A year or so ago, I spoke with Rolf Halden about his work in detecting the amounts of drugs in a municipal sewage stream.
Halden is a professor of environmental engineering at Arizona State University in Tempe, and runs the school’s Biodesign Institute.
He and his fellow researchers have used technology to parse out all that’s in a city’s wastewater — antihistamines, viruses, opiates of one kind or another, and much more. Some 350 cities worldwide use his group’s sewage analyses.
Sewage is an information superhighway, in Halden’s estimation, for all it can tell today about our health and wellness.
I called him again not long ago when I heard he was using this same technology to help a city determine where its outbreaks of coronavirus might be happening, starting first with Tempe.
Here’s my conversation with a fascinating fellow – about 20 minutes. Hope you like it. Please share it if you do.
The New England Journal of Medicine startled everyone this week by a posting a one-sentence warning over the so-called Porter & Jick letter to the editor that the journal published in January of 1980.
The warning note reads: “For reasons of public health, readers should be aware that this letter has been `heavily and uncritically cited’ as evidence that addiction is rare with opioid therapy.”
I find it remarkable that the NEJM did this, particularly so long after the letter itself was published in the journal. Apparently this kind of note is very rare.
But I think it confirms what I wrote in Dreamland – in which I interviewed the main author of the letter, Dr. Herschel Jick.
I think it’s important to reiterate the impact, as well as the intent, of the letter.
As written, it is entirely correct. That a data base of hospital patient records, that Dr. Jick ran, and still runs, found the following: of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.
Remember this was data taken from the 1960s and 1970s, a time when narcotic painkillers were rigorously controlled, and never given to patients to take home with them. So it stands to reason that patients, under such strict controls and administered the drugs only in hospital, would rarely develop addictions – as the letter’s headline in the journal read when it was published: Addiction Rare in Patients Treated With Narcotics.
They simply didn’t have access to large supplies of narcotics, and especially drugs to take home with them, as patients routinely do today. Hence they didn’t run much risk of addiction. (The whole thing, btw, helped change my mind about what ignites a scourge of addiction, which I now believe is not demand, but supply. Supply first sparks demand.)
The problem came not with how the letter was written, but how it was interpreted, then used, by others. Through the late 1980s and 1990s, it was widely cited, quoted, footnoted – as my research in Dreamland made clear and as a recent letter to the NEJM from the Canadian doctors confirmed. It was deemed to be proof that somehow science now knew that addiction was rare when opiates were used to treat pain. Through the years, it became known, through a process similar to a game of telephone, as some kind of “landmark study” that presumably refuted much about what we know about narcotic painkillers and addiction.
The Porter & Jick letter – 101 words – neither did, nor intended, anything of the kind.
It was also used, of course, by pharmaceutical companies – especially Purdue Pharma, manufacturer of OxyContin – as proof that their drugs no longer caused addiction when they were used to treat pain. The company used the statistic that “less than 1 percent” of all patients administered opiate painkillers drugs – especially OxyContin – grew addicted to it. This was not true nor supported by any science. It was not supported by Porter & Jick, which was making an entirely different observation. Yet the letter was used to convince a generation of doctors that science now knew new things about narcotic painkillers and one was that they were “virtually nonaddictive” when used to treat pain. A claim that, again, has no basis in science or the letter.
All this I wrote in Dreamland, which came out two years ago. I found the whole story to be an unsettling episode in how scientific thinking changes based on no evidence at all, but due instead to deft and relentless marketing.
I’ll add one more thing. The NEJM’s warning note was prompted, as I said, by a review of the letter and its influence in scholarly studies that was published by some Canadian doctors in the journal this week.
I read the letter these doctors wrote and I don’t see Dreamland credited or footnoted.
I’m trying to take it all in with equanimity. Yet I’ll admit to some frustration to have done so much research and storytelling that brought this to light as part of Dreamland’s larger story of how this opiate-addiction epidemic spread, and which others have read and learned from, and then not have it reflected in the work those people do. On the contrary, the Canadian doctors’ letter is presented as some new revelation, which it is not.
So I’ll just say that it would have been nice to see my work credited in the recent NEJM report by those Canadian doctors, as well as media coverage of that letter. I’ll leave it at that.
The DEA today issued a press release that begins like this: “Heroin use has increased across the United States among men and women, most age groups, and all income levels. The greatest increases have occurred in groups with historically lower rates of heroin use, including women and people with private insurance and higher incomes.”
The release discusses a new report by the FDA and CDC about heroin’s use across the country.
The only fact it appears to leave out is that almost all the new addicts are white.
Still, for a long time, heroin has seemed to me a way of talking about America.
One reason for that is what the DEA expresses – that heroin is so widespread and in areas and populations that never knew it.
