Central Line

Episode Number: 147

Episode Title: LIVE from Center Stage: Opioids in America with Sam Quinones

Recorded: October 2024

(SOUNDBITE OF MUSIC)

VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Well, hello, everyone. Welcome to this special episode of Central Line Live from ANESTHESIOLOGY 2024, in sunny Philadelphia. It is a great pleasure to be joined today by Mr. Sam Quinones, who gave the keynote address this morning at the ASA annual meeting. And Mr. Quinones has a special insight into the current opioid epidemic, given his extensive work over the years. He was a freelance journalist in Mexico. He spent a number of years as a journalist for the Los Angeles Times. And he is author of two bestselling books on the opioid crisis, Dreamland and The Least of Us, which have come out in the last few years. Dreamland, back in 2017, was it 15 and the least of us in 2021. Right? So Mr. Quinones, welcome to the show. Thanks for joining us.

MR. SAM QUINONES:

Thank you very much for having me.

DR. STRIKER:

Well, um, we're going to try to cover a lot of ground in the short time we have. This is a really large topic, and I know a lot of it was covered in the keynote address, but a lot of our listeners are going to be hearing this sometime later in the next, probably a few weeks from now, if not after that. So might overlap a little bit. But let's start this way. To get us started, why don't you tell us a little bit about yourself, and maybe specifically your story and how you got involved in this topic?

MR. QUINONES:

Yeah. So I've been a reporter 37 years. I started out writing for newspapers. Um, I in particular, one ,the Stockton Record in Stockton, California, was a wonderful first kind of job, and I was the crime reporter and that kind of determined… So I covered homicides, I covered gangs, I covered prostitution, drug, all this stuff on a very local level. I had some great editors and that just got me started in this.

Eventually I went down to Mexico, lived down there for ten years as a freelancer, which means like, basically almost like starving to death. Uh, but American newspapers at the time were really interested in Mexico. We just found NAFTA. There had been this, um, you know, just a expectations of major political change in Mexico, which eventually did happen, very similar, resembling like kind of the end of the Berlin Wall in a sense in Europe. Um, and so it was a really effervescent time. I learned a lot. Um, that combined with my daily journalism in Stockton was magnificent. And it was the kind of training that you couldn't pay a school to give you. And so I really loved that. I just threw myself into it. My idea was I would know more about law enforcement, crime and criminal investigation than anybody outside law enforcement in the area.

Went down to Mexico, did a lot of writing about immigration, about stuff like that. Came back and worked for the LA times and at the LA times. I happened to have a conversation with an a supervisor of the DEA in Phoenix, Arizona, and she said, we are now seeing huge increase in heroin use, which I could not explain because I didn't know why anyone would go back to heroin. And I was in Mexico during the whole OxyContin, Purdue Pharma time. And so I wasn't paying attention to anything that wasn't about Mexico. And so I didn't know what an OxyContin was, you know. But little by little, I investigate this one town that became kind of one of the focuses of my Dreamland book. And along the way, I realized that these guys had this new market for heroin because of a much, much larger story, which was the opioid revolution in pain management. So most people came to that story through the pills and then eventually, oh, yeah, and it leads to heroin, too. I backed into it. I started with heroin. And then I realized, oh, you know what? There's this enormous story behind this that I had no idea of. Again, I didn't know what an OxyContin was. Didn't know much about pain management at all. Addiction, all that kind of stuff. All I really wanted to do was write about Mexican heroin traffickers but you couldn't without writing about the other stuff. And so that's kind of what ended me up in this this topic that basically changed, you know, my life and my career.

DR. STRIKER:

Well, it's a good segue because covering this topic, it's it's incredibly difficult. It's so complicated with the number of facets to it. But one facet I did want to cover, and you already mentioned was maybe the origin of the current epidemic which you traced to the overprescribing, or at least laying the groundwork.

MR. QUINONES:

It was that push on, on the part of pain specialists who had lived for years, very frustrated that they couldn't really treat pain very well. It's a very, very difficult thing, as much art as science, I believe. And eventually they came to the idea, I think, they were they were sincere in all this. I think that, well, you know, if we use these pills, these narcotics, these opioid painkillers, a little bit more than we've been using them, it would help control pain. And they had to fight against the idea that they were addictive because people were very, very reluctant. They'd learned in medical school not to use these pills, except for under very tight scrutiny and certain occasions. So they had to fight against the idea that these were addictive. I think what ended up happening was they began to feel this kind of messianic fervor to change pain in America, to eradicate all American pain. And that led them to ideas that were that they took shortcuts to and or they used language that could easily be be construed as shortcuts. And and in the end, what end up happening the interpretation was, you know, opioid painkiller will result in addiction if the person using it is a pain patient. Um, that's not true. But they kind of like drank the Kool-Aid. Everybody began to drink the Kool-Aid. Then you get the pharmaceutical companies added to that. And then very importantly, I think you get certain major institutions buying into this very big way, like the VA.

