Data Nation

Munther Dahleh (00:04):
Welcome to Data Nation. I'm Munther Dahleh, and I'm the director of the MIT's Institute for Data, Systems, and Society. Today on Data Nation, Liberty and Scott are investigating the opioid epidemic in the United States.
Liberty (00:25):
Americans are dying, but the main killer isn't what most people think. It isn't gun violence. It isn't COVID-19. For 18 to 45 year olds in the United States, the leading cause of death is opioid overdose from illegal fentanyl. And like here are the hard facts. Guns don't come near to opioids in terms of the number of dead Americans. And unlike gun deaths, opioid deaths are only increasing. In 2020, 19,384 Americans died of guns, and this number is higher than in the past couple of years. But in the 1960s and 1980s, there were the same number of gun deaths in the US.
(01:07):
One can easily argue that the numbers of gun deaths are very steady over time. However, deaths by drug overdoses have more than doubled since 2015 and are increasing exponentially with over a hundred thousand Americans dying in the past 12 months. This is all while we have been spending trillions of dollars fighting the "opioid epidemic." But how did we get here?
Scott (01:34):
How we got here? The beginning of the opioid crisis can be traced back to the mid 1990s when Oxycontin, a highly addictive painkiller, triggered the first wave of deaths linked to legal prescription drug use. Oxycontin was being promoted by Purdue Pharma and they were promoting this painkiller as less addictive than other opioids. However, it was later found that this was a fraudulent description of Oxycontin. Purdue Pharma had known the truth, but decided to advertise it as less addictive so they could sell more of the drug.
(02:03):
Prior to this, Oxycontin had been approved by the FDA, and it was around that time that the government largely removed themselves from any enforcement on how or where the drug should be prescribed. Basically took themselves out of their own job, leaving it largely up to the doctors, as well as the pharmaceutical industry themselves to do. With this being the case, the pharmaceutical companies were going to do what they were going to do. They were going to ship more of them, sell more of them so they could get paid.
(02:29):
They encouraged doctors to prescribe their drug to the patients, incentivizing doctors to prescribe the drugs, like Oxycontin, in large quantities and to many people who may not have needed it at all.
Liberty (02:40):
I think what's important to note is that over time, the dependency on these drugs for pain relief shifted to an addiction. The US Drug Enforcement Administration did work to stop the mass prescribing of these drugs, making it a lot harder to obtain opiates. But that didn't change the fact that many Americans had a newfound drug addiction, and probably more importantly, that the drug dealers and cartels now had a newfound revenue stream. With limited access to opiates, prescription opiates, a lot of people turned to heroin to fuel their addiction, trading one drug epidemic for another.
(03:15):
Furthermore, with legal opioids becoming more expensive and harder to come by, addicts turned away from legal methods to obtain their pills and instead turned to the black market, where pills are usually, not even often, usually laced with synthetic opioids like fentanyl to reduce production costs. Here's a fact. In 2010, illegal fentanyl was related to only 14% of drug related deaths. Now it's related to 70% of drug deaths.
Scott (03:45):
Even today, opioid addictions have become more widespread. We're finding that the usual therapies don't work, and we're seeing no change, just more death. When it comes to the opioid crisis, there are a lot of people from different spheres responding to the epidemic. There are the people collecting data and researching tirelessly how to stop this, and the people on the ground who watch the crisis as it began and face their communities every day.
Liberty (04:08):
Chief Tom Synan is someone on the ground, and we're going to talk to him today. He was the tactical team leader of SWAT before becoming the chief of police in Ohio. He has testified before the US Senate Homeland Security Committee on synthetic opiates, and his work with Hamilton County Heroin Coalition has been cited by many in both national and international media. Chief Synan, we all started to hear about the opioid epidemic in 2016. The Washington Post had all these reports on it. It culminated in this DEA database that tracks the path of every pain pill sold in the United States. You're on the ground. Did you see this before it became something in the news? Did you see this opioid crisis?
Tom Synan (04:50):
Oh, absolutely. It was oxycodone. It was kind of strange. We would have people come to the police station and say, "Hey, someone stole my prescription pills of oxycodone." The first time you're kind of like, "Wow, that's kind of mean. Why would someone do that?" Then about a week later, the same person come down, "Hey, someone stole my pills again," and you're thinking, "Okay, it's kind of weird." And then they come down the third week in a row and say, "Hey, someone stole my pills again."
