Episode 103: The US Pain and Overdose Crises

Woman gazing out window with arm resting on windowsill

Liz Chiarello's research provides a street-level view of the opioid crisis. Photo by Todd Dionne

EPISODE 103: The US Pain and Overdose Crises, with Liz Chiarello

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On This Episode

According to the US Centers for Disease Control and Prevention, drug overdose deaths have risen fivefold in the past two decades. What’s driving this crisis, and what can be done to alleviate it? Our hosts discuss the issue with Liz Chiarello, a sociologist who is finishing a book about how the dual US crises of pain and overdoses have transformed law enforcement and healthcare.

This episode was recorded on June 30, 2023.
Released on September 21, 2023.

Guest

Liz Chiarello, an associate professor of sociology at Saint Louis University, is a medical sociologist and sociolegal scholar whose research lies at the intersection of healthcare and law. During her fellowship year, Chiarello worked on a book about the US overdose and pain crises, using the overdose crisis as a case study in how medical providers make decisions about opioid provision—and in how these decisions affect patient care.

Credits

Ivelisse Estrada is your cohost and the editorial lead at Harvard Radcliffe Institute (HRI), where she edits Radcliffe Magazine.

Alan Catello Grazioso is the executive producer of BornCurious and the senior multimedia manager at HRI.

Jeff Hayash is a freelance sound engineer and recordist.

Marcus Knoke is a multimedia intern at HRI, a Harvard College student, and the general manager of Harvard Radio Broadcasting.

Heather Min is your cohost and the senior manager of digital strategy at HRI.

Anna Soong is the production assistant at HRI.

Special thanks to Cabin 3 Media for their invaluable contributions to the editing of this podcast episode.

Transcript

[MUSIC]

Ivelisse Estrada:
Welcome back to BornCurious, a new podcast from Harvard Radcliffe Institute. I’m your cohost, Ivelisse Estrada.

Heather Min:
And I’m Heather Min.

Ivelisse Estrada:
Now, I’m someone who likes to get wowed by learning new things, and here we are, sharing some of that wow with you. Today, Heather and I will dig deep into the opioid crisis. So, let’s dive in, shall we?

Heather Min:
For those of you who do not know her—

Ivelisse Estrada:
Liz Chiarello is a medical sociologist and sociolegal scholar whose research lies at the intersection of healthcare and the law. During her fellowship year in 2019 and 2020, Liz worked on a book about the US overdose and pain crises, using the overdose crisis as a case study in how medical providers make decisions about opioid provision and how these decisions affect patient care.

Heather Min:
And now she’s back as a summer fellow, putting some finishing touches on that book. It’s good to have you back, Liz.

Liz Chiarello:
Thank you. It’s good to be here.

Ivelisse Estrada:
I’ll start with my question, which is you’ve been asking questions about opioid use since 2009. What brought you to this work?

Liz Chiarello:
I came to this work quite by accident. My dissertation was on pharmacists and the emergency contraception because at the time, there were a number of pharmacists who were refusing to dispense emergency contraception, Plan B, or the morning-after pill, because they thought that it was an abortion. I designed my dissertation so that I could look at the kinds of factors that influence their decision-making, like whether it was their personal beliefs, the pharmacy that they worked for, the political environment that they were situated in, or the law.

I went to four different states and I interviewed 95 pharmacists. And the first question I asked them was, What would you say are the key ethical issues that pharmacists face in daily practice? I thought they were going to say emergency contraception because that’s all anybody was talking about, and across the board, they said opioids.

I ended up with all this data on how they made decisions about opioids. And this was before the opioid crisis was really on the national agenda—before everybody knew who the Sacklers were. And so, I was kind of ahead of the curve in that way, but it also meant that I saw how pharmacists were really struggling in making these decisions. And so that’s how I got into it— kind of stumbled upon it.

Ivelisse Estrada:
Wow.

Heather Min:
And you often say America has two crises—one is the pain crisis and the other is the opioid crisis. Why do you think that it’s important to make that distinction?

Liz Chiarello:
I think because if we look historically at how opioids have been treated in this country, we had a moment in the early 1900s, where it was very, very popular to provide opioids largely to rural middle-class housewives.