DR. STRIKER:

Yeah.

MR. QUINONES:

VA, JCO. All all these kinds of pain societies and so on. There began this drumbeat, early mid 90s to change pain. We've got to treat pain. Pain is a killer. And therefore anything we do to is okay. And I think that was really that began it. In my opinion. There was more to it. But but it was that idea that we need to, we can eradicate all pain. And if if we use this one tool that we erroneously believe is too dangerous to use. Right.

DR. STRIKER:

Well, and many anesthesiologists are familiar with the concept of the Swiss cheese effect, where a bad outcome is a result of a number of factors lining up to have that one outcome occur. From what you're describing, it's almost like a Swiss cheese effect on a global or public health scale. You have the supply issue. You have this groundwork of trying to treat pain and trying to eradicate it. You have, um, perhaps other conditions, whether it's community or economic ones that lay.

MR. QUINONES:

There were many. There was the idea that, um, uh, one of the things I wrote about in my book, which stunned me because I'm a layman and all this stuff, but, um, there was the famous Porter and Jick letter. The Porter and Jick letter was a written by Hershel Jick. The the the other signee to the um, the letter was Jane Porter. No one really knows what became of her, but basically this letter was published in the back of the book of of the New England Journal of Medicine in January of 1980. And it was it was really just reporting Hershel Chick's findings. He ran a big database about three, 400,000 patient records from hospitals about what happens to drug use in in a hospital. This is what he was always studying. And his computer guy crunched the numbers on how many people had been in hospital, given narcotics, and then ended up addicted. And the number was 11,000 and 4. Four people got addicted. So he writes a letter just saying that. But the New England Journal of Medicine publishes it under the headline Addiction Rare in Patients Treated with Narcotics. It was a it was a really bad headline. Because it was really untrue. The problem is, that as far as it went, he was right. If you this was remember his data was from the 60s and 70s. When people were not given large amounts of opioids, they were not given, uh, bottles to take home and then refills. It was very, very scrutinized. And so under a very scrutinized supply, yes, very few people get addicted. But, um, Purdue Pharma, other companies, uh, pain specialists began to promote this, began to use this as documentation when actually all it was was a letter to the editor. That's all it was. But soon you began to get, well, it was it was a report or was a study, and then it was a report, and then it was a landmark study that does much to change what we know. I mean, it got blown out of proportion. Hershel Jick didn't even know it was going on. The first thing he found out how his letter was being used was when he was asked to testify in a case against Purdue Pharma in the mid 2000. And I interviewed him and he said, I never knew what they were talking about. I did not mean anything like this. He was correct as far as it went. The reason I bring it up is, that was the one of the main pieces of evidence that the pharmaceutical companies and the pain specialists used to promote the idea that there was no risk to prescribing opioid painkillers to patients who were in in pain, using the Portal Jick letter. And eventually--I don't know when the New England Journal of Medicine has ever done a version of this-- but eventually, after my book came out, um, they had they put a red online. Remember when the when the porter and Jick letter came out? It was in a back of the book of an edition of the New England Journal of Medicine in 1980. It was not it was not on online for for 20 years before, after that 15 or something like that. And so nobody really could go look it up. So they took the word of the pain docs and the and the pharmaceutical companies. Oh, this is new evidence. I wasn't aware of this. This letter. It's 101 words. It's in no way a study. It's certainly not peer reviewed or anything. And Herschelle Jake did not mean it as anything but hey, you know, just found this and it was used throughout the the promotion of opioids. If you look at it, they use some version of that. Less than 1% of people used using this for pain get addicted, which is the only place you find that is in the Porter and Jick letter. So to me, I was a layman and I was going, is this how science is done? I mean, this is so nuts. It's a remarkable idea that that you could use something so, you know, casual and, you know, and inconsequential and blow it up to prove that now it was okay to prescribe opioid painkillers for all manner of pain because nobody was going to get addicted to it.

