The Great Antidote – Sally Satel

On this episode of The Great Antidote podcast with Juliette Sellgren, she is joined by guest Sally Satel M.D.. In their discussion, Juliette and Sally cover the misguided perception of addiction, policies aimed at fighting addiction, and the future of public health.

Guest Bio

Dr. Sally Satel is a resident scholar at the American Enterprise Institute and the staff psychiatrist at a local methadone clinic in D.C. Dr. Satel was an assistant professor of psychiatry at Yale University from 1988 to 1993 and remains a lecturer at Yale. From 1993 to 1994 she was a Robert Wood Johnson policy fellow with the Senate Labor and Human Resources Committee. She has written widely in academic journals on topics in psychiatry and medicine, and has published articles on cultural aspects of medicine and science in numerous magazines and journals. She has testified before Congress on veterans’ issues, mental health policy, drug courts,and health disparities. Dr. Satel is author of Drug Treatment: The Case for Coercion (AEI Press, 1999), and PC, M.D.: How Political Correctness Is Corrupting Medicine (Basic Books, 2001). She is coauthor of One Nation under Therapy (St. Martin’s Press, 2005), co-author of The Health Disparity Myth (AEI Press, 2006), and editor of When Altruism Isn’t Enough: The Case for Compensating Kidney Donors (AEI Press, 2009). Her recent book, co-authored with Emory psychologist Scott Lilienfeld is Brainwashed: The Seductive Appeal of Mindless Neuroscience (Basic, 2013).Brainwashed was a finalist for the 2013 Los Angeles TimesBook Prize in Science.


Episode Transcript

Juliette Sellgren: It is my pleasure today to talk to Sally Satel. Sally is a resident fellow at the American Enterprise Institute. She’s a psychiatrist and an addiction specialist who has done something quite remarkable in the pursuit of understanding addiction better. She spent a year in Ironton, Ohio to better understand how opioids and heroin, and fentanyl became drugs of choice for people in that part of the country. What she found out is that abuse, it isn’t new and that people have been using all sorts of substances whether legal or illegal for decades. She also found out that the standard narrative about addicts isn’t quite correct and she is tirelessly setting the record straight. Welcome, Sally.

Sally Satel: Yeah. Thank you so much.

Juliette: So before we jump into all of that, what is the most important thing that people my age or in my generation should know that we don’t?

Sally: Oh, well, I don’t know what you don’t know. But I can tell you one of the things maybe I wished I knew back when I was your age or early twenties, late teens, is just how important it is to find your kind of intellectual niche[?]. And I’m talking now kind of in a professional sense here. But, you always hear people or at least you hear the commencement speeches and the inspirational talks about, do what you love, do what you love. Well, you obviously can’t do what you hate and be happy or even probably do it, you are not really inspired to do and be happy, but it is more than that. We just have to find an environment, the right environment, to do it.

I mean, I’ll just give you one example from my life which is not very dramatic but still it’s where I think this finally kicked in. So, as you mentioned, I’m a physician and all doctors go through medical school. And we do what’s called rotation so you work in the emergency room, and you work in a clinic a little bit, and then you work on the general medical floor, and you work in the psychiatric unit, this kind of thing, for about a month or so each. And when I was assigned to the cardiac care unit, which admittedly is very complicated and they certainly didn’t expect me, thank goodness, to do much. That was beyond of early student’s capacity because you go to a cardiac care unit when you had a heart attack. I mean, these were people who are very, very, very sick.

But, I just found that environment just overwhelming where I didn’t find an emergency room overwhelming. I can’t even quite articulate what about it was so difficult for me, but I think I lost thirty IQ points there. It just didn’t work and in most other rotations, I was successful. So it may sound like not a very dramatic example, but I think even folks who are still in their twenties and thirties, excuse me, twenties, you’ve lived long enough to know that certain environments just elicit your talents and attract the kind of people you’re most comfortable with. Not to say that you shouldn’t be challenged working with people you’re not comfortable with is an important experience to have as well and will certainly happen throughout your life. But, anyway. If I had to boil it down to an aphorism, it would be kind of find your fit.