Heather Min:
And what do you mean by opioids?

Liz Chiarello:
Opioids are a class of drugs that derive from the opium poppy. We now have synthetic versions of those drugs, meaning that they’re man-made; they don’t necessarily derive from the plant. Things like OxyContin and Vicodin and Percocet and fentanyl—the prescription fentanyl, not to be confused with illegal fentanyl, which I’m sure we’ll talk about. So that’s the group of drugs that gets considered opioids.

Heather Min:
And they’ve been around for 100 years?

Liz Chiarello:
Hundreds of years.

Heather Min:
Hundreds of years.

Liz Chiarello:
Yes.

Heather Min:
And going back to the question of why do you make that distinction between opioid crisis and why is it a crisis in contrast with the pain crisis?

Liz Chiarello:
Yes. So, the way that we’ve treated opioids, and the way that we’ve treated people in pain and people with substance use disorders—or colloquially we sometimes think about them as people with addiction, but the medical term is people with substance use disorders—has really changed over the last 100 years. We’ve kind of had this pendulum that’s been swinging between more liberal approaches to providing opioids—kind of handing them out more readily—to very conservative approaches to opioids.

In the 1970s—well, leading up into the 1970s—we had a lot of people in pain who couldn’t get access to opioids. And opioids are meaningful because they are some of the most powerful medications that we have for treating pain. The hospice movement in England, in the ’70s and leading into the ’80s, really pushed back. They said, “We’ve got people dying in pain and they can’t get access to this medication that would help them at the end of life.”

And the US pain management movement really followed on its heels to say, “Look, people shouldn’t have to die in pain, but they shouldn’t have to live in pain either.” And that opened up this kind of liberal moment of drug provision that in some ways helped to spur the overdose crisis, but that also addressed a real problem with pain. So, we keep asking ourselves, Should we provide opioids readily, or should we be really, really conservative about them? And either approach hurts somebody.

So, you over-provide, you create this glut of opioids that are available for misuse, but you under-provide, and you put people in pain in horrible pain. And you also motivate people who have substance use disorders to turn to the illegal drug supply, which is far more dangerous than the legal drug supply. These two groups get pitted against each other in our fight over opioids. And so, it’s important that we talk about both of them.

Ivelisse Estrada:
I was just thinking that you’d be hard pressed to find someone who hasn’t been touched by this opioid epidemic in some way. Why has it been so far-reaching?

Liz Chiarello:
It’s a really good question. I think partly because it is the intersection of two crises. Not only do so many people have some sort of substance use in their family, but a lot of people have pain in their family, too, and so people have seen both sides of this crisis.

I think also it just all happened so fast. So now there are over 100,000 deaths per year. We’ve lost over a million people to overdose and then we’ve also lost people to pain, to death by suicide because of pain. I think it all happened so fast, it’s touched a lot of us pretty quickly. And then COVID, obviously, didn’t help.

Heather Min:
You’ve referred to the Sacklers, who were the family who founded and actually promoted marketing malfeasance, I suppose, of oxycodone, or OxyContin—

Liz Chiarello:
OxyContin is the brand name, yeah.

Heather Min:
—of Purdue Pharma, their company, and there’s been litigation and they’ve been indicted, but then got off. But there’s the aftermath of their activity, which was to encourage physicians who prescribed these medications to do so very liberally, and little did we know that it was very easy for many people to get addicted to them very quickly.

So that certainly exacerbated the crisis and played a key role in doing so. Where do we stand now, though?

Liz Chiarello:
So, I want to talk a little bit about the Sacklers, because the Sacklers have become the poster child for this crisis. And they’re a pretty convenient villain, much in the same way that opioids are a pretty convenient scapegoat for a lot of problems that we have with our society.

I want to be really clear about the Sacklers. They engaged in some really bad activity and they hurt a lot of people, and we have to acknowledge that. But we also have to recognize that the reason people use drugs is not just because drugs are available. The way that drug policy experts talk about this is the difference between a supply-side story and a demand-side story.