DR. STRIKER:

Well, in some ways easier for facilitators, whether clinicians, physicians, distributors, suppliers feel, it's easier to believe that, you know, everybody doesn't need to have…

MR. QUINONES:

Everybody wanted to believe it. Doctors wanted to believe it because pain patients were were the biggest drain on their time. Right. And now you're in the middle of, you know, the mid 90s. You begin to get in the middle of managed care. So the amount of time primary care docs have for, for each patient is, is reducing to 15 and 13 minutes per patient. And you just don't have the amount of time anymore that allows you to really spend time understanding chronic pain patients who are the class of patients that really, really needs lots of time.

DR. STRIKER:

Sure.

MR. QUINONES:

You know, and so so this is kind of what began to happen. And a lot of doctors didn't, by the way, a lot of doctors were like, this is nuts. This is crazy. You can't possibly suggest that we should be prescribing it for X, Y, Z, all these different things and then give refills and then more refills. Well, yeah, that's how it became interpreted eventually. By by the late 90s, that was absolutely the case. And you could be dinged as a doctor if you did not do this or you could be denied hospital privileges. Your hospital could be called on the carpet for not properly addressing pain. The VA just totally adopted a, um, opioid treatment for pain. Many times at the expense of other therapies. Insurance companies stop covering physical therapy, you know, various kinds of other therapies that were used to help with pain treatment. But were all kind of had to be done together. And pretty soon the pills just took up all the oxygen in the room. And then it was just pretty much pills for everybody. And and after a while, patients started getting addicted and then off the pills where all they wanted.

DR. STRIKER:

Well, so let's take that, fast forward to the last few years, because that laid the groundwork for what I want to talk about next, which is the fentanyl scourge. And fentanyl is most responsible for all the increase in opioid deaths in the last couple of years. Right.

MR. QUINONES:

Right. Illicit fentanyl from Mexico

DR. STRIKER:

Right. And so I do want to before I get to the specifics of that fentanyl, I did want to ask you when when your last book, the Least of Us came to publication, you had predicted that we'll probably see close to 100,000 deaths from opioids.

MR. QUINONES:

Very soon.

DR. STRIKER:

And I wanted to see if now that it's 2024, if you will, how you feel that has borne out.

MR. QUINONES:

Well I think that was exactly what happened. You could see it happening because, um, there were so many people out there who were addicted to opioids, and a lot of them were increasingly being given fentanyl and the supplies of fentanyl were growing. You could see that through seizures, data and stuff like this. And so it was just a matter of time. I think it was two years later that it maybe three. I can't remember now anymore, but at two years, let's say, and it and it crossed the 100,000 threshold and then went up to 112. Turns out maybe last year it maybe maybe a decline. But it's really not back to anywhere near what it was like, say, in the late 90s or anything like that. You know, it's still. Yeah. And fentanyl. Yes. I think fentanyl is due for, due to almost all of the deaths, the ones that don't list fentanyl as their death. I mean, I'm wondering does that common or that medical examiner rather have the budget to be able to test properly? Because there's no heroin on the street anymore. Fentanyl is so potent you develop tolerances far beyond anything you'd get on heroin. And so what you need to do is, if you're, you're addicted to fentanyl, you can't buy heroin, do nothing for you. And so everyone's using fentanyl. Now, there are very few people in America today who are actually like addicted technically to heroin. They may call it heroin, but really it you know, it's not. It contains everything but heroin. Seizures for heroin have plummeted. They almost, you know, very, very small now.

DR. STRIKER:

Well, as you probably know, I mean, as anesthesiologists, we deal with fentanyl every day.

MR. QUINONES:

Yes. And it's a great drug.

DR. STRIKER:

Let's talk about the specifics of fentanyl as it relates to the street versus medical use. Are we talking about the same substance or are there are we grouping together?

MR. QUINONES:

No, I think it's the same substance. There was a there was an interesting difference. The first supplies of fentanyl began coming from Chinese chemical companies mailed through the mail, usually to a dealer. The first ones to figure it out were pill dealers in the States that were most known for the Ohio, Kentucky, and West Virginia. So you began to see the chemical companies that made fentanyl in China. And many do were sending it. You could order this stuff over the web, and they would send it in nondescript packages, manila envelopes and whatnot to these guys. And these guys, they thought they'd won the lottery. Fentanyl was like, promising these like, mega profits. The problem is with fentanyl you have to mix it with something because it's so potent, as you probably know, that just a few grains of it will make you high. A couple more will kill you. You can't sell that on the street. You have to mix it with some other inert powder. The problem is these guys are idiots. They don't know what they're doing. And so the myth grows that the way you mix your fentanyl. The best way to mix your fentanyl is with a magic bullet blender, which you could get at target for 29.99, right? This is a huge mistake because, I mean, any of you who have the magic bullet blender, you know, I have one at home--they're great, we love them--know that they only really are good for mixing liquids. Powders need to be mixed in a different way. Blades mix liquid. Powders you have to mix by turning them over. Nobody in the in the underworld back then understood this, and what began to happen is they had really awful mixes. So it'd be like chocolate marble ice cream, you know, some you'd have nothing. Then you have these big amounts of fentanyl. And what you begin to see is fentanyl began to create like 50 overdoses in a weekend in a, in a, in a one mile square area or something like that.

And then the Chinese dealers or the Chinese companies began to switch. They began to switch to Carfentanyl, Fiorano fentanyl, cyclopropyl fentanyl, all these different fentanyl analogues because they wanted to stay away one step ahead of the Chinese authorities. Fentanyl was now illegal to make. So now you make fioranal fentanyl or cyclopropyl fentanyl … one of those. And so you began to see all these different permutations of fentanyl much more potent than fentanyl itself. And that's when you begin to see lots of people, um, basically huge amounts of people, uh, overdosing.

When the Mexicans take over, really about 16 or 17, they dispense with all the analogs. You really don't see a lot of analogs being made because they know they're doing this illegally. They just want to make the simplest form of fentanyl possible, that's all. They don't want to care about cyclopropyl fentanyl or whatever that stuff is. Forget it. And so you began to see this transformation of the of the fentanyl supply in much greater quantities. You stop seeing all these strange analogues as much. And it was just straight up fentanyl. Just it was very deadly. So you began to see this kind of change happen in the illicit fentanyl market, which which is really now what we're talking about on the street. It's almost no, like legitimate legal made for surgery kind of fentanyl on the streets. As far as I know. It's all made like in little backyard labs and stuff like that.

DR. STRIKER:

Right. Well, as anesthesiologists in our, you know, we have a few minutes in the intraoperative not when we're treating chronic pain patients in the clinic, but in the intraoperative realm, we have a few minutes, typically to establish trust with our patients and tell them what was going to happen to them for their surgery. We use fentanyl, as you know, daily. From your perspective, as a non-physician, Is there something we as physicians can do to alleviate any fear that patients may have? Because I've had the fear expressed not only by patients, but also nurses I've worked with too, who are nervous about us ordering it. Not often but…

MR. QUINONES:

There’s only one solution to that. It’s just basically wider education. Going into the media and talking about fentanyl, the legitimate fentanyl, the revolutionary effect that it has had on surgeries and allowing for all kinds of surgeries that may not have been possible with just straight up morphine or the opioids, the other opioids. Um, you know, I really believe that a lot of that is where anesthesiologists really need to play an important role, going on local radio and saying, you know, you don't understand the the beneficial effects of of fentanyl.

I came to understand, as I was saying earlier, um, because I had a heart attack in 2017. They gave me fentanyl and all of a sudden I understood, oh wow, this is actually a great drug. I'm not I'm not out for four hours. You know, I'm out for more like a minute and a half after they're done with the surgery. And then I'm back to action. You know, it's an amazing. It's a remarkable drug in that way, I have to say. I mean, I, I talk about it every time I get a chance in these kinds of public forums because I think it's very, very important people understand that and don't start proposing wacky kind of public policy that would, you know, defeat everything. It’s a remarkable drug. You should use it. But of course, it belongs in the surgical setting and and and no place else.

DR. STRIKER:

Right. And I think all anesthesiologists appreciate the not the potency but the potential dangers with fentanyl, which is why when we when we do use it in the clinical setting, we're taking the appropriate precautions.

MR. QUINONES:

The first people to get addicted to fentanyl were anesthesiologists. I've interviewed a few. This was like mostly in like the 70s again. It was all about supply. They had access to the surgical supplies of fentanyl, and they had little by little began to self-medicate. And then after that there was a very quick downward slide. And I think, I think the, the profession, as far as I understand, it took some measures to get control of it. But but I do know that, that the first I invited two of them got addicted in 1970s just because the supply was so, you know, available. It was so easy to come by.