(05:12):
And then as cops, sometimes we look for clues. Sometimes it takes us a little while, but then you started realizing, wait a minute, there's something going on here with oxycodone. There's something going on not just that people were using them, but they were selling them, and they were also highly addictive and they were getting them from doctors. So yeah, we saw this well before.
Liberty (05:30):
What did you all start to do? What did you see as really the way that the prescription opiates, that oxycodone that you got from doctors, how did you all try to fix that? What were the methods used?
Tom Synan (05:42):
Well, it was more from a state level. It was more from the pill mills, these doctors that were prescribing these pills, what they call pill mills in Ohio. What law enforcement is really good at is enforcing laws. We went after the pill mills and shut them down in Ohio. One of the trends we saw here in Ohio is when we shut those down, people started driving to Florida and you would see thousands of pills being brought back from Florida to Ohio.
(06:08):
That trend continued, until nationally people started shutting down these pill mills and became more serious. And to your point, the DEA got really involved and started shutting down these doctors illegally prescribing in the pill mills. And that's when we saw the transition from prescription pills to then the street drug of heroin.
Liberty (06:26):
When you say a pill mill, can you explain to me what you mean?
Tom Synan (06:29):
Yeah, it was basically doctors that were just prescribing people, making money off of it. You would walk in and not necessarily you had pain. There was not necessarily a physical someone was giving you. Some doctors were just prescribing these very powerful pain prescriptions, these pills. We actually had people from my little town here drive to Florida and go to a doctor's office there, get thousands of pills, and bring them back. We had some information. We would do some interdiction and stop the cars and find the pills. They would then either use them or sell them or a combination of both.
Scott (07:02):
What are the things we're dealing with today, like this crisis that we've been following for years? But what is today's problem related to this?
Tom Synan (07:09):
Well, I've never seen a drug that you can literally do a checklist of the steps going forward. You went from the prescription pills to black tar heroin, then you went to regular heroin. And at the time, in the Cincinnati Hamilton County area, we were calling it an epidemic then, when we saw heroin and we were getting about 20 to 25 overdoses a week, with on average one to two people dying every single week in the county. And then in 2016, you literally saw this shift from the organic opiate of heroin to the synthetics of fentanyl. In Cincinnati Hamilton County, it was one of the first areas or first cities in the United States to see carfentanil.
Scott (07:47):
When you look at polling data on people and the opioid crisis, a lot of different ways you can ask questions about it, but if you look at it in Ohio, Pennsylvania, basically the Midwest, usually between 50 and 60% of the people can say they either know someone or have someone close to them who's been affected by the crisis. No, the definition's a little bit loose there. I don't know that everyone knows everyone died, but whenever you have 50 to 60% of the population saying that they can relate to it or know someone who can relate to it, that's a pretty big deal. Are you seeing this stuff cross socioeconomic lines, like this is not just four people, this is people of all walks of life and all backgrounds?
Tom Synan (08:22):
It is all backgrounds, races, economics. It has impacted every part of the community. And now that it's evolving into these fake prescription pills, it hits a different market and it's going to continue to grow.
Liberty (08:36):
How do we fix this? I hear arguments. We have NARCAN everywhere. Well, then, okay, does NARCAN just mean that people will keep doing drugs because they know they can save themselves with NARCAN? Or do we give safe injection sites, which means we're basically just giving people free rein to inject themselves? What is the argument to actually fix this that doesn't sort of give that give back of, well, you're just allowing people to do drugs?
Tom Synan (09:02):
Oh my gosh, I wish I knew what that answer was. We'd be fixing it. I helped start what we call now the Hamilton County Addiction Response Coalition. What we did is we brought a community together, and it followed kind of the similar four pillars that you hear all over from law enforcement prevention, harm reduction, treatment. We started with about a dozen people. We now have close to 400 people that are involved in it and over 150 different agencies. It really took a community coming together to try to work on this aspect. The first meeting I walked into with the coalition, I was so upset. I was pounding the table with the treatment providers, with the harm reduction people.
(09:36):
Public health saying, "Why can't you do something about this? Why can't we fix this issue of addiction?" I got about a two hour education on how complex addiction really is, the human aspect of it, the change in the physical and mental aspect of it. There's a group of people who say, "Not only do we need harm reduction like NARCAN safe injection sites, but let's get a safe drug supply in the system." I'm open to anything now. There are so many deaths that I'm open to anything. But I will say this, that as much as harm reduction is advocating for that, there is a mother or father, a brother, sister, son, or daughter who's advocating for not just saving their loved one's life, but get them into recovery.
