12 Hard Lessons: Richard J. Baum on America's Opioid Crisis

The arc of the opioid crisis is, by now, familiar to most people. Over-prescribing of legal opioids in the late nineties caused escalating numbers of people to develop use disorders. In the 2000s, new prescribing guidelines and controlled substance monitoring went into effect, and the legal supply of opioids rapidly reduced - so quickly that many people with opioid dependence turned to heroin to stave off withdrawal. But that only made the problem much worse.  And then by the mid 2010s, fentanyl and its multitude of analogues hit the scene and overdose deaths exponentially skyrocketed.  And then the pandemic hit, and the death toll literally doubled. 

Richard J. Baum is one of those few individuals who has had a bird’s eye view of the crisis the whole time. 

Baum served in the Office of National Drug Control Policy through six presidential administrations from the late nineties until he became Acting Director under President Trump. This month he joins us to discuss his perspectives.  

Baum is now Adjunct Lecturer at Georgetown University, where he is teaching a course based on his comprehensive book, Inside America’s Opioid Crisis, which draws on more than three decades of work on national drug policy. In this conversation, we talk about how the crisis unfolded, but focus on the current moment defined by shifting drug trends, unpredictable overdose spikes, a large grey market of unregulated dangerous drugs sold as supplements, and the rise in stimulant use even as fentanyl overdoses decline. 

Baum has learned a lot from his experience on all aspects of this crisis, like treatment, prevention, and how best to inform the public about the dangers of each new drug threat.

As always, any opinions expressed in this episode reflect those of the guest, and do not represent the opinions of the University of Tennessee. 


Learn more:
Richard J. Baum: https://richardjbaum.com/ 
Inside America’s Opioid Crisis: https://richardjbaum.com/book 
SMART: www.smart.tennessee.edu 

https://smartpolicypodcast.buzzsprout.com/

Transcript

The Opioid Crisis Arc

SPEAKER_00 0:03

You're listening to the Smart Policy Podcast, a production of the University of Tennessee's Institute for Public Service. The arc of the opioid crisis is, by now, familiar to most people. Overprescribing of legal opioids in the late 90s caused escalating numbers of people to develop use disorders. In the 2000s, new prescribing guidelines and controlled substance monitoring went into effect, and the legal supply of opioids rapidly reduced. So quickly that many people with opioid dependence turned to heroin to stave off withdrawal. But that only made the problem much worse. And then by the mid-2010s, fentanyl and its multitude of analogues hit the scene, and overdose deaths exponentially skyrocketed. And then the pandemic hit, and the death toll literally doubled. Richard J. Baum is one of those individuals who has had a bird's eye view of the crisis the entire time. Baum served in the Office of National Drug Control Policy through six presidential administrations from the late 90s until he became acting director under President Trump. This month he joins us to discuss his perspectives. Baum is now adjunct lecturer at Georgetown University, where he is teaching a course based on his comprehensive book, Inside America's Opioid Crisis, which draws on more than three decades of work on national drug policy. In this conversation, we talk not only about how the crisis unfolded, but we focus especially on the current moment, defined by shifting drug trends, unpredictable overdose spikes, a large gray market of unregulated, dangerous drugs sold as supplements, and the rise in stimulant use, even as fentanyl overdoses decline.

SPEAKER_01 1:59

We have still incredibly high overdoses of football stadium of a year. Americans are dying, and that should never be acceptable. We need to drive that down further. So we just need to be faster. Things move more quickly.

SPEAKER_00 2:13

Baume has learned a lot from his experience on all aspects of this crisis, like treatment.

SPEAKER_01 2:18

That the key to successful treatment is the quality of that treatment and the duration of that treatment.

SPEAKER_00 2:25

Prevention.

SPEAKER_01 2:26

We have just decided, as a country, not to give every student in the United States evidence-based drug prevention education information.

SPEAKER_00 2:37

And how best to inform the public about the dangers of each new drug threat.

SPEAKER_01 2:41

Take a lesson from Coca-Cola and let's invest in good messaging for our young people. It's just uh a dereliction of responsibility that we're not doing media messaging and doing it on the cheap.