The supply side is the drug is available, you have a drug company that’s pushing that drug, getting doctors to prescribe it hand over fist. That really does push out a drug into the world, and people who probably would never have gotten an opioid in 1970 could pretty easily get an opioid in 2001. However, drugs are available and a lot of us don’t use drugs. And a lot of people who use the drugs that we understand to be highly addictive—heroin, OxyContin, cocaine, other kinds of drugs, do not meet the criteria for a substance use disorder.

We have a lot of variation in terms of who’s using drugs, and then how those drugs are affecting them. We really do have to think about the demand-side story, which is all of the kind of social factors that lead people to use drugs and to use drugs chaotically. A lot has been written about deaths of despair—about economic issues, lack of jobs, living in poverty, those kinds of things— and how they lead to drug use. And so those are the kinds of things that we really need to be looking at, and that’s the lesson we need to take away.

Unfortunately, the lesson we have taken away from this crisis is the Sacklers are bad. They did evil things. They’ve now been sued. We’ve taken all of this money back from them. But that is just, frankly, terrible public health policy. We can’t let bad things happen for 20 years—we can’t lose a million people over 20 years—and then try to claw back ill-gotten gains and think it’s going to make a difference. And so, if we don’t use that money to actually invest in what works, we’re going to be right back where we started.

And in fact, the pendulum has swung so far back. We swung towards this really liberal prescribing moment, now it has swung so far back that doctors are celebrating doing surgeries with almost no opioids. We have opioid-free emergency departments. We have people going home from surgery without opioids, and so what we need to do is rightsize our use of opioids. We need to make sure that the right medications are going to the right people, in the right circumstances—and that’s just not where we are right now.

Right now, we’re in a moment where a lot of communities stand to get an enormous windfall from the Sacklers and from other companies that were implicated in the overdose crisis, but we have to make some really good decisions about how we use that money.

Ivelisse Estrada:
Let’s talk about how that swing happened—and I think your book talks a lot about this, which is the PDMPs and your work around those.

Liz Chiarello:
So first, why don’t I tell you a little bit about what the PDMP is, and then we’ll talk about the kind of effect that it’s had. So PDMPs are prescription drug monitoring programs. They are statewide databases that gather all of the information about controlled substances dispensed in a state. Controlled substances are not just opioids. They are drugs that are under the Controlled Substances Act. So, they include things like benzodiazepines that are used to treat anxiety and they include stimulants—all kinds of different things fall under the rubric of controlled substances.

So not all prescription drugs are controlled substances, only a smaller subset that are understood to be riskier than other drugs. PDMPs gather all of the pharmacy dispensing data in a state about controlled substances. If you went to your pharmacist and they gave you Vicodin, that information would go into the PDMP. And then, in most states, a private company that used to be called Appriss—it’s now called Bamboo Health—they aggregate all of that information and then they feed it back to health care providers in the form of a PDMP report so that they can use it to make decisions about patients. But it also feeds that information back to law enforcement so that they can use that information to make decisions about both patients and providers.

Heather Min:
Local and federal law enforcement?

Liz Chiarello:
So, it depends on the state who can get access and how. In some states, law enforcement has just a direct login, where they’re able to see all of the PDMP information. It’s kind of on the honor system. They’re supposed to do it in a situation where they have an active case going. But then in other places, they have to go through the board of pharmacy or the board of health, whoever holds the PDMP, and get the information from them.

Heather Min:
Why is law enforcement getting this information?

Liz Chiarello:
Law enforcement gets this information because healthcare providers are regulated by law enforcement. Take the DEA, for example. The only reason that physicians can prescribe controlled substances is because they have a DEA registration. If you don’t have a registration with the DEA, you can’t prescribe anything that falls under that category of controlled substances. The DEA is also responsible for making sure that physicians are prescribing appropriately, and the PDMP is part of how they find that out.

Heather Min:
The PDMP, however, holds information about actual patients. Are they then being monitored?

Liz Chiarello:
They are being monitored. And one of the things that was really shocking to me to find out about the PDMP is it’s not protected under HIPAA. So even though it is what most of us would recognize as individual-level sensitive healthcare data, it is not treated that way in the law. So yes, the DEA can see a patient’s individual healthcare information based on these prescriptions.

Heather Min:
What is the role of the pharmacist in terms of what their responsibilities are to patients, but sharing same database with law enforcement?