Scott (10:17):
Where you see now, are we winning? Overall, do you feel better today about what we're doing to combat this? Not are we going to win this by tomorrow, but like where you were in 2015 and 2016 and today, do you feel good about it? What do you think? You're on the front lines of this.
Tom Synan (10:34):
I don't think we're winning. I don't think we've ever been winning when it comes to the war on drugs, if we're going to call it the war on drugs. I don't think there really is no winning with this. The drugs are so pervasive. They're so ingrained in our society. It's not something we're going to be able to stop. From my perspective, I'm extremely frustrated that in 2015-'16, we were talking about fentanyl and how it needed to be treated differently, how we needed to do more not just from the street level, but from the political level. And to your point, The Washington Post had an article a few years back talking about how they saw the government solve fentanyl coming in in 2008 and didn't take it serious enough.
(11:16):
And now it's so ingrained, we have to do something different when it comes to addiction because of fentanyl. We've not done enough. No, we're not winning this. Over 107,000 Americans died last year. I am hopeful and optimistic though, that conversations like this, some of us in law enforcement changing our view, the healthcare system becoming more involved. People like you talked about who have a family member now recognizing that addiction is a chronic mental medical health condition. Hopefully in the future, down the road, maybe 10, 20 years down the road, we do things differently, we see things differently when it comes to addiction. But right now, we're not doing enough to win this.
Liberty (11:59):
Here's an interesting approach, Scott. In November 3rd, 2020, Oregon made the decision to try a really different approach to the opioid epidemic. They elected to decriminalize all drugs, including heroin and cocaine. Possessing small amounts of these substances no longer carries the threat of jail or prison time. What it really does for people who live in Oregon is it allows them to seek treatment without fear or penalty of incarceration, and it allows these treatment centers to be established for addicts to use the drugs that they're addicted to in a safe way, rather than if they were getting those drugs off the street.
Scott (12:36):
It seems rather than trying to reduce the number of people using these kinds of drugs, Oregon is instead trying to decrease the number of people dying from these drugs by stopping them from using drugs that may be laced with fentanyl and lethal synthetic opioids. This initiative appears to save Oregon significant money on law enforcement and they also see increased tax revenue through the sale of marijuana. Due to the lack of access, just one in 10 people with drug addiction seek treatment in the US. If we're going to see this change, we're going to need to see more people in treatment and we need to see more of states take unique approaches like Oregon to see this happen.
Liberty (13:09):
I think the thing to point out, Scott, is just what you said, this is one state's response, and not every state is on the same page with this approach. I don't know how else to say it, but the hard truth is that voters aren't that sympathetic to drug addicts. And therefore, the politicians who make the legislation aren't that sympathetic to drug addicts. This negative stigma that comes with addiction isn't going anywhere anytime soon. I guess the point would be that even if you don't care about the people dying of opioids and illegal fentanyl, then maybe look at it different way and you should care about your bank account.
(13:44):
There are trillions of US tax dollars that are lost in this fight. Between the federal government shelling out to solve it, the cost to the economy, the lost productivity, healthcare costs, criminal justice activities, I am not exaggerating when I say that we have lost trillions in the fight against the opioids. And guess what? We are losing this fight big time. We need to have other methods to come up to fight this crisis.
Scott (14:09):
I'm glad you brought up the money because it's clear, it's big business and opioids are... It's a big factor. It's something I want to understand how it works and realistically, how can you solve the crisis when you're looking at it through a business aspect? Because we have this combination of drugs, death, and money and complexity around business around it, you can imagine there's a lot of competing forces and a lot of contradictory data and a lot of people with their own agendas. That's why I'm glad we've got Professor Andrew Lo, who's a professor of finance at the MIT Sloan School of Management.
(14:41):
He's also director of the MIT's Laboratory for Financial Engineering, a principal investigator at MIT's Computer Science and Artificial Intelligence Laboratory, and was recently named one of Time Magazine's 100 Most Influential People in the World.
Liberty (14:55):
Professor Lo, the opioid crisis has always been, to me, a health issue. I see it in the medical community, I see it in addiction, but there has to be an enormous amount of money and business aspects to the opioid crisis that I wouldn't even think of. Could you tell me a little bit about where the business world intersects with the opioid crisis?
Professor Andrew Lo (15:17):
First point to make is that because opioids are addictive, they end up generating lots and lots of revenues. People can't stop taking it. That's one aspect of business incentives that ultimately caused the crisis to begin with.