SPEAKER_00 2:53

As always, any opinions expressed in this episode reflect those of the guest and do not represent the opinions of the University of Tennessee.

A White House View

SPEAKER_01 3:02

Great. Uh well, fabulous to be to be with you, Jeremy. Thanks so much for having me at the uh Institute for Public Service. Appreciate what you all do. Um it's great to be out at the RX Summit uh a few weeks ago in uh in uh beautiful uh Nashville, Tennessee. Uh so uh my name is Richard Down. I am a long-term staff member at the Office of National Drug Control Policy until late last year, where I retired because I had to leave government in order to publish a book. I had been toiling on for three years. The book came out early this year. It's called Inside America's Opioid Crisis, 12 Hard Lessons for Today's Drug War. I have a lot of uh free information on my website, RichardJBalm.com, including videos and info about the book. If you're interested in buying the book, that's great. That's uh available on Amazon. But I'm trying to uh my uh my objective uh in my uh now that I've departed government is really to share my lessons learned in government about American drug policy and to think about the future about what we need over the next few years as the uh opioid crisis evolves. So it's great to be with you today.

SPEAKER_00 4:16

Thank you so much. Uh it's it's really an honor to have you here. You were at the Office of National Drug Control Policy for quite a while, through three terms.

SPEAKER_01 4:24

And I would love it if we could get a brief uh Yeah, actually six presidential terms, 28. Oh goodness. Um and yeah, uh and uh so I joined in uh 1997 under uh Bill Clinton. And I I know I should make this point. So I'm I was uh a White House civil servant, meaning that I have a permanent uh position like other civil servants in government. But you know, when the president changed, our bosses changes. And when you really think about it, I I it may seem odd that one moment you're working for President Trump, and the next one you're working for President Obama. But it's good that there's some um qualified, experienced experts at the key agencies in the White House, OMB, and uh Office of National Drug Control Policy, National Security Council, we're there to support, advise, and serve for whoever the people elect.

Missing The Early Warning Signs

SPEAKER_00 5:14

So from 1997 to the late 2010s, 2017, 2018, when you become acting director, this is the arc of the whole rise of the opioid crisis. You saw the rise of overprescribing, you saw the rise of heroin, and then immediately the takeover of fentanyl. I would love to talk about what was happening in the office during this time.

SPEAKER_01 5:34

So really good question, Jeremy, because I would have to say that I wish we in federal government are faster in seeing the emergence of first the prescription drug epidemic, and then as it evolved, just like you said, to heroin, uh fentanyl, and then the poly uh polydrug crisis we have today with uh such heavy methamphetamine cocaine involvement and other drugs as well. Uh but for most of my career, I was focused on, and the office was focused a lot on cocaine.

SPEAKER_00 6:10

Yeah.

SPEAKER_01 6:10

And that was, you know, a an outgrowth of the crat cocaine epidemic, which admittedly was ebbing in the late 80s and 90s, but still a very uh serious concern. And over time, you know, uh it was 1996 when OpsyCottin came out, it was the early 2000s when we began to see the increase in opioid misuse and overdose. And then at the start of the Obama administration, 20 of 2010, 2011, there was really a major focus on the prescription drug crisis. And and you know, I really wish that we had gotten involved um earlier on it. And I also wish that during the Obama administration we were able to invest uh more resources, resources, energy, and focus on it. To be honest, it drug policy wasn't a top priority of President Obama. He was concerned more about the social justice aspects of uh drug policy. And don't get me wrong, that's an important part of it. And the number of arrests for marijuana, almost uh 800,000, 900,000 a year, was concerned and I know that they wanted the Obama administration wanted to deal with that, but at the same time, we had this rising prescription drug crisis that that ONDCP was uh working hard to address.

