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Brian: It's The Brian Lehrer Show on WNYC. Good morning, everyone. We have kind of a New York political all-stars lineup on today's show around 10:30. It's our monthly Call Your Senator segment with Senator Kirsten Gillibrand. Among other things, she just announced she's running for re-election next year, so we'll have some campaign-type questions, plus things facing the new divided Congress and your calls. Later part four of our six-part series, The Year of Bill and Rudy, How 1993 Helped Set Up the World of 2023. Today on the Clinton Crime Bill meets Giuliani's NYPD with former Police Commissioner William Bratton and the Reverend Al Sharpton both joining us live.

Right now, here's a stat you may not have heard yet newly released that should probably be getting a lot more attention than it is. There were 2;668 fatal drug overdoses in New York City in 2021. That's the last year data has now been released for. 2,668 fatal drug overdoses in the city in one year. We make such a big thing out of trying to stop 400 murders, which isn't to say we shouldn't do that, but 2,668 fatal drug overdoses in one year in 2021, 85% involving opioids and many more than before specifically involving fentanyl. The new provisional data from New York City's Health Department and they still say provisional, even though it's for 2021, reveal that fentanyl was detected in 80% of overdose deaths in the five boroughs.

These local trends mirror national trends. For the period ending October 2021, according to stats from the Centers for Disease Control, so national stats, annual overdose deaths reached a record high and nearly doubled over the two years prior, claiming the lives of more than 107,000 people nationally. Two-thirds of those deaths involve fentanyl and other synthetic opioids. What we'll do now is try to get beyond tabloid coverage that often feels dehumanizing, and try to get into what makes fentanyl so deadly and resistant to efforts to stem its abuse, and ask what policies are the best to try to do so.

Our guests are Sam Quinones, independent journalist and author of Dreamland: The True Tale of America's Opiate Epidemic, now in paperback, also The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth. Both books by Sam Quinones, and Courtney McKnight is also with us, clinical assistant professor of epidemiology at NYU’s School of Global Public Health. Sam and Professor McKnight, welcome both of you to WNYC.

Sam: Thank you very much.

Professor McKnight: Thank you.

Brian: Professor McKnight, can I ask you first, for the many uninitiated out there, what is fentanyl?

Professor McKnight: Fentanyl is a synthetic opioid that's about 50 to 100 times more potent than morphine. We started to see it in the illicit drug supply, particularly the heroin supply in New York City right around late 2014, early 2015, and it has just increased since that time. Just a little bit of background as to potentially why we're seeing these rates of overdose continue to increase is that most people who are using heroin or not seeking fentanyl, but fentanyl is being mixed into the heroin supply in particular, but there's some evidence that's being mixed into other drugs, but really, heroin is the primary drug.

Fentanyl is being mixed into heroin, and people are using it without their knowledge. That has changed somewhat over time, but our data indicate that there are definitely still people who are injecting drugs here in New York City that are unaware that fentanyl might be in the drugs they're using.

Brian: If that's the case, is it being mixed in because it's cheaper as an additive than pure heroin?

Professor McKnight: Yes, exactly.

Brian: Sam, what makes it so potent? How much more potent is it? How would you begin to put it in words or numerically, even then oxycontin or what they call black tar heroin?

Sam: Well, it's significantly more potent and then as the professor said, it was designed to be a fast-acting anesthetic. In fact, it's a fantastic drug when used surgically. I've had it myself. It's been a workhorse drug in the surgical setting since 1960 when it was invented by Paul Johnson, a Belgian chemist who invented many, many other drugs, but that was a major one for him. It's really transformed surgery. It’s when it gets into the hands of the underworld, and as it is now fully, that it becomes a catastrophic thing, and then also an additive.

I think it’s being added to heroin, it's also being added to cocaine. I think you see this all across the country. Now it's being added to methamphetamine. There are cases now of it being added to marijuana as well in some areas.

Brian: It's more dangerous than pure heroin or pure cocaine?

Sam: Oh, my goodness, yes. It's extraordinarily dangerous when not used in the surgical setting. The anesthesiologist in the operating room have the ability to control it and they do so very well. They have for decades. They use it millions of times a year in this country. It's just that when it's being used by people who have no clue or are entirely motivated by profit that it becomes the catastrophe that it has become for this country. It now of course now covers the country. It's pretty much everywhere in the United States coming up from Mexico, primarily.

