago realized that, hey, Naloxone is a drug that is harmless if you use it in error. If you gave it to a baby or something like that, they would have zero effect. The only thing it does is reverse overdose. And if somebody is physically dependent, that may cause withdrawal symptoms, but it’s a really, really safe drug. So he was the first person in the 90s. He went out and distributed it and got lots of other people to distribute it. And those grassroots organizations have grown enormously and they doubled the amount that’s out there within the last ten, 15 years or so. And it’s now available over the counter. Government organizations like health departments are distributing it. You can you can go into a pharmacy and buy it on all of the syringe exchange programs that are in the harm reduction sphere. Almost all of them provide it as well. Recently there’s unfortunately been a backlash against harm reduction where people are like, you give people the lock zone and then they’ll just take more risks. And that’s simply not true. The data doesn’t show it. And people who are using, you know, every day, it’s being used at least hundreds of times, I think. And, you know, the people who run in New York City, we have a safe consumption overdose prevention site where people can take their drugs under medical supervision. And they, you know, they reduce overdoses there all the time. There are hundreds of these facilities around the world now, and they have never seen an overdose deaths at their site ever, despite, you know, millions of injections having been done by now. So, you know, we do know that when people are when people have access to naloxone, they will use it to reverse overdose. And when they have access to safer spaces, they will use them. So, you know, it certainly does seem to have had somewhat of an impact. I personally think it should be. You know how they mailed those Covid kits to everybody? I think they should mail it to everybody so that it’s in your first aid kit, whether your three year old gets into your codeine or your teenager does something dumb.
Krys Boyd [00:16:58] What is the dose of the stuff cost if we were to buy it at a pharmacy?
Maia Szalavitz [00:17:01] You know, it’s too expensive right now. I mean, it can vary everything from, you know, 10 to $15 to like 50 or so. It’s crazy. It’s like and there’s some versions of it that are really expensive. I think insurance is required to cover it for a lot of people now. And if you go to there is an online site where you can just order it and get it for free. If you Google free naloxone, you can probably find that. There are also health departments and they’re working really hard to get this out there as much as possible because again, like if you happen to use it, if somebody is having a heart attack and you give them naloxone because you think they’re overdosing, well, you’re not going to solve the heart attack, but you’re not going to make it worse either.
Krys Boyd [00:17:47] Okay. And, you know, presumably this stuff is carried on ambulances. But it turns out it really is helpful that people at risk of dying can sometimes get a dose of this stuff even before an ambulance might arrive.
Maia Szalavitz [00:18:00] Yeah, that’s really important because in medicine they say time is brain. And the longer you’re unconscious, the more your brain is deprived of oxygen and the more likely you are to have severe brain damage. So if you get naloxone to somebody right away, they won’t have any brain damage. But if they’re actually starting to experience severe oxygen deprivation, they could end up with brain damage.
Krys Boyd [00:18:30] We’re talking through some of the reasons, Maya, that these overdose deaths are declining in this country. One thing you don’t think is probably contributing to that fall in overdose deaths is more widely available, effective drug treatment. What are some of the treatments that can keep people from dying but are not as available as they could be?
Maia Szalavitz [00:18:50] So we have to be fair. We have actually dramatically increased access to on buprenorphine and methadone. And these are the two medications that if you take them long term, cut your rate of overdose in half for as long as you’re taking the medication. So this is like a really, really powerful intervention. But unfortunately, methadone, you still have to go to these very specialized clinics where they make you show up every day and pee in a jar all the time. And it you know, a lot of people find it basically like being on chemical probation. Now, again, some of them are doing wonderful work and are working around the federal restrictions that make it such a difficult thing to get buprenorphine. You can get from pretty much any doctor now who is willing to prescribe it. Unfortunately, lots of doctors aren’t willing to prescribe it and lots of pharmacies aren’t willing to carry it. So, again, we have these medications that could do enormous good. We should be making it almost as easy to get these medications as it is to get drugs from your dealer. And, you know, if we can’t make it entirely as easy because you don’t want like 15 year olds getting it or something. But for people with established addictions, you should be able to go into, I think, an emergency room or any medical facility and just be given a dose, no questions asked.
Krys Boyd [00:20:17] So broadly speaking, these drugs will keep you out of withdrawal but will not make you high in the way something like a traditional opioid would will.
Maia Szalavitz [00:20:26] They will make you high if you’re not already addicted.
Krys Boyd [00:20:29] Okay.