SPEAKER_00 7:42

Yeah, that's those those are really interesting points because I worked in the hospital in the later half of the Obama years across emergency departments, and we saw what from our end, because hospitals at the time didn't didn't see fentanyl coming, didn't have testing capacity for it, we knew quote unquote heroin was getting bad because we kept seeing the overdoses getting worse. So something was happening with the heroin. We knew that, we knew it was strong, and more and more people seemed to be doing it. But it it kind of caught us by surprise. Nobody really started talking about fentanyl until the latter half of that decade. And at least at a large enough scale to where it became a common name. Now, on the flip side, we're on the other end of the pandemic. We don't necessarily need to cover the entire trajectory of fentanyl, the doubling through the pandemic and everything, but we're on the we we've been hearing some great news over the past few years. Three consecutive years of decline, at least in Tennessee. Some states are seeing it worsening, but uh for the most part, the national average of overdose deaths is coming down, thankfully, for the first time, and in significant enough quantities in this way. That decline is starting to slow down, at least in 25. So the problem is still pretty significant, and we are still at least 2025 data above the level when President Trump declared it a national emergency in 2017. So plenty of work still to be done. Fentanyl is still a large problem, meth is still a large problem, but we're also seeing a resurgence in cocaine now again. So, and not to mention some of these other drugs, cyclorophene, metatomidine, xylazine, these waxing and waning trends that are causing a lot of chaos and confusion at the first responder level, at the overdose prevention level. So, with all that in mind, these past few years, what would you say we've been doing right? How have we been getting these numbers down? And then on the other end, what should we be thinking about now that this decline is slowing, appears to be slowing? How do we how do we ramp that back up and keep the numbers coming down faster?

What Drove Recent Overdose Declines

SPEAKER_01 9:46

Jeremy, that's a lot of questions, really important ones. And that's certainly, of course, it's a tremendous relief after, especially when I was acting director in 2017, 2018, when the understanding of what was happening with fentanyl was hitting the country and overdoses were escalating dramatically, it was a terrifying time, frankly. And uh, me and others who are working on drug policy were scrambling, trying to understand the facts on the ground, trying to drive change, trying to get investments in the right place. But I just want to highlight one point is that unfortunately, when we were dealing with prescription drug epidemic, we weren't really thinking sufficiently about what could happen next. We were focused on reducing prescribing, and the country did that. However, a significant minority of people who lost access to their prescription opioids migrated to the um illicit market. And and I think we people thought that perhaps uh the uh the obstacle of injecting would have made it hard for people to do it. Of course, we know you can also smoke fentanyl, but not everybody, no, not even a majority, but there was such a large number, say around 10 million people who are misusing prescription opioids. The fact that maybe a quarter or so migrated to the illicit market meant a giant number of people migrated to fentanyl use. And especially early in that process, uh, early in that timeline, when people weren't aware of the dangers of fentanyl, when narloxode was getting out, but not everywhere, a lot of people died. And so that was a disaster. And I really wish more could have been done. And I I've met a lot of families who have lost uh a child, often an adult child, and it's really a tragedy that we didn't uh do more better. But going forward uh to your question, it's a relief that overdoses are down, and and I think that several things that we uh the government, the country did right, the focus, the supply side focus internationally in sometimes working with China, sometimes pressuring them, sometimes going to the UN and getting international uh scheduling of uh fentanyl, synthetic uh anal synthetic analogs to fentanyl, other synthetic opioids, all uh has made a difference. And uh if I had a rank the uh the cause of uh of the uh causes of the decline, and I think we're still figuring this out, so I don't want to overstate it, but definitely supply aspect of it was important and appreciate everything uh folks at uh DEA and DHS and State Department others did to uh to drive change. But in addition to that, getting out narloxone, trying to get the word out people not to use alone, increasing um availability of bubenorphine and direct engagement with drug users, deflection, diversion on all these tools. I think they were a factor. And I think to take a step back now and think about here we are in 2026. We have still incredibly high overdoses of football stadium a year. Americans are dying, and that uh that should not never be acceptable. We need to drive that down further. Yeah, there is maybe a bit more time because people now have more tools to uh manage the consequences. But my concern is the rate of addiction, you know, the rate of complicated problematic polydrug use is very high. And you you're right to mention cocaine, methamphetamine is very prominent. And uh some uh studies, and it was a millennium health study out, says that about 85% of people who test positive for fentanyl also test positive for a stimulant.

unknown 13:47

Yeah.