Liberty (15:33):
Just to get a little bit of a sense of the scale of this, if all drugs were just magically legalized and I had no morals, my goal would be as a company to come and create the most addictive drug I could possibly come up with and sell it to people, because then they're going to keep buying it, what is sort the market that was created around the opioid crisis in the first place? How much money are we talking, especially in comparison to other drugs or to other things that companies were doing? What was the level of incentive that companies had to make these opiates?
Professor Andrew Lo (16:05):
But just to give you a little bit of a sense of scale, let's take a look at the settlement involved in the opioid crisis. As of February 25th, 2022, Johnson & Johnson and the other three big distributors finalized a $26 billion opioid settlement agreement. It's looking like at least $32 billion now will be involved in the settlement. If that's the settlement for the crisis, you could probably guess at how much more money was generated in revenues beforehand over the course of the years leading up to this crisis.
Liberty (16:45):
When we think about in the tens of billions of dollars of the scale that was created just in selling the opiates, we're now, I would imagine, potential for tens and tens of billions of dollars in the therapeutics to treat the opiate crisis. Where do you incentivize companies? How do we fix this crisis by incentivizing companies?
Professor Andrew Lo (17:07):
There's a really important problem right now, and that is that the whole area of opioids, both opioid addiction, as well as pain medication, has gotten a kind of a bad rep because of the negative publicity surrounding it. In fact, some of the pharma executives that I've spoken to have said that this entire area is kind of toxic and nobody wants to deal with it because they don't want to be tarred with the same brush that has been clearly identified as the problem that created the crisis.
(17:38):
The first thing we need to do is we need to reduce the stigma around the opioid crisis. In fact, I think that there's a stigma with the people that are addicted, because very often we attribute addiction to some kind of a personal moral or ethical failing, when in fact it's a medical condition like getting COVID. We need to first acknowledge the fact that this is not a moral failing. This is a disease and we need to treat it like a disease. We need to come up with therapeutics.
(18:10):
Companies now need to be brought back into the fold of this particular area, and they need to be made to understand that they will not only be financially rewarded, but they will receive the gratitude of the millions of patients and their families and the government if they're able to come back into the space and develop non-addictive pain medication, as well as ways to deal with opioid addiction so as to be able to address the crisis at its root causes.
Liberty (18:38):
Are these treatments or solutions going to be coming from the four or five international conglomerates that we could come up with? Or is there an opportunity for someone in the proverbial garage, someone who already exists in this market, to come up with their own solution?
Professor Andrew Lo (18:55):
The way that we dealt with COVID was an all hands on deck kind of an approach. Everybody chipped in, from the big pharma companies to government, to CDC, to the international community, to scientists around the world. I mean, it was really an unprecedented collaboration of all stakeholder groups. I think we need to do that for the opioid crisis, because we're talking about millions of people whose lives have been completely destroyed by this addiction. This is not a small thing. We need to take that same approach and have all stakeholder groups. We've got to get payers to step up and be willing to fund opioid addiction treatments.
(19:36):
We've got to get new therapeutics into the clinic so that we can treat this disease at its root causes. We need pain medication that isn't addictive, and there are a number of innovations in that area of science and medicine that we should be funding. And finally, we need to have all of the various different public organizations attuned to the desperate need of these patients without stigma, without blame to deal with the disease as a disease. All of these things really have to happen at once.
Liberty (20:04):
Professor Lo, you've written about how it's actually really hard to develop new drugs. I read a quote from you. It said, "As we get smarter in biology, drug development can actually become harder," which is highly counterintuitive, but drug development has certainly become more difficult when it comes to opioid crisis. The usual therapies don't work. When it comes to investing in new treatments, it seems like this is a truly risky investment for drug companies who goal is to make money. How much risk is involved for these drug companies in investing in a treatment and how could they mitigate that risk and optimize the reward, while quickly working towards a solution to the opioid epidemic?
Professor Andrew Lo (20:46):
From a financial perspective, I look at all of these various different problems as an issue of resources and risk. Do we have the resources that we need and how much risk are investors willing to take? With regard to the opioid crisis, there is tremendous innovation on the scientific and medical fronts in how we deal with the problem. I've spoken to a number of clinicians that have tremendous resources from a big point of view in being able to deal with these at the root causes of addiction, but they need money in order to further their work, in order to do the scientific and medical research needed in order to get these therapeutics into clinical trials and ultimately to get approved.