Juliette: That is some good advice. I will definitely be keeping that in mind, especially going into college, going into all the stuff that is leading to a job.

Sally: Yes.

Juliette: Yeah. Okay. So, drug overdoses have been an issue for like decades. More recently, the focus has shifted towards opioids because of the increase, like the dramatic increase from like twenty-one thousand deaths in 2010 to fifty thousand in 2019. And every state has opioid users, but the bulk of the crisis was concentrated in places like Ohio and West Virginia, and particularly in those states in the depressed areas. And the standard explanation blames expanding the prescriptions and advertisements of opioids. But also the fact that drugmakers hide potential for abuse because they’re pushing these drugs out of greed.

Your work shows that the standard narrative, that’s way too simple, and so it overlooked a lot of important fact about where the crisis is happening and what it means, and what we’re thinking about addicts. So, before we kind of get into the deeper things, I kind of want to set the stage. So, can you tell us what opioids are and where other drugs fit into this crisis?

Sally: Sure. Well, opioids, it’s a broad term and it includes what are called natural semi-synthetic and synthetic opioids. But, basically, the first opioid, of course, came from the poppy plant. And if you look at a poppy plant, it sort of has gorgeous flowers, but under the flower, it has what looks like a bulb. And the Sumerians figured this out thirty-three thousand BC, so it’s been around for a while. If you take a knife and cut open this little bulb, a white substance oozes out and that’s called the opium, basically. And chemists have found three basic opiates in there, morphine, codeine and something else called thebaine. Most people have heard of morphine and codeine. Those are opiates.

Opioids are drugs that include usually the thebaine I mentioned, T-H-E-B-A-I-N, plus something that’s done in the lab and what you get, when you combine thebaine and some chemical alteration, you get Percocet, or I should say oxycodone because that’s the active ingredient in Percocet. You get oxycodone or hydrocodone. Those are the main semi-synthetics. There are others but those are the main ones and they go by generic or I should say trade names as Vicodin, Percocet, Norco. People have probably heard of those.

And then finally, there are the synthetic opioids. And that is fentanyl, that one’s getting a lot of attention. Fentanyl isn’t outstanding painkiller. If you went to surgery and came out, chances are you would be hooked up to a pump and you could actually regulate the amount of fentanyl you get. Obviously, it has a stopping point so you can’t overdose, and it’s very potent and you get micrograms that are dropped into your vein. And it’s a wonderful painkiller, but it’s also been basically trafficked largely from China and it’s very dangerous and it’s on the street now. And that’s the synthetic opioid. I’ll just say one other synthetic opioid that people might know, which is methadone, which is actually a treatment, so it’s a kind of a replacement treatment for heroin. Oh, heroin, excuse me, heroin is also a semi-synthetic. It’s diacetylmorphine.

So, I hope that has not been too much. That’s sort of what we say when we mean opioids. And they’re painkillers, they’re narcotics. And the word narcotize, obviously, means to sedate and morphine comes from the Greek god of Morpheus, god of dreams. And these are phenomenal substances if you’re in pain, physical pain. They also tend to be phenomenal substances if you’re in mental pain and that’s where the abuse comes in. But, anyway. So, we’ll get to that. So that’s what opioids are and heroin’s been around since 1898. In fact, it was manufactured by Bayer, the same company that produces Bayer Aspirin and many other things, but it’s very well known for Bayer Aspirin, which I believe came out the next year, 1899. And it was prescribed by doctors, by pharmacists. People could even just buy it on the streets and I don’t mean illicitly. But that got out of control in the early 1900s and there was a big crackdown on patent meds, which had more morphine in them and also heroin.

So, as I say, this has been going on for an extremely long time and we’ve had heroin epidemics, illicit heroin epidemics on and off since the late ’40s. Well, that would be the ’50s, after the Korean War, was probably the first ones after the early 1900s. When you look at the shape of drug epidemics, you usually find a kind of cycling between stimulants, which is cocaine and methamphetamine, and the depressants, but in this case, it’s usually an opioid, which is usually heroin. Now the fentanyl is something that’s quite unique to this last phase.