SPEAKER_01 13:48

So people are have this complicated drug use, and now's the time with overdoses trending down to focus on getting people into some level of treatment or care. And so that to me is the most important question. Uh we we know that most people are not proactively seeking treatment, they're not receiving it, and so we've got to drive those numbers up of persuading more people to uh get access to treatment. The dun the drug supply has a little bit less uh concentration in fentanyl. So that's great for now. That won't last forever. It has these other substances in it, and it's still dangerous.

unknown 14:28

Yeah.

SPEAKER_01 14:28

And uh treatment is more complicated with the um addiction to multiple drugs.

SPEAKER_00 14:33

That's a perfect point. I one of the substances I mentioned, metatomidine, there's been some important conversation around that. For example, it precipitates withdrawal symptoms really rapidly and can cause a sudden heart attack. And yet, if you don't know it's there, you may not expect it. So you might discharge somebody, get them set up at a you know, abstinence-based recovery house, they might show up, and then if they don't know to expect it, the need to suddenly get cardiac care from a first responder could take some people off guard. So just as a quick example of those complexities you mentioned, when you talk about the need to get people in treatment, there was an article about Tennessee in Axios not long ago about the rate of opioid use disorder diagnosis in Tennessee was top of the list. And that caused a lot of consternation. But the first thing that popped to my mind was well, you need a healthcare provider to make a diagnosis. So conversely, it might be a good thing in that people are clearly getting seen and diagnosed, which sets them up to get that treatment in the first place. Uh perhaps that's part of the puzzle as to why our overdose rates are coming down a little bit higher than the national average. That being said, ensuring that connection to treatment is made is an open question mark across the country. People are trying to figure out how best to facilitate that. Peer support to keep people coming back to appointments has been an important strategy. I mentioned recovery houses. So, yeah, open conversation with the support groups, with the recovery houses, these things are all critical. But I would love your thoughts on what is and isn't working with establishing the continuity of care, uh, especially at the policy level.

SPEAKER_01 16:25

Yeah,

What Effective Treatment Really Requires

SPEAKER_01 16:26

a very important question. You know, I emphasize this a lot in my book because the research is so clear that the key to successful treatment is the quality of that treatment and the duration of that treatment.

SPEAKER_00 16:40

Yeah.

SPEAKER_01 16:41

And people need a year or more of continuous treatment and then post-treatment recovery support. And systems aren't really built for year-long programs the way they need to be. So I I think that is really critical. And the other thing is I think people get wrapped around the axle over sort of harm reduction versus recovery-oriented uh treatment. And I I think that we really need to like stop arguing over it. Let us go to people where they are and start them on something to move them in a direction towards recovery at the pace that they're ready to do. And uh, you know, I I think that those I think it's a relatively small percentage, but of those few people who are supporters of uh harm reduction who say, oh, well, we can't tell people when to have treatment, or we can't get involved, or it's their right to use drugs if they so choose. A, I just think that's wrong. And and B, even uh even if that the I could see that point of view maybe 15 years ago, but now with the drug supply being so dangerous, right? You have to, we have to reach out to people and move them in the right direction. And let's just not get wrapped around the axle about the intervention. You don't want to do syringe service programs in your state, but don't do it. People need a lot of things, they need basic health care, they need nutrition, they need a kind word, they may need a place to live, they need help with uh legal work, paperwork. Get the mobile vans, get outreach workers out there talking to people who are are currently using drugs, you know. You know, you can't get more people into treatment if you don't talk to people who are using drugs, right? If you wait until they stop using drugs, I mean it kind of defeats the point. And then I I have no no issue at all with AA and NA. It's helped millions of people. And for a lot of people, that is the perfect program, and they love it and it touches them and it changes their lives. And God bless, that is wonderful. There are a lot of people who are addicted to powerful substances like fentanyl or methamphetamine in particular that need to be on medication. And so I would say let's let's I mean, nothing wrong with the policy debate, but uh, but really someone who's out there using drugs, our systems, our government systems, our NGO systems needs to be in touch with the current people who use drugs. If we're not looking for them, if we're waiting for them to knock on the door of the treatment center, we're doing something wrong. You know, and and this is being done, and people know how to do it. It could be done through police facilitated deflection, where either an officer or an officer uh working with the community or family sort of engaged with someone who may need help getting into treatment and facilitate access to that treatment. It could be done through um drug treatment, drug treatment courts. But you know, the the first thing to say is you gotta start by looking for your clients and your customers. If you're a treatment center and you're brick and mortar center and just waiting for people to show up, you're not doing it right because you're you're you know, people who need the services are out there. So yeah, I think that's the number one priority. It's it's just at most, there's been different studies, but at most, about a quarter of people with an opioid use disorder are getting quality treatment. And with the danger of dangerousness of the drugs uh they're consuming, that's terrible. And we shouldn't be satisfied with that.