Maia Szalavitz [00:20:29] And this is why they have the restrictions on them, because, like, you don’t want teenagers. Methadone can kill you very quickly if you don’t have a tolerance to opioids. So it should be slightly more restrictive. But we’ve gone way too crazy with the restrictions. Buprenorphine is very, very unlikely to kill you, but it can cause a high if you have no prior experience for opioids. Most people who get their hands on buprenorphine, they would way prefer to have heroin or sometimes even fentanyl or, you know, any like OxyContin or something like this. So it’s not like a preferred street drug at all. But there’s been so much fear that people will just sell it that we don’t give the people who need it access to it. And there would be very little market for it if, as I was saying earlier, you could just go and get it a dose like without any strings attached. That would make a huge difference because again, it’s going to reduce your risk. And also, if you find out that, hey, I’m doing pretty well with this, maybe I can actually get into treatment and stop using the other substances and that it often works in that way. Like a lot of times people come into buprenorphine treatment and they’ve used it on the street like when they wanted to, you know, go visit their mother or something and they weren’t near their drug dealer or these kinds of things. And they’re like, okay, this works. And so then when they’re ready, they seek treatment and now they can get it not on the street, which is better. And also get other services if they need them. So, you know, it it’s complicated. You know, I mean, you don’t want to like put methadone in the drinking water or something like this, but you also really shouldn’t restricted to these clinics where there’s not that many of them. Nobody wants them in their neighborhood. And it makes it really difficult to access something that can cut your death risk in half.
Krys Boyd [00:22:36] So if properly prescribed these medication to the right patients, these medications can help people gain back control of their lives. But they are pretty much off the table for people who want to use a 12 step program. Is that right?
Maia Szalavitz [00:22:51] Well, it’s again, it’s complicated. So the 12 step program, Narcotics Anonymous, which is the one that is for people with opioid addictions, they see people who use medications, even if they are taking the medication exactly as prescribed. They are not high. They are working again. They’re not homeless anymore or they’re reconnected with their friends and family. This doesn’t count as a recovery in NA because you still have an opioid substance in your system and so you’re considered not clean, which is really stigmatizing language. And you can’t count your days in many meetings. You’re not allowed to like share or really participate. So this is a serious problem. The complication and interesting thing is that AA, Alcoholics Anonymous and if you have a problem with both alcohol and opioids, many people in that situation will go to AA. And AA says that your decisions about medications are between you and your doctor. And if you’re honest with your doctor and your doctor prescribes this, it’s none of AA’s business. So for people who do like the 12 Steps and want some community support, I would just say just go to AA instead so that you can avoid that. But unfortunately, a lot of the rehabs are still stuck in that NA mindset that these drugs, you’re still always high and you are not really in recovery. And what’s what’s confusing about this is like, let’s say I put you have an alcohol use disorder and I put you on alcohol maintenance and I switch your gin for vodka. Right. You’re still going to be impaired because alcohol doesn’t produce complete tolerance. But if I put you on the right dose of methadone or buprenorphine for you and you take that dose every day at the same time every day, you have complete tolerance to the high. You are not high. You are not emotionally impaired. You can drive. You look just like anybody else. I could currently be on a massive dose and you would never know it. It’s so this is like difficult to understand because the like, but the substance is still in your body, you know? And yeah, but the thing is, what has happened is the person has changed from being addicted, which is compulsive drug use, despite negative consequences to simply being physically dependent, which we’re all physically dependent on food. I am physically dependent on antidepressants, as in, if I don’t take them, I will get depressed again. And so it’s really just like any other insulin or any other medication like that. Once you’re on the right dose for you and you are taking it properly.
Krys Boyd [00:25:33] We’ve been hearing recently that the GLP one class of drugs that are currently mostly prescribed for things like diabetes and now weight loss seem to have an effect in helping some people overcome compulsive use of alcohol and other drugs, even problems like shopping and gambling addiction. What sort of research is being done to investigate what thus far are mostly anecdotal effect?
Maia Szalavitz [00:25:56] So, I mean, it’s interesting because there have actually been some large medical record studies where they just looked at like 100,000 people’s medical records and they compared like if you are on a GLP one drug and you also have opioid use disorder, are you more or less likely to on overdose? It cuts the risk of overdose by 40% in that group. So this is like these have enormous promise and they are starting clinical trials directly for various addictions for that reason. I mean, it’s it’s what is really interesting is what these drugs seem to be doing in the brain is not making it unpleasant to take drugs or unpleasant to eat, but making you feel like you don’t want or desire more. And so if you have something that like, stops the desire but doesn’t stop you from experiencing ordinary pleasures, that’s the ideal anti addiction drug. And so I am really interested in seeing how this plays out because I’ve talked to people who have experienced it and they talk about how, you know, they just become much less compulsive about stuff in general.