I think your next question was, how did this all start?

Juliette: Yeah, yeah.

Sally: Okay. Well, it’s a long story so I’ll talk for a while but feel free to interrupt me if something is not clear or if your eyes are glazing over. So, basically, if you look at graphs, you’ll see that there actually started to be an increase in prescribed painkillers, and those could be morphine, they could be Percocet as I mentioned, they could be Dilaudid or hydrocodone. Anyway, their prescription by doctors started to go up in the early ’90s and that has nothing to do with a medication that many people have heard of called OxyContin. Now, I’ll just say a word about OxyContin, the oxy in the name means oxycodone. So that was the semi-synthetic opioid I mentioned. And contin simply is for the word continuous. And the whole idea behind OxyContin is that it would be a slow release of oxycodone, and that’s good if you have lasting chronic pain, because it keeps the blood level pretty level. And that’s what you want if you’re in pain all the time. You don’t want the drug to wear off.

I’m going to get back to OxyContin, but it’s really important because, frankly, it seems to be that’s all people hear about. That didn’t come along until 1996 and prescribing started to go up nationwide in the early ’90s. And that’s because what’s called the pain treatment movement was starting to get real traction. And the pain movement was, I think most doctors agree and I certainly do, a very much warranted movement to be very serious about treating cancer pain and other pain in palliative settings. And even to some extent non-cancer pain because as you must know, there are people who have just awful conditions with their backs or neurological problems or any neurological problems. It’s like having a migraine, like migraines, but it’s like having the worst sort of headache every day that you’ve ever had multiplied by a hundred every day of your life, depending on what organ it’s in. Obviously, if it’s neurological, it may be a headache but it could be in various body parts. There’s a horrific bladder condition that makes people’s bladders feel as if they’re kind of on fire, interstitial cystitis.

Anyway, these are a whole class of just terribly debilitating illnesses. And the idea was that maybe these strong medications should be used for them too, not just for people with cancer pain, which is notoriously horrific. And up until around the ’70s and even into the ’80s, pain was not sufficiently treated. So the pain movement was an effort to compensate for that and it started getting underway, and I think that’s when pain medication was starting to be prescribed more. But in 1996, things did seem to take off then and that, as I mentioned, is when OxyContin came along, and it was a highly abusable drug. And all painkillers have always been abusable drugs. But, OxyContin was especially abusable because, as I mentioned, the idea was you took it for twelve hours. So you’d only took it twice a day, whereas like a Percocet if you needed it for pain, you take up to four to six times a day.

So having to take a long-acting pill twice a day would be very good. Turns out some people needed it three times a day. So if something’s going to last that long, then obviously, there’s got to be a lot of painkiller in it to last, to leach out of your special formula where it’s going to leach out of a tablet over twelve hours. That meant that if you crushed the tablet, you would release an enormous dose, oxycodone, anywhere between like 40 milligrams and, at one time, up to 160 milligrams. Now, compare that to a regular oxycodone pill which was between 5 and 10 milligrams, okay. So if you release all that high-potency medication at once and snort it or inject it, assuming you’re already familiar with this job because if you are, I did it, we would probably die.

But, for people who’ve already been abusing these drugs, that was really attractive. And that’s why OxyContin just took off like that. And it took off at first in places like where I went, the Southern Ohio, which is part of North Central Appalachia and also in Central Appalachia, Kentucky being a real ground zero. Actually, also up in Maine. And the probable reason for that is that these are places with mining in the case of Appalachia, and logging and fishing in the case of Northeast, where mostly men had engaged in these jobs. I mean, for decades, their dad did it, their grandfather did it. This was the family job. These are utterly backbreaking jobs and we should get injured, they’re backbreaking if you didn’t get injured, but the rate of injury was high.