Brian: Listeners, we can take your calls on the record number of overdose deaths fueled by fentanyl locally and nationally. If you have a story to tell about your own experiences or the story of a loved one's experiences, perhaps help Sam Quinones report this story. Help Courtney McKnight understand it as a professor of epidemiology at NYU, 212-433-WNYC, 212-433-9692, or tweet @BrianLehrer, or for any of you who've read Sam's books, Dreamland: The True Tale of America's Opiate Epidemic and The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth, you can ask this independent journalist who's done such great work on the topic a question about his work as well. 212-433-WNYC, 212-433-9692, or tweet @BrianLehrer.

We already have a tweet that's just come in it says, "Thank you for fentanyl awareness. I'm frightened for my young friends who experiment with party drugs, coke, ecstasy, that are white powdery and fentanyl getting mixed in.” Professor McKnight, how did we get here to this eye-popping stat of 2,668 drug overdose deaths in New York City in one year in 2021? How quickly did we get here from a much lower number and why?

Professor McKnight: We've seen overdose rates in New York City increase really since 2010, but when fentanyl really came on the scene in late 2014, early 2015, the increase was much more dramatic. We did have a stabilization of overdose rates, still way too high, but we had a stabilization between 2017 and 2019, and since then we've seen a significant spike. Between 2019 and 2021, our overdose mortality rate has increased by 80%.

We know that a lot of this has to do with the pandemic and pandemic-associated isolation. In the research that we conduct with people who inject drugs here in New York City, what we're hearing is that people are using their drugs alone more frequently, and that's due to a multitude of reasons, but the pandemic restrictions, lockdowns that happen and just got public health guidance to really not be close with other people, to mask really affected how people were using their drugs. Less in groups, less with partners, which is some of the harm reduction messaging to help people prevent a fatal overdose.

Brian: For you as an epidemiology professor then, does it cast a different light than you might have thought you were looking in at the beginning of the pandemic for the public health risks as well as benefits of lockdown and masking?

Professor McKnight: I think we're all thinking about this across all populations, young people and their mental health outcomes as a result of the- -isolation due to the pandemic. But I think from the perspective of our participants, a lot of them have several underlying health conditions which really concern them about getting close to other people, getting COVID, because they could potentially have a much more severe outcome if they did.

I hear your point about was the isolation and whether the lockdown is the best approach, I think we did the best that we could with the information that we had at the time. I think from our perspective and the folks that we see in our studies, they are very concerned about COVID and they are using lots of precautions to prevent infection.

Brian: Sam, can you put those shocking numbers from New York in terms of 2021 overdose deaths into national perspective? Based on your reporting, is this similar to or different from what's going on around the country?

Sam: No, I think it's very different from what's going on in other countries where we have--

Brian: Oh, no, around the country. Sorry. It was my question.

Sam: Oh, around the country [crosstalk].

Brian: If you want to talk about other countries, you can do that too.

Sam: No, I misheard you. No, this is absolutely what's going on all across the country, and that's the remarkable thing the drug trafficking world in Mexico achieved. The sad thing about one of the tragedies of COVID is that it happened, it came on just as the Mexican trafficking world had achieved an unprecedented event, and that was to cover the country with not one synthetic drug, but two. Really methamphetamine as well, which is less apparent in New York City, I know, but is clearly all over the country.

When people were locked down and then relapsed, the drugs that most frequently greeted them when they were relapsing were these extraordinarily damaging drugs, fentanyl and methamphetamine, damaging for different reasons, but the issue is always the same. There are synthetic drugs made with chemicals, no plants involved in their making. What you have is down in Mexico almost unlimited access to precursor chemicals through certain shipping ports coming from China and India and other places. These ingredients allow the trafficking world, which is very robust and a throbbing ecosystem of dope, to make quantities of these drugs that simply just boggle the mind, just staggering quantities of drugs.

You find fentanyl in Maine. You find methamphetamine pretty much everywhere. Now fentanyl is being laced into cocaine pretty much all across the country. Baltimore, which was a longtime heroin town, I don't really think has much heroin anymore. It's just all been fentanylized in a sense. Everybody's been transitioned from heroin to fentanyl. This is something that's going on all across the country, and the issue is, of course, the enormous unrelenting supplies coming out of Mexico in the last several years.

Brian: Well, now I'll ask you the question that you thought I asked you, and therefore you put the thought in my head. Is this a uniquely United States problem?

Sam: To the extent that it's so intense and widespread nationwide, I would say yes. However, I would say that there probably are not too many drug traffickers or drug dealers who have any interest in selling or making heroin anymore. I would imagine that-- You see fentanyl outbreaks, you've seen them in Sweden, Estonia, different places like that, and I would say that eventually, all heroin producers are going to transition to fentanyl because it's just so much easier, and, of course, synthetic drugs have enormous benefits over plant-based drugs.