Krys Boyd [00:27:15] As we pivot here, Maia, to folks who aren’t benefiting, we should also be very clear. We still have far too many Americans dying from overdoses every year, Right? A reduction in raw numbers is a great start, but we are not past a crisis of these deaths.
Maia Szalavitz [00:27:30] Yeah. No, it remains an enormous crisis. I mean, we went from 100,000 deaths per year to maybe 80 or 90,000 deaths per year. That’s still an enormously high death toll and it is racially disproportionate. Black people and Hispanic people are still seeing rises in overdose deaths and so are Native American folks.
Krys Boyd [00:27:56] So when you first started seeing this reduction in deaths, you were sad because of this phenomenon that epidemiologists call a depletion of susceptibles. I mean, it sounds so clinical. What does it mean in non-clinical terms?
Maia Szalavitz [00:28:10] Sure. So it basically means that the people who are vulnerable, most of them are already dead. And that’s why it’s it’s saddening and depressing. And I suspect that that is part of why we are seeing this turn, because when you are killing a large portion of your market every year and thankfully new kids are not starting, that population is going to shrink. But, you know, those are mothers and fathers and sisters and brothers and people who are loved. And it’s just awful the amount of grief that I hear in the harm reduction community of people who’ve just lost, you know, dozens of people. It’s like, you know, the bad days of Aids.
Krys Boyd [00:28:55] Why do you think younger people seem to be less drawn to opioids than older generations have been?
Maia Szalavitz [00:29:02] Well, there’s a phenomenon that tends to occur in drug epidemics where the younger kids, they see like, wow, my older brother died of an overdose or my mom is just really messed up from taking that stuff. So they’re like, I’m not going to take that. They might still take other substances, but they tend to turn away from the one that is seen as the most dangerous and the one that they have seen themselves. Like it’s not like just like, the government says this is bad. It’s like I’ve seen that this is bad. So they would be like, okay, I’ll smoke pot or okay, I’ll drink or, you know, or I won’t take anything at all. But like, kids will usually experiment with something.
Krys Boyd [00:29:49] Yeah. And you mentioned those racial disparities. How have those come to light, particularly as overall deaths from overdoses are falling?
Maia Szalavitz [00:30:01] So people fortunately, do track these things by race and gender and age. And when you looked closely at the numbers and a couple of studies have come out on this, now you just see this dramatic rise among the black people and Native Americans. And as you know, a slight rise or stabilization in Latino people. But, you know, so the most of the decline has been among white people. And it’s also there’s also geographic variation because Central hit the East Coast several years before it arrived at the West Coast. And so before and I’m going to forget the year, but I think it might be 2016. Yes, I think it is 2016 before 2016. 80% of the deaths from opioid overdose were east of the Mississippi.
Krys Boyd [00:31:03] Maya, how might geography play into all of this? Why might the opioid crisis be burning itself out in some places and raging to life in others that hadn’t previously experienced high rates?
Maia Szalavitz [00:31:14] So fentanyl is an enormously destructive drug. And one of the things that’s been difficult about drug policy is just that every time we have a crisis related to drugs, it is made to see that that current crisis is the worst ever. We never got anywhere near 100,000 overdose deaths per year until we had fentanyl. So fentanyl started on the East Coast and in the Midwest. And so that was where whatever gangs distribute it started doing so. And at this, you know, 2010, 2011, up through 2016, you’re seeing massive rises in overdose deaths. But they are almost all concentrated east of the Mississippi. And so until either 2016 or 2017, we didn’t really see availability of that much fentanyl on the West Coast. And then it spread. And I did a graphic for the New York Times where you could the artists did the art. I did the writing. But you can actually see the wave as fentanyl moves across the country. And fentanyl is 50, depending on the variety. Could be 50 to 10,000 times stronger than heroin. So if heroin is killing, say, 1 to 2% people per year and suddenly you get fentanyl, it’s now killing 5 to 10% people per year who are using you are going to end up with this really crazy association between when fentanyl appears in a place and the death rate because it’s going to skyrocket immediately, even if you have really good policies in place.