So, I’ll just finish up this part by saying it wasn’t unusual for doctors, especially in very small rural towns where coal mining was the sole job to give these medications out very, very freely and kind of the way you can think of an NFL coach medicating the guys. Get out there, you got to get out and play, you got to get out and play. Well, if you didn’t go to your job in the coal mine, you could be fired. And there was no disability, these were days before the union intervention. And some of the guys didn’t work, they didn’t get paid, and they could get fired. So there was an enormous pressure to take the medications, plus the doctors who are prescribing those pills were employed by the mining company. So, there was a great familiarity with taking these drugs in these areas. So that when OxyContin became available, it was really no big deal, in a way, to change doctors’ minds. Doctors in those areas were not suffering from what’s been called opiophobia, a fear that everyone would get addicted if they gave them opioids because they were using them for so long.

So that’s, I think, a persuasive explanation for why it kind of started there. But, by now, over the years, it migrated to all over the country, opioid abuse. And I’ll just say a final word about what’s considered the three phases of the current opioid epidemic, which is not over, that it started with prescription pills. They were prescribed for many patients, but they were also diverted, some of those patients sold their medications. Some of those patients had their medications stolen. Also, there was just a lot of diversion from the trucks that would bring them to the pharmacies. The pharmacies, some of them were not that careful. It became a real underground drug as well.

Excuse me, these prescription pain relievers figured prominently in opioid deaths up until around 2011. And I should add that most people who overdosed and died from an opioid also had other substances in their bodies at the time, alcohol or Valium type drugs. So, reinforcing the idea that it wasn’t that common from your average person who never used an opioid before to start a habit. It happened, but it wasn’t the common story. So the second phase was heroin that came in around 2010, because there was a real crackdown on the prescribing. Doctors became much more careful. These so-called pill mills, which were really shady doctors’ offices where a person could come in and say, ooh, my arm hurts and walk out with, like, contra pills with cash. Those were shut down. The DEA really got serious about those. And then heroin moved in to fill that vacuum because now folks were addicted and they wanted opioids.

And then around 2014, fentanyl, which is about a hundred times as potent as morphine and fifty times as potent as heroin started coming in and causing many more overdoses and are now probably responsible for about three-quarters of all opioid overdose.

Juliette: So, let’s talk now about the idea that addiction is a disease of the brain. In your recent piece, Dark Genie, Dark Horizons, The Riddle of Addiction, dark genie in the title comes from a metaphor used by Anthony Bourdain, who was a longtime heroin and cocaine user. And you write, “I’m a physician yet I too am hesitant to call addiction a disease.” You continue by writing, “While I’m not the only skeptic in my field, I’m certainly outnumbered by doctors, addiction professionals, treatment advocates, and researchers who do consider addiction a disease.” Why do you think the majority of doctors or health professionals have settled on the idea that addiction is a disease? Specifically one in your brain, like a neurological disease. And what role did funding from the National Institute on Drug Abuse, like what role did that play in making this definition such a central piece of the fight against addiction, I guess?

Sally: Well, the National Institute on Drug Abuse, which is part of National Institutes of Health, its director back in 1995 really came up with this idea that this formulation of addiction is a chronic and relapsing brain disease. That was the big formulation and is still come[?] to very vigorously these many years later by subsequent directors and it’s been picked up. It is basically, I think, accepted as the definition of addiction.

But to give them some credit, this is rhetoric, and rhetoric has a purpose, and their purpose was actually pretty noble in that the more you make something into a disease, the more you make it involuntary and then the less likely it is for people to blame the person who’s manifesting this condition. So the idea was to try to soften the stigma against drug addiction. I don’t know that we should soften the stigma against drug addiction. You certainly understandably want to soften it against people who are struggling with addiction because you want them to get help. So, I understand that. And they also really wanted to get it kind of out of the realm of the criminal justice system. So, in other words, this is the crime. It’s not a sin. It’s something that needs treatment, and I’m actually quite sympathetic to that.