You don't need land or sunlight or rainfall or farmers. You can do it all in a lab away from the prying eyes of helicopters. It reduces the risk dramatically. Fentanyl is remarkably easy to smuggle because it is so dramatically more potent than anything we've ever seen, and so you get an enormous risk reduction and enormous increase in profit.

My feeling is that there really is no benefit to drug traffickers anymore to actually be making heroin. The money is in fentanyl, and so this is really something. This is the phenomenon I've described nationwide, is really something that does not benefit users. It's not what users demanded. It's a very, very deadly thing, but it does benefit traffickers. It's all about what benefits traffickers here with synthetic drugs.

Brian: I think Agnes in Manhattan has a question about exactly that, what the users want and what the traffickers are distributing. Agnes here on WNYC. Hi.

Agnes: Hi. Thank you for taking my call. I don't get the point of the narcos. They want to make money. They want to create more and more addicts, but they are distributing a drug that is killing their clientele. I just don't get it. They're killing the people that they provide it to. Thank you.

Brian: Sam.

Sam: It makes a lot of sense viewed from one perspective, though, because fentanyl has a way of creating more clientele very quickly. You're seeing that, I think the professor mentioned it early on, where you're seeing it mixed into heroin, mixed into cocaine, and when it does that, it creates a new customer. A customer who buys cocaine, buys maybe, let's say, twice a week, can take a two-week vacation from cocaine, but once that person is transitioned to fentanyl, that person is buying every single day, and fentanyl requires them to use far more times in a day than it does heroin.

You're using fentanyl four, five, six times, seven times a day, when before you were using maybe, if you were using heroin at all, you were using it once or twice or three times at the most. The other truth is this, and this goes back to long ago in the heroin days. That is that when someone dies in the world of people who are addicted, that is not a warning. That is an advertisement that, “That dope is pretty good. Go find that dope. It knocked so and so on his butt, but I'm not going to be hurt. That guy died because he's a fool. I'm not going to be hurt.” It's this self-delusion.

The problem is, of course, with fentanyl the truth is also though, that nobody lasts on the street. There is no such thing as a long-term fentanyl user, but this is short-term gain we're thinking about here. This is what dealers think about only.

Brian: What do you mean there's no such thing as a long-term fentanyl user? You mean they either die or kick the habit?

Sam Quinones: They all die. No. Well, if they don't get treatment, if they don't get off the street and get away from the dope, they all die, and this is happening all across the country. It's a common phrase that you hear. Talk to drug counselors and they'll tell you this over and over. Talk to addicts and they know it's true too, that nobody lasts a long time. Heroin, I've interviewed heroin addicts who have been using 20, 30, 40 years. They don't have a very nice life in any way, but they're not dead.

Part of what the caller is asking about is absolutely a rational question, why would you sell something that kills people? Well, because it helps you for the very, very short term. Talking about people who are thinking about short-term consequences only, and it has that effect, when everybody's addicted to fentanyl, as many people now are, to say, "Oh, this guy's got good stuff, it killed somebody, let's go get that stuff."

Brian: Wow. Mary in--

Professor McKnight: I just want to make a--

Brian: Go ahead, professor. Yes.

Professor McKnight: Okay, I just wanted to make a point about Sam’s thing that they all die. I don't think that's borne out in the data yet. I don't think we have enough years of data to determine that. I also think in New York City, we're seeing 82% of the people in our study tested positive for fentanyl, meaning that they've used it in the previous two days. Most people are actually being exposed to fentanyl regularly multiple times a day, not necessarily always overdosing and certainly not dying.

That could be due to a multitude of reasons and that some people might be overdosing, and then naloxone is administered. It could be that they're using less, which we hear all the time because people are very concerned about overdosing. They're changing their behavior around their drug injection practices, trying to use less, trying to test their doses. I take issue with the notion that everybody's going to die, but I want to just caution that the drug supply in New York City is incredibly unstable. The drug supply across the country is incredibly unstable, but I'm not sure that the data bear out that everyone's going to die.

Brian: What does unstable mean? It's unreliable as to whether you can get it or something else?

Professor McKnight: It's just unpredictable. For instance, to know whether or not there's going to be fentanyl in every bag, we did have about 20% of people in our study were just using heroin in the last two days. When we look at their urine tox results, we see that they reported using heroin use, which 98% of our folks do, and then there's a subset of people that were actually just using heroin, which was- -new to us. We assumed that everyone was being exposed to fentanyl but we are seeing-- it's a small subset, and that subset is likely to be reduced, but that's what I mean about the unstable unpredictability.