Krys Boyd [00:32:58] You note in the piece that white users tend to have greater access to naloxone to reverse the effects of a potential overdose than black or Native American users. What is that about?
Maia Szalavitz [00:33:09] So in the black community, there has historically been a lot of opposition to harm reduction and needle exchange and these kinds of programs. And a lot of that has come from the idea that like, you’re giving white people treatment and you’re just going to give us needles and let us die, which is an absolutely valid critique. But if you don’t give the people who are using clean needles, they will spread diseases. And so there have been some amazing, valiant people in the black community who stood up for harm reduction and went and did the work and went out there and got the clean needles, founded needle exchange programs, began naloxone, distribution, etc.. But unfortunately, there’s still that kind of leftover from that opposition. And so Ricky Bluestone Thall, who is one of the founders of the Oakland Needle Exchange, I mean, he experienced it from both ends like he would he got arrested by the California police for doing this and his organization got firebombed because the community was pissed. So it is really, really difficult to be a black person in harm reduction. So but this has had this legacy where there is less access. And in terms of the Native Americans, unfortunately, that population has just been enormously neglected in general. So you just have less access to everything there. And this has resulted in there being less access to harm reduction among the people who need it most. And this may well be why we are seeing continued rises in those communities as opposed to elsewhere.
Krys Boyd [00:35:06] What do we know about the way that race affects whether people receive treatment or punishment for their struggles with substances?
Maia Szalavitz [00:35:16] So this is another horrifying thing. A lot of people think that, you know, if we just lock people up, we would get more people into treatment. They don’t know that. First of all, in jail, there’s almost no treatment available. It’s starting to change a little bit. But for the most part, people are in jail for two weeks and they just lose access to medical care rather than gaining it. People actually die of withdrawal in jail because they don’t get their medications or they were just in withdrawal because they were coming off the street drugs and didn’t have medications in the first place. So we have this idea, you get arrested, you get treatment. This almost never happens. And if you actually look at the statistics by race, black people are something like five times more likely to be arrested for drug related crime than white people, even though white people use and sell drugs at equal rates. And so you think, okay, well, if jail gets you into treatment, then black people must be getting a ton of treatment. Well, in fact, black people are less likely to get treatment at all on less likely to get high quality treatment and less likely to be able to stay in recovery. Because one of the things that really helps people recover is like having a job and a home. And if you have a criminal record, it is much harder to get those two things. So the whole idea that like, we need to criminalize everything, we need to lock people up for this is completely backwards. There is no health care that is better in jail than on the street.
Krys Boyd [00:36:57] To your point, many people have lamented the insufficiency of the war on drugs in all its various forms and actually ending this country’s drug problems. Have the laws designed to disrupt fentanyl production and distribution had any effect on the available supply in this country?
Maia Szalavitz [00:37:16] Well, what we know from history is that, like, you can have very brief effects on supply. So, for example, during the pandemic, there were a couple of shortages. This required international trade to be shut down almost completely, but it rebounded really quickly such that overdose began increasing way more in the pandemic. So if a world pandemic doesn’t stop it, you know, okay, so one tractor trailer full of pure fentanyl could supply everybody in the United States who currently uses opioids for a year.
Krys Boyd [00:37:57] Wow.
Maia Szalavitz [00:37:57] Do you know how many tractor trailers go through the Mexican border every day and go through the Canadian border every day? And how many ships and planes and all kinds of vehicles go through? If you wanted to shut down international trade, you could possibly have an effect on the supply. But it would. If history is anything to go by, it would be very short lived on and then it would rebound worse than ever. Part of the reason we ended up with fentanyl in the first place is that if you are trying to smuggle something, something small is easier to smuggle than something large. And since fentanyl is 50 to 10,000 times more potent, it is way smaller. It’s also less smelly because on opioids, heroin is a plant product.
Krys Boyd [00:38:49] Which is to say we will never be able to just filter out drugs coming in from elsewhere, let alone drugs produced domestically.
Maia Szalavitz [00:38:59] Well, exactly. And once, you know, I mean, what we did to the methamphetamine market, we used to have all these meth labs blowing up all the time in the United States. And meth used to be a sort of mom and pop business by local biker gangs or other people. And then we made it very difficult to get one of the precursors for making it, which is a antihistamine that’s available over the counter. So we made that very difficult to get. What it did was it switched meth production to Mexico. All the mom and pop labs pretty much went out of business and the cartels took that business over. And we have more and purer methamphetamine than we had when it was easy for you to go and treat your cold with the antihistamine.