But heroin is also a way of talking about our loss of community and publicly shared assets – streets, parks, etc. Of a retreat indoors, figuratively and literally.
I believe heroin is the final expression, the final extension of our multi-decade exaltation of the free market, the individual and consumption. How else to view a drug that turns everyone addicted to it into self-absorbed hyperconsumers?
That’s why I wrote Dreamland and didn’t have one addict shooting up. To do so would have been to distract from the larger point, that this drug thrives in areas without much community feel, community anchor – the area could be poor, could be wealthy. What they share is a lack of community and public interaction and encounter.
The advisor told me Mrs. Clinton had been hearing a lot of very passionate comments from parents with addicted children as she campaigned in Iowa and New Hampshire.
We spent an hour on the phone, talking about policy, about pain pills, pill mills, Mexican heroin trafficking, and about the quiet surrounding this epidemic that had allowed it to spread.
So I’m glad to see that Mrs. Clinton is now coming up with policy proposals to address it, one of which is to begin talking about it and end the stigma and silence surrounding addiction.
This epidemic is neither a red nor a blue issue. Thus I hope candidates from both parties will respond as well. I’ll be happy to chat with them, if they want to call.
I’d hope, moreover, they would focus not only on heroin, but on the broader problem of overprescribing of opiate painkillers, which so often provide the gateway to heroin. (Pain pills have their legitimate role in medicine, but too often are massively and unnecessarily prescribed.)
But there’s another important point in this. I believe parents of addicted children need to use this approaching presidential campaign as a way of magnifying their voices.
As a longtime journalist, I know that the most poignant stories are the ones that can have the most impact. Sadly, many parents up to now have kept silent, ashamed or simply worn out by their children’s addiction.
That is changing. More are stepping forward, as Mrs. Clinton was hearing on the campaign. Some are mentioning heroin overdose as a cause of death in their children’s obituaries – an act of enormous, and necessary, courage.
But these stories are still not being heard the way they need to be.
During past drug scourges, public violence aroused public ire. The crack years, for example, saw drive-by shootings and carjackings. I was a crime reporter during those years and saw this first hand.
None of that public violence has happened during this epidemic. So the job of arousing public attention falls almost entirely to parents.
I believe this presidential campaign offers an opportunity to be heard, to magnify voices. Make opiate abuse (pain pills and heroin) and overprescribing a point of presidential debate.
To do that, parents in particular need to step forward and tell their stories the way no one else can.
Another family has stepped up to acknowledge in an obituary that a child has died of a heroin overdose.
Daniel Joseph “DJ” Wolanski, of Mahoning County in Ohio, died April 20. Read his obituary.
It must be so difficult for this family to come forward and say this publicly. But this scourge has spread because so many people before them have kept quiet, allowing the rest of us to imagine that the problem really isn’t as bad as it has become.
So it’s important to acknowledge the courage of those who do step up, speak publicly.
The obituary reads….
“Over the course of DJ’s life, he made many bad decisions including experimenting with drugs. Unfortunately, his five year addiction and battle with heroin took over. His family and friends truly loved him and tried everything from being supportive to tough love as he struggled with his own inner demons and heroin. …
“DJ often talked about the growing number of friends that he had lost to this destructive drug and how it destroyed families. They used to say it takes a community to raise a child. Today, we need to say that it takes a community to battle addiction. Someone you know is battling addiction; if your “gut instinct” says something is wrong, it most likely is. Get involved. Do everything within your power to provide help. Don’t believe the logical sounding reasons of where their money is going or why they act so different. Don’t believe them when they say they’re clean.”
Profound words – the way to attack a drug that turns every addict into a silo, a loner wrapped in a cocoon – is through community.
I’m on tour to promote Dreamland, and along the way I’ve have had conversations with parents of addicts, doctors, public health employees, and the public in general.
Often the conversation revolves around why this is a problem, and why it continues to be — if we see that massive prescribing of pain medication has clearly led to heroin addiction.
This letter from a nurse practitioner at a chronic-pain clinic in a mid-sized town in the western United States helps explain.
______
The clinic I work at has a reputation for liberal opioid/opiate prescribing and there is a culture of dependency and codependency that has been instilled by the owner. Prior to coming to this clinic I worked in a psych and drug rehab hospital in a rural part of the United States for five years. I saw all the patients that became addicted first by pain medication or other means. It is a struggle for me everyday to know that I now contribute to this problem.
Every day I try to have the conversation with patients on what it would be like to get off the medication. Most patients tell me no one has ever had that conversation with them. It makes it that more difficult because then I look like the jerk that wants them off their meds when every provider before me told them they would be on pain medication their entire life.
I have developed a reputation as being a terrible provider by many of the clinic’s patients. The front desk asks my medical assistants what it is like working with me since all they hear is terrible things about me.