But I think you lose a lot when you turn addiction into a brain disease, and actually it’s the brain disease part of it that has bothered me much more than disease. I mean, there are certainly disease elements to this. It’s certainly a pathological behavior to be using drugs to excess, not to be using drugs but to be using drugs to excess to the point where it’s compromising your life. You’re missing classes. You’re missing work. Your wife is about to leave you. Your kid starts to hate you because you don’t come to any of his ball games. I mean, your health is now compromised. You spend too much money. Now you have a criminal record. I mean, that’s a lot to sacrifice for a drug. And so it’s such a paradoxical and seemingly irrational behavior that it can appear to be kind of disease light[?].

So I get that. But what I’ve always really had a problem with was calling it a brain disease because, yeah, obviously, drugs affect the brain. Why would people take them otherwise? But I just feel that it’s just not the most productive level sort of explanatory level on which to think about addiction. I mean, unless you’re a neuroscientist and then it’s a fine level of analysis to use. But, there are other explanatory levels that give us much more insight into why people do what they do and how to help them, and those are the psychological level. Why do people use drugs? And the environmental level, why do they use drugs in this situation, not that one? And the behavioral level, what about situations where you’re surrounded by other people using and then you effectively have some kind of Pavlovian response to drugs? Well, that’s really important, understanding it from a conditioned behavior standpoint.

These are all really important and I think they get flattened when we think about addiction or encouraged to think about it from a strictly neurological level. So, that’s been my mission since 1995 is to tell people, I don’t really mind if you call addiction a disease. I prefer you don’t call it a brain disease because you’re shortchanging its complexity. But if you want to call it a disease, you have to understand the kind of disease it is. And unlike, God forbid, cancer or juvenile diabetes, things like that, or pneumonia, where you could be in a coma and I could give you medication for pneumonia and you wake up three days later and you wouldn’t have pneumonia anymore. But there’s no way that a person with addiction can be treated and not be at the same time motivated to change behavior, change his thinking, change his life, usually, and get better. It’s just not that kind of disease.

So, the kind of disease it is, is one that people engage in for reasons, even though they often fight against those reasons and it’s usually a vast kind of unhappiness which takes lots of different forms. If you read addiction memoirs, the theme that seems to be prominent is self-loathing. But maybe that’s just in people who could write memoirs and child abuse, horrible traumatic experiences, just despair, my life will never get better on and on. So you want to be kind of oblivious understandably or get pleasure in any way you can. But that goes to the kind of disease it is, it’s one that people use for reasons. And unlike a classic rate of disease, like a brain tumor or a Huntington’s disease or Parkinson’s, it doesn’t respond to contingencies. And we know that addiction response to contingencies all the time because everyone who’s ever come into my clinic has come in because something bad happened.

I mentioned before, the wife leaving, the kid hating them, the boss going to fire them. If you had a disease, if I had a brain tumor or breast cancer or something, it doesn’t matter who’s going to leave me or who’s going to fire me or who hates me. That disease has an autonomous process that doesn’t respond to such contingencies. Also, it means that we’ve got tons of tons of research on this that if you reward people who abuse drugs, or addicted to drugs, you offer them incentives like cash or any kind of a reward, which has to be delivered quickly, because you can’t delay a reward if you want the behavior to change. People will cut back or stop their drug use.

So, again, if I had a brain tumor, you could tell me, I’m going to give you a million dollars if your brain tumor doesn’t expand or if your Alzheimer’s doesn’t worse then and your memory doesn’t deteriorate, I’m going to give you million dollars if your memory doesn’t deteriorate or I’m going to shoot your dog if it does, that wouldn’t matter. But addiction is the kind of condition, even though there are brain changes, there’s no question, that still can respond to these contingencies.

Juliette: Yeah. I feel like I understand it’s kind of a gain in terms of, well, at least now addicts are not seen as criminals or something like that. But, the brain thing other than just being wrong, I feel like there are consequences to that. So can you kind of tell us what the main consequences are of calling it a disease and not only a disease, but a disease of the brain?

Sally: Well, I think it makes some people actually cynical because they know that there’s a lot of purposeful action that folks undertake and, of course, that’s of being addicted. For example, refusing treatment. Here, I am giving you a way out, and yet you still prefer to use drugs. Now, I understand that because I think the person doesn’t believe that the treatment will work or they just can’t even imagine not having their drugs. I get that. In addition, there are other consequences and, again, many psychological studies was through that. The more you describe a condition as neurological or genetic or something that sounds kind of immutable, because it’s out of your control, the more pessimistic the public is that you will ever get better and the more afraid they are of you.