DR. STRIKER:

Yeah, you're absolutely right. We all learn this in our training and then in continuing education after training about opioids. But fentanyl specifically, we're all attuned to the dangers. And I think we're we probably all have a personal story within the clinical realm of someone succumbing to an addiction. And usually it is…

MR. QUINONES:

And I think this is another example of how … this story is always about supply creating demand. You know, it's about that. If you did not have that supply there, those people would never have been addicted to that, to that stuff. And I think opioids really the story is always about supply, creating demand and then exacerbating the demand. The more supply you have, you push out there. It happened with the pain pills. And I think it's happening certainly with with fentanyl and methamphetamine to actually to a certain degree.

DR. STRIKER:

Well, we're talking about the addiction potential specifically of something like fentanyl. And in your book, The Least of Us, I did want to ask, um, or just get your thoughts, what I thought was interesting in this book were a number of stories that you told, um, of everyone that deals with these substances, and we'll broaden it out to opioids, is affected in some way. And I thought it was in a way ironic that whether it's the drug supplier or the, uh, physician prescribing drugs or the someone using drugs, that everybody in some fashion became addicted to some facet of dealing with the opioids.

MR. QUINONES:

And that's what, if you read the the magnificent criminal complaints that Tennessee and Massachusetts attorneys general have put together, you will see that it's a remarkable idea that the opioids, um, even addicted the Sackler family that owned Purdue. Not to the drug, but to the the money. No amount of money was enough. So in 2010, Purdue Pharma generated payments to the to the family of $889 million. It's like the most they ever got. $889 million for like a family of maybe like 20 or something. I don't know what it was. And, um, and yet you could still see from the emails that were subpoenaed ,and it became part of the public record, the Sackler family saying, no, we need more. We need more. You know, come on. It's like nothing's ever enough, which is classic addict behavior. It's just in this case, it was the cash. It was money. We got to have more. And, you know, they wanted to cancel the annual, um, sales retreat in Florida because that meant that the sales people wouldn't be in the face of doctors for two weeks. Oh, my God, we can't have that. You got to be in, you know, and that kind of thing. So everybody who deals with opioids, particularly when there's almost no scrutiny and it's a very, very laissez faire kind of approach to the drugs, there are many examples of people in all these different aspects of that who get addicted to something. Very often it's the drugs. Of course. I think very often too, though, it's just as much as the money. Yeah. Because the the drugs do the job for you. You start people out a little bit, and then a little while later they're double and then a little while after that, they're double more, you know. And yeah, it's, um, it really struck me. It's like the perfect thing to study in an economics class. The the effect on decision making of, of opioid addiction or the money from opioid addiction. You know, it's a fascinating idea, I think.

DR. STRIKER:

Yeah, certainly the the couple other interesting, to put a little personal note on the, on the epidemic, uh, a couple other interesting character, um, character stories or profiles in the book. One is physician, but there was another one, Tommy, who I thought perhaps distilled the epidemic down into the in the severe phase that we're currently in. Somebody who had been addicted for some time to other opioid substances. But he had a great support system. His family continued to be invested in trying to get him off of these substances until fentanyl came around.

MR. QUINONES:

And yeah, that's the thing he lasted battled for, I can't remember now. 12 something years. He got addicted to pain pills for injuries that he had on them. Then that became heroin. And then heroin just dominated his life for, for for many years. Um, and, uh, but that's the point. Heroin, you can kind of live on heroin. And as soon as fentanyl entered the--he was in Akron, Ohio--as soon as fentanyl entered the Akron, Ohio drug stream, he was dead in two months. You know, and that's the thing. That's what we're seeing on the streets. I believe in, um, uh, towns across America. That nobody really has, let's say the life expectancy is very short for people who are using fentanyl. It's not like heroin you can last 15, 20 years. Tommy Rall was one of them. He probably still be alive today, in fact. But fentanyl came along. And the same guy who was using magic bullet blenders to mix his fentanyl sold him a dose that was way, way badly mixed. And and he was dead. He was on the toilet. Um, I think he was shooting up. Or maybe he was smoking it, but he was dead where he before he fell forward and hit his head. Hit the. Hit the bathtub. He was dead before that, you know, he just went bam. And he was he was out and he was found in this kind of praying position in between the toilet and the and the and the and the bathtub because fentanyl, well, this was oh, this was a fentanyl analogue. I can't remember which one it was now, but it was a fentanyl analog. That's what the detective said. I used to I used to do heroin overdoses. And you could see that people on heroin overdoses, would have time to get relaxed so you'd find them in their sofas, cigarette burned down to the to the finger tips. You know, but with fentanyl, they die immediately. There's no time to get relaxed. And so people just keel right on over wherever they are. They don't have time to even break their fall. They just bam, they're dead.