(21:28):
That's where risk comes in. Investors do not want to put money to work if they think that there's going to be very little payoff at the other end because of potential lack of failure. And now more than ever, investors are also worried about reputational risk. They don't want to see their reputations tarnished by investing in an area that has already had such negative stigma. What do we do about it? Well, we use what in finance we call a portfolio approach. Instead of investing in one at a time, what you really want to do is to invest in multiple shots on goal, to use a hockey or a soccer term. You don't know where the next innovation will work.
(22:10):
You have to try lots and lots of different possibilities. In order to get something to patients sooner rather than later, I would suggest doing it all at the same time, not one at a time and waiting for years before you hit success. The idea from a financial parent point of view is to create a portfolio of opioid therapeutics to be able to provide government support, perhaps in the form of a guarantee on some of the loans that are used to borrow money in order to fund these clinical trials, and to do it at scale. I'm talking about multiple billions, possibly tens of billions of dollars devoted to opioid therapeutics, as well as opioid treatment.
(22:54):
And if you do that at a large enough scale, the chances are you're going to hit one or two or three different really successful, really powerful drugs that can deal with both the crisis, as well as with pain management.
Scott (23:07):
Do you think there's enough money in the system to cure it?
Professor Andrew Lo (23:10):
Absolutely. I think that there's more than enough money out there to be able to cure it.
Scott (23:15):
Got it. It's just the system itself needs to be re-engineered. Interesting.
Professor Andrew Lo (23:20):
Well, I think COVID is a good proof of concept. Because prior to COVID, if you had asked anybody in the industry, "Do you think you could develop a vaccine in, I don't know, a year," they would've laughed you out of the room. Because prior to that, the fastest that a vaccine had ever been developed in the history of the industry was maybe three years. But the typical time length it takes to develop a vaccine, nevermind to test it and get it approved, is maybe 10 years.
(23:52):
We did it. Moderna did it in 62 days. From the time that the SARS-CoV-2 sequence was identified to the time we injected the first patient with a vaccine, 62 days. That was extraordinary. The same kind of thing can be done in the opioid crisis if we have the will to marshal the same kind of resources.
Liberty (24:15):
Well, it seems almost that actually with the opioid crisis, it's a whole lot clearer than it ever was with COVID. It's affecting all races, all age groups, male, female. It's affecting everybody.
Professor Andrew Lo (24:27):
It's an equal opportunity killer.
Liberty (24:29):
Exactly. It's an equal opportunity killer. When the choice is, well, you can die of an overdose or you get an injection, it actually seems like it should be a lot easier for us to fix this crisis actually than it ever was with COVID.
Professor Andrew Lo (24:38):
I think we need to develop the political will. I don't mean to blame just the politicians, because obviously they have their constituents that they need to respond to and they've got other competing interests that have to be addressed, but I think that as a system, we need to acknowledge that this is broken and we're not going to be able to fix it unless we come together and be able to marshal the same kind of resources that we marshaled to deal with COVID-19.
Liberty (25:08):
How do we solve the opioid epidemic? We know what's not working, waiting years, prolonging solutions because of red tape and cost, and creating one drug at a time, trying it. When it fails, we create another one and have to wait another 10 years. What do we do instead? We copy a model that we already know is a success. We take $30 billion and try out 150 drugs all at the same time. As Professor Lo said, This method both has an excellent return on investment for investors and solves the issue at the same time. We could have a cure for the opioid crisis in a matter of months, just like we did with COVID.
Scott (25:49):
So then why haven't we done it? I guess it seems like the hardest part's done. We have the money. $32 billion is just sitting there as settlement money from the pharmaceutical companies. But instead of pulling it together like we did with COVID, we're doing the same old, useless political hackery of individual states and even counties getting the money and politicians shelling it out in the same old, clearly useless ways.
Liberty (26:10):
I think we have to remember that the United States and the world, for that matter, but really the United States mobilized behind finding a cure for COVID because we knew how many deaths were coming our way if we did nothing. The only way that we're going to solve an exponential crisis that spans all socioeconomic classes is to come together in the same way again. We have the money. It just seems like we don't have the political will. But before we know it, and this was clear from Chief Synan, if we don't act, we will continue losing more Americans.
(26:46):
And pretty soon it won't just be that random person that you don't know, but it's going to be your friends or your family or your loved ones. It is going to affect everyone.
(26:58):
Thanks so much for listening to this episode of Data Nation. This podcast is brought to you by MIT's Institute for Data, Systems, and Society. And if you want to learn more about what IDSS does, please follow us @MITIDSS on Twitter or visit our website at idss.mit.edu.