SPEAKER_00 20:38

Yeah, I want to re-emphasize that number you said. At most a quarter of people who need treatment are getting it. And we've seen for years that number hover more like one in ten, especially in the South. You mentioned meeting people where they are, quite literally. Nashville's overdose unit through their police department has been particularly impactful in this way. They truly go out to where these were where people who are frankly destitute or unhoused, homeless, meets them where they are, finds out you know what kind of substances they're using, gets them to lock zone, gets them set up with partner organizations for treatment options, recovery support. It's it's been pretty instrumental in saving lives. And similarly, we also see first responder programs like Quick Response in Hamilton County, where Chattanooga is, for example, uh they've recently launched a program uh built out of their EMS that has a follow-up. So if there's an overdose responsors, follow up with that person to get them connected. So yeah, it is it is exactly that kind of thing you're talking about, that kind of strategy of of engaging people actively using, and not just waiting for them to say, yeah, I'm ready for something now. Because you're right, if you wait for that, they could quite literally die with the lethality of the supply these days. So in thinking about that uh as a almost a public health framework, the lethality of the problem, you mentioned in the early 2010s w there wasn't enough urgency yet. Uh that and that that we missed the mark and and in that way and fentanyl hit systems that weren't prepared to handle it. Have we changed course? Have we started meeting the moment? Are are are we adequately addressing this uh for the public health crisis than it is?

Scaling Care With Recovery Coaches

SPEAKER_01 22:29

It has moved in the right direction. And I want to say that a lot of people in Congress, the executive branch, uh, and state government have done a lot. There have been more investments and more focus. And that's important. So on the one hand, I want to give credit to that hard work that's that's that's occurred. But on the other hand, we have never scaled the response to meet the need. And it's it's hard to draw an analogy, but think of the literally trillion dollars of federal commitments for COVID, which obviously isn't a problem and it was an emergency. Uh and however, I mean, I I wish there was a similar emergency supplemental for for anti-drug efforts. You know, in my book, I I was trying to be disciplined in thinking about okay, what do we need to really move the progress forward? And and I proposed a 20% increase in the federal drug budget. And I, you know, even for us in Washington, big numbers can be like hard to keep track of because uh, but we have a federal drug budget of about 46 billion dollars. That's supply and demand, that's everything. So that's a big number, but we're a big country and it's a complicated problem. I proposed a billion dollars a year in about a 20% increase in federal spending targeted in these programs that have proven to be successful around the country during this crisis, but are not yet scaled. So I see that's the thing that I think it really drives me a little bit crazy because we know everywhere around the country there are model programs and policies that people on the ground in their state, in their city, in their town, they have worked on, they have developed, they have uh perfected or improved that can be adapted and taken to everywhere in the country, but we're not funding it. We're not funding programmatic federal uh resources to take, say, police facilitated deflection, which again is popular and is in a lot of places, hundreds and hundreds of places, but we need thousands of programs. You know, there's so many police departments and and fire, fire departments and others who could do this with some federal resources. And it's the same across the board with other innovative programs. And I think sometimes people like like you and me who who are focused on drug policy, we see, we visit these and we hear about these great programs and we think, okay, this is a no-brainer. We now, I thought so. I thought when I first was in Providence, uh, Rhode Island, and I met recovery coaches who were going to meet people after their non-fit overdose in the hospital and helping to transition them into treatment and just to work with them. And I'm like, oh my God, recovery coaches, this is such a great idea. So there should be recovery coaches everywhere. I know I I I proposed that the federal government fund hiring 100,000 recovery coaches across the country, which is a bit of a callback to uh President Clinton calling on 100,000 community police officers back when he was president, maybe a bit before your time. Uh but recovery coaches can do something that nobody else can do. They can develop quickly a rapport with people that are current drug users. Yes. And they can be sort of a trusted interpreter and translator to say, hey, Richard, you've been coming here into our clinic, you know, for some services, but you're still you've been using drugs for a while. We have this puprenorphine clinic, or there's this doc over here, this nurse practitioner. You know, let me go over and introduce you and we'll see if you like it, if you're ready for it. And I think it's a it's a shame because there's all these people in recovery, almost 25 million American, many of them, want to give back and share what they've learned. We ought to be hiring them and putting them to work and bringing all these people with an addiction problem into some level of care. And and frankly, nobody could do it like someone with a lived experience because they just it's just hard. It's hard for someone in the middle of an active addiction to listen to someone to even a well-meaning doctor or nurse who feels they don't understand their lives. Someone who's been there can do it. So let's get going. It's so much cheaper to get people into treatment and care earlier in their addiction than have them go into the emergency department or struggle or have a uh require a 911 call and EMS response. So, really, we're uh we're wasting resources and lives, and we can do a lot better. So that's a couple billion dollar a year program, 1.8 billion, uh uh, and it would be a great investment for the American people. So to answer your question, no, we're not doing enough. We haven't committed to what it takes, and there are more people who are going to be lost that don't need to be.