Liz Chiarello:
Yeah. I know. It is a lot to wrap your mind around. I think a lot of us think we have a lot more privacy in terms of our healthcare data than we do. HIPAA is actually relatively narrow. But the PDMP is kind of a workaround. It’s a way that law enforcement gets access to data that they otherwise would not have access to because they can’t get access to, for example, the electronic health record because that is protected under HIPAA. But they can get access to the PDMP.

And this is part of why I talk about PDMPs as enforcement tools. They were created for law enforcement in the first place and they’ve only within the last 20 years or so, really become a staple of medical care and pharmacy care—of healthcare. And so, this is part of why in my book, I talk about PDMPs as Trojan horse technologies. They were built with law enforcement in mind. They were built with these ideas of surveillance in mind.

When they move into healthcare, they don’t just become a healthcare technology just because a healthcare provider is using them. They’re still an enforcement technology. What I show in the book is how physicians and pharmacists who use the PDMP become more and more committed to things that we think about cops doing: surveilling patients, trying to catch patients in lies, getting rid of patients. But pharmacists are also in a tricky position.

An individual pharmacist would have a very hard time saying “I’m just not going to submit my patient data to the PDMP” because they’d have to fight their pharmacy, like Walgreens or CVS, they’d have to fight their state, they could lose their license. So, they’re in a really tricky place as far as all of that is concerned.

And I will say, the law is not entirely settled on how we make sense of the PDMP data. But there is a law professor, Jen Oliva, who writes about this in detail, and so she’s a good person to look to if you want to find the nuances of why it’s not exactly health care data and how that gets treated.

Ivelisse Estrada:
Tell us about your book, because we’ve been talking around it, but not about the form that it’s taking.

Liz Chiarello:
Yeah. My book is called “Policing Patients,” and it is based on 10 years of data that I gathered with physicians, pharmacists, and enforcement agents. And when I say enforcement agents, I mean everybody from local police, to sheriff’s narcotics task forces that are at the county level, to the DEA, including both the criminal side of the DEA and the administrative side of the DEA—and I can talk about the differences there—to people who do investigations for medical boards and pharmacy boards, fraud investigators at the state and federal level, people who serve on medical and pharmacy boards, and prosecutors who prosecute cases against doctors.

When I chose the enforcement folks, I was really looking for people who had anything to do with cases against physicians, because I was interested in the enforcement environment that surrounds healthcare providers and how that might influence their decision-making about patient care.

Heather Min:
You’ve covered a lot of ground here in terms of how you think about the opioid crisis. You’ve talked about different professions; you’ve talked about structural ways that enable these crises to be in the culture at the moment. Could you explain how you look at this crisis? What your key questions are? And, as I understand it, you describe yourself as a medical sociologist. What is your perspective on all of this and how do you approach trying to get your arms around it?

Liz Chiarello:
Yes. Let me just say that I find sociology to be such an incredibly helpful discipline for trying to understand social problems like the overdose crisis and the pain crisis. Sociology, of course, is the study of society. The last time I checked, I think we have 53 subfields of sociology. So, if you want to study sports, or immigration, or families, or subcultures, or any form of inequality— organizations, you name it—you can study it sociologically.

I always think about that old iPhone commercial, “There’s an app for that.” There’s a sociology for that. Anything you want to understand, there’s a sociology for that. My background is actually in social movements and organizations. That’s what I was formally trained in in graduate school. And then, over time, as I got really interested in pharmacy issues and in law enforcement issues, I moved into medical sociology and then what’s called sociolegal studies.

Medical sociologists are people who think about the healthcare field through a sociological lens. We often think about healthcare organizations, and how they operate, and how they articulate with one another. We think about healthcare professions—how they become professions, how they relate to one another. Why do doctors do the tasks they do, and nurses do a different set of tasks?

We think about why social problems become medicalized. Why do we treat gambling addiction as a medical issue instead of as some form of badness or criminality? And you can see social problems kind of move through different fields where they get criminalized for a moment, or there’s a real moral bent to them for a moment, and then there’s a medical bent to them, and then maybe they get completely de-medicalized, decriminalized. So, I really work at this intersection of medical sociology and sociolegal scholarship.