Krys Boyd [00:39:45] I understand your point, Maia, that stigmatizing substance use does not help at all. May in fact interfere with people receiving appropriate help to overcome their problems. I have to ask if stigmatizing helps at all with keeping people from developing problems with substances in the first place. Is there any evidence of that?
Maia Szalavitz [00:40:10] I mean, it’s a complex question for most of the people who are deterred from using drugs by social stigma or by being told how dangerous they are, are people who, if they use drugs, would not develop addiction in the first place because they’re not people who are traumatized and or mentally ill and seeking some way of escape. So you basically deter the low risk people. If you deter anybody and you possibly encourage the high risk or end up punishing those folks. The thing is like, we shouldn’t go around saying drugs are fabulous. Everybody should be shooting up. And it’s great to be addicted to fentanyl. That is not a sensible way to proceed. We should stigmatize behavior that harms other people. That is appropriate. But what we should not do is stigmatize having a condition that results from people trying to self-medicate trauma and or mental illness. And that is what we end up doing with the war on drugs. It is perfectly fair to say you can’t smoke in this neighborhood or this particular, you know, outside this door here. And to like make restrictions on where people can do various things. We shouldn’t be locking up homeless people who don’t have an alternative. But the you know, in terms of smoking, we have really made a lot of progress by raising the prices and limiting where people can do it and perhaps to some extent by stigma. So but it’s a very blunt instrument. And the people who are the most vulnerable to becoming addicted are also the most vulnerable to being harmed by being stigmatized. So it’s really not your best way of doing it. I mean, I think if we’re talking about prevention, the best things you can really do are deal with childhood trauma early or ideally prevent it, deal with incipient mental illness early or ideally prevent it by preventing childhood trauma. And teach people about what people are seeking when they do drugs. Because, for example, if there’s a kid who’s depressed and they’re like, wow, I just like, found this drug that makes me feel amazing. That’s a really high risk thing. We would prefer that not happen if that does happen. The kid should know enough, at least the educated enough to be like, Wow, this is risky rather than, Yay, I found the answer. You know, it’s really difficult, but if we could educate people to be more socially connected, reduce bullying on know what the symptoms of things like depression and anxiety disorders are, and that this can be treated with therapy and or medication without the risks of substances. The thing is that adolescence is when these conditions tend to start. And that is also the same time when teenagers tend to be resistant to authority and pushing against their families just because they need to get out of the house. And evolutionarily. So it makes it really difficult to. And I personally think that because risk taking naturally escalates during adolescence, you’re never going to be able to prevent all first use because kids are going to take some risk. What you want to do is like minimize what that risk is and maximize people knowing that if they do have something that they’re trying to self-medicate. There are ways that work other than drugs. The problem with a sort of just say no thing is it tells people that feeling okay is bad and you have to like if you feel okay, naturally you need to earn any pleasure and honor and pleasure is bad. And so if you are naturally feeling horrible in your own skin all the time and you want to feel better, you’re stigmatized for that. So rather than doing that, we have to help people understand that your baseline is different from everybody else. You may be feeling horrible. Everybody else may be feeling fine. And you have the right to feel fine just like everybody else. And we should find ways for you to do that. Because when parents tell kids not to do drugs, kids here, I don’t want you to have any fun. I want to control you. And when they say, you know, get your depression treated well, I don’t want you know, they want me to feel flat and not have any pleasure and not have any fun and they’re going to give me the bad drugs. You have to work to debunk that. You have to have the kids be aware that with appropriate treatment, they can feel way better and the drugs won’t be that desirable anymore and they will be able to have a happy, productive life.
Krys Boyd [00:45:31] Maia Szalavitz is a contributing opinion writer for the New York Times, which published her article “Not Everyone is Benefiting From Drops in Overdose Deaths.” Maia, it’s always nice to speak with you. Thank you for making the time.
Maia Szalavitz [00:45:43] Thank you so much for having me.
Krys Boyd [00:45:45] Think is distributed by PRX, the Public Radio Exchange. You can find us on Facebook and on Instagram and any place you get podcasts, just search for KERA Think. If you want our website that’s think.kera.org. and when you’re there you can learn about upcoming shows and sign up for our free weekly newsletter. Again, I’m Krys Boyd. Thanks for listening. Have a great day.