SPEAKER_00 27:45

So that trust is a critical element of this, and that's something that peers bring to people struggling with substance use disorder. Um establishing that trust. In terms of informing people across this landscape, this is multiple sectors healthcare, law enforcement, criminal justice, recovery support, on and on and on, different people, different sectors. The media landscape and the information landscape is chaotic, to say the least, even more so now in the age of AI, on top of social media, on top of fragmented media ecosystems, and on top of everything else, right? So w how are you finding is the best way to communicate new changes in drug supply, new changes in policy ideas, new threats? What is the best way of communicating with people on this issue? And do you feel you're getting through?

SPEAKER_01 28:42

Yeah, Jeremy,

Prevention Messaging We Refuse To Fund

SPEAKER_01 28:43

it it's a really important question about how we're communicating to the public. Uh and there are different ways to answer it and there are different channels. But I I would say, especially for young people, adolescents, we have just decided, as a country, not to give every student in the United States evidence-based drug prevention and education information. They're great programs, but we uh the country eliminated in the Obama administration the safe and drug-free schools program, which provided direct grants to uh school districts around the country. That was uh an almost $300 million program. It's gone. There's no direct federal resource to educate uh students in schools. There is a uh set aside, a 20% set aside of two of the two large grant programs. So there is some federal money coming in. So we haven't decided as a goal. Every student in America should get evidence-based, age-appropriate information about uh curricula, about prevention. At a younger age, it's more about resilience and social interaction and behavior, understanding your emotions. As you get older, it's more specific. But we know how to do it, but we're not funding it. And that needs to change. And just also, you know, I was just in the UK and I saw I was walking around and I took a picture of it. I saw this ad for a sneaker company that had the slogan, Above the Influence. And I don't know if you're old enough, Jeremy, to remember, but Above the Influence was the national brand for ONDCP's anti-drug media campaign. It was at its peak about $180 million, federal dollars, managing grant spending, sorry, matching spending by the private sector to provide advertising. We need that. And what we've done now is we've, to be honest, if I could just be blunt, we're doing it on the cheap. You know, we get a chunk of money, a couple hundred thousand. We work, all these fees done some good work with the Truth Commission. They produce some ads, they roll them out, they get some free media, but they're not advertising strong anti-drug messages, evidence-based focus group messages the way Coca-Cola is advertising. Right? They're not doing it. And like we know advertising works because these big corporations wouldn't be spending the billions and billions on advertising if they didn't know it worked. So we know how to do it. We've done it in the past. Above the influence was very successful. It would have to be, I'm not saying we have to use that slogan, you have to do what works for uh the target audience. But I think a couple hundred million dollars, which is what I proposed in in my book, a year to have strong media messaging to young people. Again, with the messages, the slogans, the whole design, not based on what people like me in our in my early 60s think, but what the target audience think is effective. Because we know advertising works. You know, take a take a lesson from Coca-Cola and let's invest in good messaging for our young people. It's just uh a dereliction of responsibility that we're not doing media messaging and doing it on the cheap.