Heather Min:
That helps us understand the different filters through which you’re digesting such a vast topic.

Liz Chiarello:
When I first learned about the overdose crisis, I realized, well, we’ve got healthcare trying to deal with this crisis and we’ve got the criminal legal system trying to deal with this crisis. And those are really different fields. They attract different kinds of people, they have different kinds of resources at their disposal, and they have really different worldviews in terms of how they think about problems.

And so, I thought, well, are they competing over this social problem? Do they each want to claim it for themselves? Are they sharing the social problem? And I noticed that they were doing a lot of collaboration. It became very common for police chiefs, for example, to say things like, “We can’t arrest our way out of this problem,” or “Addiction is a disease.” I really wanted to understand how were they cooperating to try to deal with this problem.

That’s why I interviewed such a wide variety of people, in three states—Florida, California, and Missouri—which I chose based on where the PDMP was located. In the Department of Justice in California, in the Board of Health in Florida, and then Missouri didn’t have one, but then they put one together through the county boards of health.

I just wanted to talk to everybody to try to get the broadest possible set of perspectives on this crisis and to understand the frontline decision-making that was happening in terms of making decisions about handing out opioids but also making decisions about which doctors deserved investigation and which pharmacists deserved to be investigated. Like, how do they do those cases? What do they look like?

Because then it helped me understand how providers were making decisions, but also the broader enforcement environment in which they were embedded. One that had become, in my view, more treacherous over time, especially with the PDMP, because law enforcement had a lot more access to information about providers’ behavior than they did in the past.

Ivelisse Estrada:
Tell us about what you did find once you started talking to people—talking to everyone?

Liz Chiarello:
I would talk to somebody in law enforcement, and I’d be like, “These doctors are behaving really badly!” And then I’d talk to a doctor, and they would give me a different perspective. And I was like, “Wait a minute, law enforcement is being ridiculous!” And so, I just found myself moving back and forth between these perspectives, which I think was good. I didn’t go in with a very clear idea of what was right and what was wrong. I didn’t have a really good sense of what was going on.

Hearing what was happening through different people’s voices and experiences was incredibly illuminating. I found that the PDMP is part of a set of surveillance tools that is helping to push healthcare providers in the direction of policing, which is why I call the book “Policing Patients.” We normally think about healthcare providers as providing care and treatment and using healthcare tools that should be in their tool kit.

But when we’re talking about pain and substance-use disorder, physicians actually have very little education—most physicians, I should say, have very little education—on those two things. They are what medical sociologists would call incompletely medicalized. You know how I was saying that medicine likes to take all kinds of things under its purview, whether it belongs there or not and whether they have a solution or not. With things like addiction, they tend to push that outside their purview. They do a little bit of not-my-jobism with that.

And so, the healthcare tools are not as robust as they should be when we think about something like addiction or chronic pain. Inserting something like a prescription drug monitoring program, which is, at its heart, an enforcement tool, really reshapes not only how professionals think about patients, but also how they think about themselves and their jobs, how they interact with other kinds of workers like law enforcement, for example, but also the dynamic between physicians and pharmacists.

All of this really results in either tightly policing patients, who physicians and pharmacists are willing to see, or pushing those patients outside of the healthcare system in ways that are incredibly problematic. So, what I find is a blurring of boundaries between healthcare and law enforcement and between treatment and punishment in ways that really undermine patient care, and tragically, that help to drive up overdose.

Ivelisse Estrada:
I feel like we need to talk about what happens when those patients who are in pain get pushed out toward those illegal drugs.

Liz Chiarello:
And it’s not just pain patients, it’s pain patients and patients with substance-use disorder. Here’s what you have to understand about our drug supply. Our legal drug supply is regulated. When you take an 80-milligram pill of OxyContin, you are getting 80 milligrams of oxycodone and you are not getting anything else. That’s all that’s in that pill.

If you take a pill on the street that is labeled 80 milligrams of OxyContin, you could be getting anything. The problem is that the illegal drug supply is so poorly regulated—I mean, it’s really not regulated at all—that you’re taking a risk any time you take something from the illegal drug supply. And of course, people might say, Well, why don’t you just not take drugs? Well, that’s really complicated. People are hooked on these drugs. Not taking a drug means going into terrible withdrawal.