DR. STRIKER:

Yeah. Well, let's talk about just briefly things that we're doing currently to help. I had listened to a podcast where a father of a fentanyl overdose victim, uh, was talking about possible solutions to the opioid epidemic. Amongst a number of issues he brought up, um, within the current status of the epidemic was that he said that available data was not as accurate. He thought, his son was he looked at it, it was a poisoning. It wasn't an overdose because someone had laced from from what I understand, the pills with fentanyl. And so he felt that the current date is not accurately reflecting the problem. So one I wanted to get. Do you? I don't know what your thoughts are.

MR. QUINONES:

The difference between … there's there is a little slight difference. First of all, it's the it is it is to some degree a poisoning because someone takes something believing it to be a line of cocaine or a Xanax bar or a Percocet or something like that. And within it is really just fentanyl. No one is saying, I want to kill this person. They're just saying, I have this enormous amount of fentanyl and I have to find a way to sell it. Remember, fentanyl has changed fentanyl. Methamphetamine too, have changed the basic question that drug dealers on the street ask. The basic question for years was, where do I get my drugs? Okay, where do I get my drugs? Because it was always changing. Your your supply was always being cut short. Your connection was always being arrested or what have you. So now that question has been answered: you can find them anywhere. They're so prevalent. You don't have to ask that question. Now the question is, where do I sell all the drugs I can get? And and at that point it becomes well, damn, anywhere.

And that's why during a Covid, um, all these social media apps became de facto street corners. So Snapchat was a main one where you would have young kids setting up and they would have all these pills they would be able to get now because there's millions of these pills being being imported or from Mexico into our country. And, um, and so and, and dealers would say, well, gee, we have this pandemic, which means that nobody can get out of the house. The only connection you have to the world is with this phone that you can't spare for a minute. Where on earth would I sell my my pills? Well, the smart phone. And so he began to see Snapchat. Some others. But Snapchat was the focus of many, many parents anger. I went to a I went to a protest in outside Snapchat headquarters in Santa Monica, California. It must have been like 80 parents, all with posters with pictures of their child saying Snapchat was complicit in the murder of my son and daughter. It was almost always during the Covid year, like, what was it, March 20 to March 21 or right in there, all of that became kind of, you know, how this stuff was sold because the supplies did away with that number one question that every drug dealer has, which is where can I get more dope to sell? It was always uneven. Now the supplies are just flooding. That is in my opinion, that is the main story. Um, and that has to do with our own, you know, our own opioid epidemic. It also has to do with the traffickers access in Mexico to all manner of chemicals coming in from from the world chemical market, principally, principally from China.

DR. STRIKER:

Now, the same podcast that that father was talking about, legislation he was working on with state legislators in Maryland to, to increase, uh, naloxone availability, perhaps in every AED box, I think they, they mentioned as a possibility. I don't know the specifics of the legislation. But the reason I'm going to want to bring it up is: what are your thoughts on the general state of affairs as it relates to harm reduction when it comes to opioids?

MR. QUINONES:

Um, well, you know, I carry naloxone in my backpack like everywhere I go. It's a very, very important thing to have available. It should be as important as as widespread as, you know, um, fire extinguishers and other first aid kits and whatnot. Right. However, it's very important to understand that it is in no way a cure all for anything. And it is in no way a is anything more than a band aid. And the problem is that in many communities in this country, it is viewed as the solution. We're just going to revive people over and over and over again, repeated overdoses over and over until. Until what? The problem is we run into several problems when it comes to this. First of all, methamphetamine on the street drives people to psychosis. And you do not have the ability to make rational decisions when you're on methamphetamine frequently in this country. Fentanyl also drives you to towering tolerances, and people refuse treatment all the time because they're terrified of being away from their drugs. So people are really not making that decision. They're not saying, yeah, well, I think I'm going to be. I'd love to go into treatment. You know, people don't do that. Um, yet we keep on pretending that they are saying something rational, and they're living in tents. They're living on the street. Feces. I mean, just horrible, horrible lives. Very, very exposed to whatever lethal temperatures are in the area and so on. And, and people just still keep treating this as if these people are rational. The problem is that meth will drive you mad, and fentanyl will kill you long before you ever make the rational decision to accept treatment, to say, yes, I want I want treatment. Just doesn't happen.