SPEAKER_00 32:00

We are seeing in the data, fortunately, though, that Gen Z is using at lower rates. We're still seeing issues amongst millennials and Gen X. And this is largely a millennial problem now, younger Gen X, older millennials in particular, in terms of the fatalities. Or is there do we need to ensure that Generation Alpha, who's currently in the single digits and early 10 or early 10s, you know, 10, 11, 12, etc., are what are the different problems you'd expect for these different generations?

SPEAKER_01 32:44

Yeah, it's interesting how it works with different cohorts. Well, uh I think that that it is likely that sort of what they said in the crack epidemic, where the younger brothers, younger sisters, they've seen their aunts or uncles, their parents maybe had problems with uh uh fentanyl use, and just like crack became sort of less appealing to people, that there's an understanding. I mean, I I I hope and I think that people have gotten the message, young people, that you just can't take a pill from anyone. It should be like how you tell your kids, you know, more so your daughters, but same with anybody, don't take a drink from somebody you don't know in a bar, right? You know, go get your own drink or see it, watch it uh come out from the uh from the bar. You can't take a pill from anyone because even your good friend who's trying to help you out because you can't sleep and you need a Xanax may have gotten it online. So I think that it's interesting because adolescent overdoses have risen uh a lot and they plateaued a bit recently, but the drug use is down. But the consequences are higher because the risks are higher. So that's good, but we got a lot of uh challenges on the horizon.

Youth Risk In A More Dangerous Supply

SPEAKER_01 33:59

Certainly I'm worried about high potency cannabis use, especially among young people. I see that the uh tobacco nicotine in various forms, whether you're taking it as a, you know, as the uh like a chewing tobacco you put it in in your gum, that little packet you can get, and and alcohol uh is still an issue. So the I think the same science still applies, is you want to discourage initiation, illegal alcohol, tobacco, or drug use of any kind among young people, delay it, hopefully prevent it, but delay it. And uh, you know, I haven't, I don't think I've we've seen evidence of people moving from high potency marijuana into hard drugs where I can draw that conclusion. But I'm worried about it because traditionally, right, a certain percentage of people try one drug. A lot of people just stay there and that's all they know. But a certain percentage, after using one drug for a while, look for something else. And, you know, having a generation of young people initiate marijuana use with these extremely powerful uh uh um uh high potency products is concerning. And frankly, you know, it's um the National Surround Drug Use and Health reports that about 20 million people with a cannabis use disorder, 3.6 million or so with a severe marijuana use disorder, people still walking around thinking you can't be addicted to marijuana.

unknown 35:27

Yeah.

SPEAKER_01 35:28

You know, it's like frankly, it's like I I respect whatever state wants to do. If a state wants to have recreational marijuana, if they want to have medical marijuana, if they want to keep it illegal, I think that's what that's where we are in the country. But we've got to get people information. People think, oh, it's natural, it's organic. These products that are fine in these stores are highly processed. I actually went into a uh a uh I was in a state that had legal recreational marijuana, and I went into the store to look around. And you know, there's a lot of muddy in marketing advertising. One of these products was uh describing they they had actually a little pouch that put it uh with a THC pouch that you could put in your in your between your teeth and gum. And it said, and the advertising says stay high all day and nobody will know. Uh and and I'm worried about the creativity of the private sector. We got to do a lot better on regulating marijuana. You know, we could still have allow states to do what they want with their law, but there's no federal system to really assess what's happening with marijuana and to regulate the marketing to think about whether there should be a THC limit. We could do a lot better. And I don't think it's great that 6% or so of 12th graders are smoking marijuana or using marijuana every day because of the vape pens, the edibles, they people can be high all day, right? You know, they don't have to go, you know, out up to the schoolyard. They can just take an edible, nobody will know. So yeah, I'm not saying that's the only issue, but it's a problem.