Brian: Who did you study, Professor McKnight? Who did you study?

Professor McKnight: It's an ongoing study that the study has been going on in one form or another for over 30 years here in New York City with people who use drugs, but our current phase of the study is with people who inject drugs.

Brian: Stephanie in Forest Hills, you're on WNYC. Hi, Stephanie.

Stephanie: Hi, thanks so much for taking my call. I was just listening to the conversation about that most people who are using fentanyl die. I very much agree with the last speaker. I'm a social worker and I work in an outpatient treatment team. I work with folks who are cycling between the shelter, the street, the prison system, and the mental health system. I have many, many folks who are using fentanyl and are very much using and continuing to use and are very, very savvy with their use.

They know that fentanyl is in their drugs and they absolutely do change their behavior. It's incredibly concerning, and I've seen a huge change in people's symptoms and presentation from their use. I really credit it with like this increase in fentanyl and with other drugs, with tranqs that we're starting to see now. The main reason I wanted to call in was just around the question of policy and what can be done differently here in New York.

One concerning thing that my colleagues and I see is that when we have folks who are using fentanyl, using other opiates, they're often committing crimes in order to pay for that drug use. I know you had a segment earlier in the week about shoplifting, about how that allows people to afford fentanyl or afford other drugs. We have a supervised release, sort of program. It's like a something that I think the city has moved more towards, which I think is really wonderful in some sense. Going to Rikers or going to jail is really not the best treatment in a polite way to help people manage their substance use, especially because usually so much trauma, and often mental health systems are behind the motivation for that use.

What we're seeing with supervised release is that it's not really a service. Instead, it's a place where people check in. For example, I work with somebody who's really, really battling a very heavy substance use addiction. He's on supervised release and he has been living at a shelter, a safe haven. We take him to a supervised release program and they just check him in. They make sure he's the right person, that's his name and that’s his date of birth, and then he leaves.

As much as we want to respect his autonomy, I think what would be more useful for him would be to consider some sort of mandated substance use treatment, which he's responded well to in the past. It seems the way the policy works now is that the only way that he would be mandated to treatment would be if he was arrested, and then mandated treatment. He's just being left in this cycle now where he shows up to these supervised release programs, and they check his name off, and then he gets rearrested.

I think we're really at a loss. We were just having a discussion the other day on my team about how we're so worried that he'll die, and that it's almost as if Rikers is the better option right now, which can you imagine, a room of social workers considering that?

Brian: Saying that, yes.

Stephanie: I think that just reflects how dire the situation is, and how much of a lack of option there is for providing support and service.

Brian: Stephanie, let me ask you a follow up question in your experience as a social worker. You said if I heard you right, that some of your clients are using fentanyl in a savvy way, they're becoming savvy users, I guess, to preserve their lives while they're addicted. In that context, what do you think of the supervised injection sites that the city is pioneering? I know they get criticized from the right mostly for encouraging potential deadly drug use.

One editorial I was reading or op-ed in the New York Post, referred to placards, I think subway placards that advertised safe use and even said go slow, telling people how to use fentanyl rather than not to use fentanyl. That op-ed criticized the safe injection sites as being part of that. How do you see it?

Stephanie: We're very proud of these injection sites. My office is actually a few blocks away from the one in Harlem and we refer clients to there all the time and walk them over. People are using. People are using regardless of if these safe injection sites are around. It is safer, for lack of a better word, to use in a place where there's someone around, where there's medical professionals around where there's Narcan around. People are going to use regardless.

I think for us the way we think about people’s safety and harm reduction is that it's going to support safer use, but also potentially get less use. I think that the critique of this will encourage people to use more is misguided. I have had clients talk about how, “Well, if I use, maybe I should go to the safe injection site and that way, they'll be people around,” and the person over time may be encouraged to use less. There may be some [unintelligible 00:25:46] [crosstalk]

Brian: Yes, and don’t they also at those sites refer people to rehab?

Stephanie: Yes, they can refer people to detox to rehab. It's such an amazing resource. I think that a lot of the early data, at least at the site in Harlem, it's been that a lot of people's lives are being saved.

Brian: Stephanie, thank you so much for your call, and Professor McKnight, how else do you solve a problem like fentanyl from a policy or epidemiological standpoint?

Professor McKnight: I think one of the primary things is we know that people who need treatment or want treatment and are not getting it. For people with opioid use disorder, only 11% of people with opioid use disorder are actually getting treatment. We need to expand our access to treatment, which there are significant efforts here in New York City to do that but I think more can be done. I think the data from New York City, the mortality data really indicate that there are significant racial and ethnic disparities in what people and what neighborhoods are being most impacted by overdose.