At the same time, very important to understand what happens with a drug overdose and opioid overdose is is the deprivation of oxygen to the brain. And that's what opioids do. They govern respiratory system. They shut down your respiratory. You stop breathing. You you turn blue and all the rest. Right. Problem is if you do that a lot, particularly if you do that a lot without any time for healing, you begin to develop deep brain impairment. And this is what we're also finding on the streets that people are developing horrible brain impairment because they now have 15, 20, 25, 30 overdoses in in a year's time and they don't have any time for healing. The street itself is a is a trauma factory, trauma inducing kind of beast. And and so over and over and over, you get people who are left on the street to, to in a, in a pretend world in which they they are making real rational decision, when really what they are doing is just being exposed to the most severe threats and eventually death, um, that they've ever been exposed to.

DR. STRIKER:

Um, I want us to leave a few minutes for for questions if the audience has any. But before we get to that, I'd love to keep talking about this, because it's such an important topic and there's a lot of ways we could go. Um, but I did want to end the main discussion with talking about the the title of your last book, The Least of Us. I know you mentioned you talked about it a little bit at the keynote address this morning, but my impression is a lot of people will pick up the book, look at the title. They may think it refers to something other than what it might refer to. So if you don't mind, just elaborate a little bit on what the title of the Least of Us refers to.

MR. QUINONES:

Well, first of all, I wrote Dreamland, and it did very, very well. And my publisher did what publishers do and said, you got to write another book. And I was like, exhausted. And I said, okay, I'll try. Let me think about it. And eventually I came around and got some time to rest and stuff. But he said, my editor said, don't worry about writing a book proposal or a book outline. Just start writing. Now that is not really good advice you need. You need a book outline, a map. It doesn't matter if you stay to it, but you do need something like that. So I did not really have a map for any of this, and and I spent a lot of time thrashing around, not knowing what I was doing, where I was going. And when that happens, I know that there's a couple of things I need to do. One is I need to interview more people, and two, I need to read more widely. And so as part of that, I began to read a whole bunch of different things, one of which was the Bible and the four Gospels. And, um, because it's really important you just spread yourself wide open to whatever ideas kind of seem to, to create some kind of synergy. Right. And, um, and I came upon at that point the, the, the book of Matthew, that which you do unto the least of these my brethren Jesus said to his disciples, you do unto me. Meaning you feed the hungry, hungry? You're feeding me when you do feed the hungry. So all of this hit me in a big way, because I had been really thinking about the way forward in all this, as small steps. We've we've just so desperately want big solutions, big magic answers. And they don't really exist. There's no substitute for just simply plodding along day to day, bringing in other people, forming networks with other people, figuring out new, new approaches to whatever problem you're trying to deal with. But in the small way. And it hit me right then. And so to me, as I got into it, that's when I began to think of the least. At first it was the least. And then I realized, yeah, that's a little too, too brief. And and I began to think, you know, one of the things that that neuroscience has, has shown us is that all of us have the brain chemistry to be addicted. We all have the ability to be the addict eating from the trash, as I say in my speeches. And so I thought, well, that's the least of us lies within us all. So we all have that person. That became kind of the the leading theme for it. But then I also began to understand that the least also applied to local recovery efforts. I mean, if you think about an addict in recovery every day, not using seems like a minor, minor thing from way up here. On the ground it's the whole ball game. You just move forward every day, slowly. Not not, you know, finding new things to to occupy you, all that kind of stuff. Right. And and so it began, I began to think of the term the least as, as also the smallest little effort should not be dismissed, but understood that together over a period of a long time, it's actually got enormous consequences. Except for that it won't look like that. It won't look like you're saving the world in some noble, you know, fashion. It'll look actually like you're just stumbling along, like we all do through life. Except for that's how you create the most lasting social change is with this small movement forward with other people eventually, and that kind of thing. And and with that's social change without the unintended consequences more likely doing that right then than then. Oh, we've got the new solution to all our problems kind of approach. And so it was thinking about all of that that made me want to really, really focus on the small stuff because we've had too many people, cynics, nihilists in this country just say, oh, you know, we, uh, nothing works or it's all pointless. I just think that's nonsense, just totally think that's nonsense. And I'm I've seen too many examples of it working to to think otherwise, you know. So that's kind of where that, that came from. It was an evolution. But after reading the book of Matthew, uh, which is strange because, you know, I'm not a Christian. Um, and me telling anybody about the Bible is ridiculous idea, you know, so but it just is kind of my, my, my little journey towards the title of my book.