While we might have an idea that we’d like for people not to use drugs or to use drugs less, we also have to deal with the practical realities that we’re facing. If you go from taking a regulated drug—actually, I do want to talk about this, but I have to backpedal a little bit. OK.

One of the other major changes that’s had a massive impact on pain patients, in particular, are the CDC guidelines for pain that came out in 2016. And they were designed to be guidelines but they’ve been treated as law and they have a lot of recommendations about, for example, the milligram morphine equivalent that a patient should be on. That’s just the dose of drug that a patient should be on. They recommended 90-milligram morphine equivalents, but patients who have been on opioids for 15 years might be at 500-milligram morphine equivalents.

What’s happened is a lot of doctors are tapering those patients down, and they’re doing it very, very quickly. And those patients don’t necessarily have a substance use disorder, but they are dependent on the drug, and they will go into withdrawal if you taper them that quickly. And not only that, it thrusts them right back into pain. You can imagine that those patients do go looking for something else.

Ivelisse Estrada:
And these are patients with chronic pain?

Liz Chiarello:
Those are patients with chronic pain. Now, I haven’t seen a lot of studies that specifically show that link between being turned away from your doctor or tapered by your doctor and starting to use illegal drugs, but there’s reason to think that that’s what’s happening.

And I always think about it in terms of alcohol. If you go to the bar and you have a drink, if you have a cocktail or you have a beer, you have a pretty good sense of how that’s going to influence you, especially whether you’ve eaten that day, how strong the alcohol is. You have a good sense of it. So, you can manage your life accordingly. You know not to drive if you’ve had two cocktails or three cocktails.

But imagine if you didn’t know. Imagine if you went to a bar and you just had no idea if the amount of alcohol you were drinking was going to give you a light buzz or if it was going to kill you. That’s what it’s like dealing with our illegal drug supply. Shoving people out of the healthcare system, shutting the door on them, and leaving them to fend for themselves invites them to venture into that illegal drug supply or leaves them with no resort but that illegal drug supply.

And that drug supply has grown more and more toxic over time. So right now, fentanyl is the leading contributor to overdose deaths. It contributed to 66 percent of overdose deaths in 2021, whereas prescription drugs only contributed to 16 percent of overdose deaths. And notice I say contributed to not caused because a lot of times people have more than one drug in their system, and so we can’t usually talk about that in causal language.

Increasingly there is a drug called xylazine, which is an animal tranquilizer—it’s also known as tranq dope—that has made its way into the drug supply. Leaving people with nowhere else to turn means that they turn to really dangerous places. If we want to stop overdose, we have to stop pushing people out of the healthcare system and take seriously that we need to provide them with care.

Ivelisse Estrada:
So, fentanyl—I had no idea it was as bad as it is. And that these new drugs are coming on the market. Must be hard to keep up. But you say there’s a solution for this. And so, you have policy recommendations that could help.

Liz Chiarello:
Yes. Absolutely. My policy recommendations fall in three categories: harm reduction, treatment, and prevention. Harm reduction is a philosophy—it’s a set of behaviors based on a philosophy of meeting people where they’re at and encouraging any positive change. It’s often contrasted with a more abstinence-based approach to recovery.

Things that are included in harm reduction are syringe services programs, or what are also known as needle exchanges—which is sometimes a misnomer because you’re not necessarily exchanging the needle, you’re getting clean needles—that can prevent things like abscesses, hepatitis C, HIV from spreading. And so we’re not having an additional problem on top of drug use.

Narcan—you’ve probably heard of Narcan—which is an opioid overdose antidote. If someone is overdosing, they can be given Narcan and brought back to life, which is pretty extraordinary. There’s been a big push to get Narcan not only into the hands of first responders, which is important, but also into communities of people who use drugs.

There’s also been a push for supervised consumption sites that has been a bit of a rocky road here in the United States but is something that exists in other countries. And these often seem very new to people, but actually there’s a very strong evidence base to support harm reduction of the kinds that I’ve talked about and a number of other approaches to harm reduction.