Many people talk about going after to the doctors to stop this opioid epidemic. The problems I see are patients with terrible insurance that doesn’t cover comprehensive pain management. What I am stuck with is a person with limited resources and a 20-minute appointment and sometimes all I have left is medication. Most of my patients get upset with me, and laugh when I give them breathing exercises to perform.
I don’t start many people on pain medication but I have kept many people on medications that I sometimes don’t feel comfortable prescribing. I go out of my way to try to find alternatives to pain medication for my patients. My hope is that one day pain management is taken out of primary care completely. Pain is too complex to dealt with in a 20-minute appointment.
The other issue is patient satisfaction. That is a huge issue in emergency departments. I have spoken with many ER docs and it seems a lot of the care is driven by customer satisfaction. Doctors fear bad reviews from patients. I think this drives a lot of the pain medication prescriptions in EDs. Because of this, I have seen some of my patients get opioid/opiate prescriptions for relatively minor medical issues.
I have found some positives. Most patients I discharge for multiple violations of their medication agreements never come back. The ones that do often turn out to be my favorite patients. When I don’t worry about prescribing controlled substances with patients then we often get to work on lifestyle changes like better management of their chronic conditions or quitting smoking.
Anyways… I probably have a lot more to say but that seems like enough. Thank you for your time.
I’m in Little Rock for the Arkansas Literary Festival, a very nice book festival held downtown.
So here’s what happened yesterday. Flew in, met my fellow panelists, learned that Southwest lost my bag, went to the hotel, took a quick nap, went to a festival reception, met someone with an opiate addict in the family (the family member is a woman in her 60s or so).
Little Rock is no different from every other part of the country I’ve visited recently.
Researching our national addiction to pain pills and heroin to write my book, Dreamland, I’ve been struck by the normalcy of addiction nowadays. Everywhere, strike up a conversation, you find someone with a family member or friend or co-worker addicted to opiates.
It’s far more prevalent than crack use was, I believe, and certainly infinitely more deadly.
I remember starting the research, flying to Dallas a couple years ago. On the plane was an elderly couple from rural Oklahoma. We got to talking and before long, they were telling me of their oldest son, addicted to OxyContin.
Not long after that, in a tavern on New Year’s Day in Covington, KY, I met a family, celebrating a young girl’s birthday. Before long, we’re talking about two people in that extended family dead from heroin overdoses.
There are many reasons why this is so.
First: the massive over-prescribing of pain pills nationwide. We often debate whether supply or demand drives drug plagues. This one is supply driven. Pain pills eventually lead to heroin addiction – as the pills are molecularly similar to heroin and much cheaper; in some areas, like those serviced by the Xalisco Boys I write about in Dreamland, heroin is easier and more convenient to obtain the pills.
But this is also driven by silence. There’s no violence to fuel public ire. Meanwhile, though, parents are loathe to talk about their children’s addiction. When they die, they camouflage it in some palatable cause of death. Some parents are going public. But far too few given the huge numbers.
The result is silence, and stories you never hear until you’re sitting next to someone on a plane, or chatting with them at a cocktail party.
When neck-deep in writing a book, I’m never sure if it’s any good. Too much time spent laboring over every phrase, whether one clause should be separated by a comma or a semicolon, which adjective best describes a person’s mood – on top of all the facts that, like cats, need to be corralled and herded in one direction or another.
And new facts you learn every day that may change everything.
Then there’s the rewriting – which is what writing is all about.
So I’m thrilled to hear reaction to the book – that people couldn’t put it down. Love hearing that, I have to say.
I’ve had great appearances at the LA Times Bookfest and at Vroman’s, with more to come at Powell’s Books in Portland, Elliott Bay Town Hall in Seattle and Bookstore West Portal in San Francisco, not to mention the Arkansas Literary Festival in Little Rock, where I’m heading as I write.
Amazon.com chose Dreamland one of its Best Books of the month, alongside books by Toni Morrison, TC Boyle and others. That was nice of them.
The NY Times ran a column of mine on the front page of its Sunday Review opinion page. Nice of them, as well.
Salon.com wrote this terrific review of the book. Kirkus Review ran a long story on it. Willamette Week published a review, and an article on Dreamland. Mother Jones, where I was once an intern (1984), reviewed it as well. Thanks, you guys.
KPCC in LA aired an interview i did on their show, Take Two, and CSPAN did the same with an interview at the Bookfest, then covered the LA Times Bookfest panel I was on with some terrific nonfiction crime authors – Ruben Castaneda, Barry Siegel, and Deanne Stillman, and Tom Zoellner doing a bang-up job moderating.
All in all, an exhausting but fulfilling first few days to a book’s life.
Thanks to all who’ve bought the book, and especially to those who’ve written me about it with such feeling.