DR. STRIKER:

Well, it's a great perspective, and I think it's a great way to to maybe conclude our main discussion because I think, like anything in life, I imagine it's always those small steps that need to be taken to get anywhere.

MR. QUINONES:

This is the thing we know that the big, big leaps rarely work. You know, uh, revolutions. With the exception of the American Revolution, most revolutions in the world have ended in people being slaughtered, you know, and revolution tends to do that now in innovation. Revolutions do change some amazing things, of course, but I think by and large we are better off when we just find others to work with like-minded people, like hearted people, and and move forward and try to and and do it on the local level and not worry that we're not changing the world in some noble, virtuous, right way. You know what I mean?

DR. STRIKER:

No. Exactly. Well, um, if we have, do we have a few minutes to maybe take one question? Two questions? Um, if anybody in the audience wants to come up to the microphone right here in the center, I think we have we'll have time for maybe take a one. I'm getting the one right. We'll try two.

SPEAKER:

Well, you mentioned this morning that you thought we were making the same mistakes with marijuana that we made with opiates. I was wondering if you could expand upon that. And two, do you think the presence of safe injecting sites and naloxone is actually making things worse? Because we're creating a risk hysteresis. People take greater risks. We may be creating more addicts by attempting to put a veneer of safety over the habit.

MR. QUINONES:

I think this with regard to that last question, that, first of all, I haven't done reporting on those safe injection sites. So I don't I don't really know that I want to comment to specifically. However, I do believe that the longer you leave people on the street with fentanyl and meth in the colossal, catastrophic supplies and potency that they now possess, that you will be creating huge, huge problems. And those people will be done. You've got to get them off the street. Just because you saved their lives once or 20 times doesn't mean you have saved their lives. Most of the people who are dead today have had numerous revivals with naloxone. Numerous, right? Many of them, anyway, have had numerous revivals with naloxone. And so to me, it feels like it's a misunderstanding. Those sites might have been okay in another period, but I don't believe they really have any validity, or they need to be taken with a grain of salt given that fentanyl and meth on the streets are changing like everything. Okay.

With regard to marijuana, again, it's about supply. It's about potency. Legalizing marijuana can be done. Well, I suppose I mean, I'm imagining theoretically it can be done well, but you have to limit potency. And that means limiting profit, right? So you have to say you can sell legally up to 7% THC marijuana. Now it's like 30%. 40%. The vapes are like 90% this kind of thing. So what we've actually done is exactly what we did with the opioid epidemic, which was, say, all you companies that are selling narcotic painkillers, you know, we'll let you write, basically write the, the statutes, the legislation governing this stuff. That's kind of what's happened with the with the marijuana industry. So they're allowed to make to, to to to put together marijuana that's 30, 40, 50 whatever percentage of THC they want because it's more profitable to do that than to say, no, it's going to be 7%. They're allowed to grow indoor marijuana in the time of climate change. The the carbon footprint of every bud of marijuana is is is horrible. It's huge. Why should you ever allow marijuana, which grows very well in the sun, to be grown indoors? It's because you want to have it all year round and you want a much more potent. And that's kind of what's going on. So marijuana is is being written by the people who profit from it, which is leaving aside the issues of public health and public safety, and it's being done all across the country, and you're seeing horrible increases in psychosis, er, visits by by 19 year olds and all the rest. It's a disaster when it could be done well, and it could be done in a way that allows marijuana to be studied as a beneficial plant, which I believe it has, some benefits, but not if you're making it primarily as a as a way for a certain small group of people to make a ton of ton of money.

DR. STRIKER:

Yeah, well, we're running out of time here in the exhibit hall. I would love to take more questions, but unfortunately. We have to wrap it up. Mr. Quinones, I can't thank you enough for your time. I it's a fascinating discussion and thank you for sharing your insight, your experience.

MR. QUINONES:

My pleasure. Thank you all very much. It's really sweet of you.

DR. STRIKER:

For our listeners, I just want to flag the ASA's Revive Me initiative that has some useful resources for anesthesiologists on reversing opioid overdoses. Visit asahq.ororg/reviveme for more. And to find out how to gain access to naloxone in your state, visit safeproject.us/naloxone/state-rules. So state rules with a hyphen in between. And, uh, please tune in again next time. We'll we'll see you again on our next episode.

MR. QUINONES:

All right. Have a great day.

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VOICE OVER:

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