Harm reduction saves lives. And the expectation is not necessarily that somebody is going to be completely off of drugs, but rather that they’re going to be able to use drugs in a safer way that’s going to keep them alive and ideally thriving. Also, harm reduction usually creates connections to healthcare providers and other people who can help people if and when they’re ready to get into treatment. So, it’s kind of fostering those connections in some really positive ways.

And then when it comes to treatment, the research is really clear. There are two treatments that are particularly effective for opioid use disorder. One is methadone, which has been around since the ’70s, and the other is buprenorphine, which has been around for the last 20 years or so. Methadone, of course, is dispensed in clinics and has a set of challenges associated with how you get access to methadone. It’s called liquid handcuffs, because you have to take it every morning, you have to show up at the clinic and get your dose. And because there’s a lot of surveillance that goes into providing methadone treatment. But the drug itself is really quite effective.

And then buprenorphine is provided in doctor’s offices, but there are too few physicians who are willing to provide it. For a long time, they had to get what’s called an X-Waiver, which was just an addition to the DEA registration that allowed them to provide buprenorphine for these purposes. And less than 10 percent of physicians chose to get the X-Waiver. And now they don’t even need an X-Waiver, they can just provide buprenorphine out of their office. We’ll see if that changes. But expanding access, particularly to buprenorphine, is incredibly important. And there are mechanisms by which pharmacists could do that.

Looking at who else can provide this care and expanding that access to care, I think is extremely important. And then when I talk about prevention, I think a lot of us have been through DARE, and so we think prevention is about going into schools and telling kids not to get on drugs.

Heather Min:
“Just Say No.”

Liz Chiarello:
“Just Say No.” That was very effective. I have to tell you this about that. But no, when I say prevention, I mean capital-P Prevention. I mean, we need to think about the social determinants of health, and we need to think about the things that harm our communities—things like jobs and housing, paying people a living wage, universal healthcare. And I know that when I start talking about this, I start to sound very pie in the sky, but the problem is that we have a number of problems that stem from our unwillingness to commit to improving the human condition.

When we treat those things as if they were separate, we put our blinders on, and then we struggle to try to deal with the problem because we’re not dealing with the underlying issues. I will tell you, just looking at the overdose crisis, we’ve been through three waves of the overdose crisis and we’re heading into the fourth. The first was prescription drugs, and we’re like, OK, how can we stop doctors from overprescribing opioids? Then we moved into heroin, and it was like, Oh, no, this is a different problem. And now we have fentanyl, and now we think that’s a different problem. Well, these are all the same problem. They’re all the same problem—they stem from the same kinds of causes. Until we are willing to address those root causes, we’re just not going anywhere. We’re going to be stuck in these terrible cycles of addiction and pain and death. We need to take seriously the factors that would make our communities better and more livable for everyone.

Ivelisse Estrada:
I love that for everyone.

Heather Min:
Yeah. Thank you for centering your recommendations on care and the need to address the pain that people are in, which really is at the heart of this, rather than getting into the quagmire of all of the institutional and professional complications and problems that also are a part of this.

Liz Chiarello:
Well, I love what you just said about pain because I think we often think we have people with addiction and we have people with pain, and these are different people. But I think these are the same people. I think these are all people with pain that is manifesting in different ways. Pain, I think, really should be one of the main things that we focus on. We have to get underneath where pain comes from and why. And I don’t mean that physiologically, I really mean that socially.

Heather Min:
Pain is part of the human condition. We all feel it, we all experience it, and we all are, as we’ve started this conversation by saying, we’re all affected by it as well.

Ivelisse Estrada:
Thanks so much. This has been just great. Love it.

Heather Min:
Thank you for explaining what is a huge problem, and while not sacrificing the nuanced multifaceted, multilayered complexity of it. Thank you.

Liz Chiarello:
Thank you.

Heather Min:
The BornCurious podcast is brought to you by Harvard Radcliffe Institute.

Ivelisse Estrada:
Thanks for joining us. You can find BornCurious wherever you listen to podcasts. And to learn more about Harvard Radcliffe Institute—

Heather Min:
Visit radcliffe.harvard.edu.

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