SPEAKER_00 37:07

Reining in the creativity of the private sector, that was an interesting phrase for this, because it does seem like that's where most of the innovation of newer drug trends are showing up is being sold as supplements or you know, some sort of natural herb or something like that, even when they're not, even when they are synthetic. So uh in one way, we have innovative on the supply side that is putting people at risk. And and again, a quick point. You were saying that the overall use being down and the risks being higher amongst youth, I think was a really important highlight. In contrast, what are some of the innovative ideas we're seeing now to fight back against these newer changes in the drug supply, the higher potency, higher risk products, uh, even in the context of a shifting youth landscape?

Testing Faster For New Drug Threats

SPEAKER_01 37:58

Well, certainly we need to um continue to invest and expand our investment in testing because new products come out, and I mean, it might have been uh metatomidine and xylozine might have been in the drug supply for 10 years, and we may not have known it if there wasn't, we weren't recognizing it. So we just need to be faster. Things move more quickly. And uh, if it's coming from China, which is the source or the primary source for a lot of these chemicals used to make these uh not just uh fentanyl and methamphetamine, but also these new cyanactive substances and other chemicals, we can try and get these chemicals scheduled and uh internationally and try and get China to stop sending them our way. So we absolutely need to invest in testing and drug checking so that people know what's in the drug supply. We got to keep doing that and be faster in understanding what's happening and getting the information out and keeping everyone informed.

SPEAKER_00 39:01

What are the policies we should be keeping in mind? What how should we be thinking about this crisis moving forward?

SPEAKER_01 39:07

Well, I I I do think we need to focus on the role of the federal government. The federal government funds support more than two-thirds of domestic anti-drug programs, demand reduction programs, treatment, prevention. And, you know, a lot of the the state, the great state programs run by governor's offices, most of them are federally funded. So I mean, there are millions of people getting uh SUD, SUD treatment, SUD coverage from Medicaid and other federal programs, and and they need it. And and uh Medicaid has been doing some important work with making sure people have safe and sober housing, transportation to treatment, recovery support, care coordination, the stuff that we know that works. In a way, I was thinking about how just how like if you're in the uh veterans administration system, if you're a veteran, you serve the country, you get a lot of support and coverage because you earned it, right? Through your service. And that has that's a more robust system than the general public has, and as as it should be. But some people in Medicaid, Medicaid has been learning what works and studying what works, and been saying, well, look, people aren't coming to their appointment. They can't, they can't get the three buses and get there on time, and they've helped figure out these problems. So you know, there's a lot of good work that's been done. We got to make sure we support what works, we fund it because we either pay now or pay later.

SPEAKER_00 40:46

Anything you'd like to add?

SPEAKER_01 40:48

No, I would just say that I do understand that this is a hard problem. Uh but there's a lot we have learned about how to help people and how to get people on a better pathway forward. You know, the question is do we are we willing? You know, are we willing to do what it takes to help more people? Uh and that requires focus, attention, staffing, and especially that initiation. I guess where I'd end, Jeremy, is recovery coaches are so important because there can be that first contact point with someone who's an active drug user and getting them to think about moving, taking some first steps into treatment and care. And we've got to do that. It's like that's the biggest problem. I mean, there are many problems, you know, but the biggest problem is that the bulk of people who are active drug users, buying drugs every day, risking their lives, are not in any level of care or treatment. And so we've got to go to them and reach them and know one better than someone who's walked that path uh of uh addiction and recovery themselves. So let's let's invest in our people and get them out there. That they're the workforce that we need. Of course, we need psychiatrists and counselors and nurse practitioners. We need a lot. But the uh uh on the ground, let's get those recovery coaches out there, let's save more lives.

Final Takeaways And Subscribe

SPEAKER_00 42:23

Well, uh, thank you, Richard Baum. It's uh been a true pleasure having you on the Smart Policy Podcast. I really appreciate it.

SPEAKER_01 42:30

Pleasure, and uh keep up the great work and uh let me know if I could ever be of assistance to uh the important work you're doing in Tennessee.

SPEAKER_00 42:36

For more episodes on in-depth discussions on Tennessee policies related to substance use disorder by a range of local experts. Please subscribe to us wherever you get podcasts and visit our website at smart.tennessee.edu. I'm Jeremy Corvellis. Thank you for listening and see you next month.