We need to be able to target those neighborhoods in order to provide more services to those communities being disproportionately impacted like in the South Bronx, for instance. We need to provide more access to treatment in those communities. I think we need to scale up overdose prevention centers. The centers’ only been open a little over a year and they intervened in 678 overdoses. The data, there's over 100 sites open in the world, and there's not been a single fatal overdose across any of those sites since they've been open. I think the data are really very clear around OPCs, or overdose prevention sites.

Canada is doing safer supply programs, meaning that they are providing prescribed hydromorphone, and fentanyl. They've been in a fentanyl overdose crisis longer than we have here in the United States. They are basically providing a regulated alternative to an unregulated illicit supply, in order to stabilize the lives of people for whom other treatment approaches have not worked.

Then we need to also scale up our distribution of naloxone, which we know is very effective in reducing overdose death. I think very importantly, which there is discussion of it, but I think we can always have more conversations about this is that the impact of stigma is very significant in terms of the effect on overdose, people using alone, people being concerned about getting into treatment, because then that means that people will know that they're actually using.

Brian: One more call. I think it's going to be a heavy one and a sad one. It's Kathy in Newburyport, Massachusetts. Kathy, you're on WNYC. Thank you for calling in.

Kathy: Thank you for taking my call. I had intended to get a hold of myself here but last September my close friend, my daughter died from fentanyl, a beautiful, talented loving girl that everybody adored and she was not a drug addict. She bought a pill in a club. I think it was an Adderall and didn't wake up. It's devastating for everybody who knew her. I want to make the point that it's not just addicts. This is not something that we can ignore those of us who think, "Oh, well, this is just addicts and who cares?"

This is our children who are dying. There's been many stories about [unintelligible 00:29:30] teenagers, young people who buy a drug that’s been contaminated with fentanyl and they can't tolerate it and they die. It's just devastating for everyone who knows them. I want to make that point. I'm sorry.

Brian: Kathy, thank you.

Kathy: That we should all care about this. It’s not just those of us who are working with the addiction community that this is something that is killing our children- -and we should all care about it.

Brian: Do you have any policies that you would like to see the government pursue to prevent more tragic deaths like that of your daughter?

Kathy: Well, obviously I think that the whole war on drugs has been ridiculous. I’m from Queens, I’m a long time New Yorker and very liberal to [unintelligible 00:30:22]. I think that there has to be much more support for those who do suffer from opioid use disorder, but also somehow, we have got to figure out a way to stop the flow of fentanyl coming in from Mexico and in a more effective way. We're not doing anything effective. I don't know how long, what is the war drugs? It's been like 30 years, 40 years, it hasn't been effective. We have to come up with a better way.

I hate to say this but we need to have a way for it to test drugs in clubs. Kids need to have fentanyl testing strips. They need to be more widely available and we need to educate people on this problem.

Brian: Testing strips. Kathy thank you for your courage. I think it took courage to call in and have to relive the death of your daughter in September to the extent that you just did, so thank you. It was a service to all our listeners. As we run out of time. Sam Quinones on one of the things that she said about controlling the fentanyl getting in better, many on the right have pointed to fentanyl as a reason that Democrats need to pay closer attention to the border and to secure the border. Is there a way to keep the fentanyl out while letting asylum seekers in?

Sam: You want me to answer that in 30 seconds?

Brian: Yes sir. Yes, I do. Do your best.

Sam: Well there most likely is but it would need a dramatic new relationship between Mexico and the United States. I lived in Mexico for 10 years. I do believe and I wrote two books about the country, I do believe that that relationship is possible and possible to sustain across administrations and regardless of what happens in the rest of the world, very, very important to do. It has not happened yet. We do need that, but this has graduated from a drug problem to a national poisoning.

It really requires now the attention, full attention of both governments, both to control the fentanyl coming north along with the methamphetamine again as I said, but also the guns that are bought here, that are smuggled south and arm those very cartels and give them the impunity to make the quantities of fentanyl and meth that are coming into this country.

Right now, it requires a very different way of viewing the relationship between the two countries, and so far, no president in my lifetime either in Mexico or the United States has really had the staying power and the attention span to actually achieve it. It is possible, it just requires a new way of looking and thinking about the other country.

Brian: Sam Quinones, independent journalist and the author of the book's, Dreamland: The True Tale of America's Opiate Epidemic and The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth. That one is just out in paperback. And Courtney McKnight, clinical assistant professor of epidemiology at NYU's School of Global Public Health. Thank you both so much for joining us today.

Professor McKnight: Thank you Brian.

 

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