Now, fear is different from stigma. It is different to see, let’s say, I’m sure most people have walked by a few within the city, especially, homeless, mentally ill person, and the poor guy or woman is raving. And, yeah, you cross the other street because you’re a little scared he could or she could lash out. But you’re thinking to yourself, oh, that poor person. You’re not thinking, oh, what a jerk or get them out of my sight. One hopes you’re thinking, oh, that poor person, I wish there were better treatment available. I wish his family could maybe take him in, whatever. It’s the sympathetic response. So while calling addiction a brain disease, it doesn’t necessarily mean people don’t have a sympathetic response, but it means that they are more afraid of addicted people as well.

Juliette: Does it do anything in terms of changing the way that addicts view, I don’t know, outcomes in terms of not only like treatment but their role in their addiction?

Sally: There are some studies that show that people who adores the brain disease framework do feel less phrases[?], self-efficacious but they do feel less empowered to help themselves. I admit I don’t know how that plays out. Like, in other words, how easily that’s undone. I mean, I could imagine that they could talk to a different therapist or talk to me and hopefully they wouldn’t see it that way. But they might be hopeless because they have no faith in themselves or because they never saw any of their other friends benefit. Or as I said before, they just don’t even want to be without their drugs. But I think I could talk them out of the fact that brain disease means you can’t get better.

Juliette: Okay. So, kind of talking about Ironton, what made you move there? And I guess, I don’t know, did you have any, not necessarily fears, but did you think there was something you were missing out on by working at a methadone clinic in DC helping with the opioid crisis there?

Sally: Well, yeah, I’ve been working in a methadone clinic right in DC for, gosh, twenty years or ever since I moved to DC pretty much. So, yeah, we’re talking around twenty-ish years. And you know what, that’s urban addiction, and I should say in a way addiction is addiction just like if you broke your leg, the agony would be the same on the moan. If you were diagnosed with cancer, it would still be as devastating no matter where you were. So there are human universals, for sure. But, the patients that I saw, and this is true of most inner city addict population, did not start with pills. In fact, they were much older, the average age of my clinic was in the ’60s. They didn’t start with pills. They started with heroin. They often started injecting as opposed to snorting, which is how most pill abusers will start out using it.

So that was different. Right, so I couldn’t quite appreciate that. And there was a racial difference and I don’t know how much that, in a way, matters. But, almost all really like 99.9% of the patients in Ironton were white and almost all, maybe 90% of the patients that are in methadone clinics, were African American. And as I said, they’re much older. So there were a lot of demographic differences and age differences. But I wanted to go because I never lived in a small town and I suspected the pill abuse was not that novel down there as it was in other parts of the country. And I keep saying average because there are exceptions, but the average person who abuses pills was not someone who’s given a few Percocets after a tooth removal and then became a raging drug abuser. I mean, that sounds like a parody but it’s often what you read in the newspaper.

And I should say, though, quickly that doctors did overprescribe these medications, there’s no question about it. The pendulum from not treating enough in the ’70s and ’80s really started to take off in the early ’90s. Then when OxyContin came along, as I said, that really created problems of abuse. Yeah. But I just wanted to sort of see that for myself, and I have to say, of course, my suspicion that most people who develop difficulties with these drugs were not naive patients, opioid naive, that’s actually a term of art, is something that you would look today, not individual anecdotes. And they do very much support that, they show several things that I just want to say before I talk more about the town.

But, first, that very few people get addicted to these medications if they’re given in the short term. So as I said, if you’ve had a severely sprained arm and your doctor gives you some Percocet, chances are very low that you will even finish the prescription and sometimes even pick up the prescription. But, you will take the medication and that will be the end of it. That is the case most of the time. Situations where it’s not the case is when the person either has a previous history of alcohol use or drug abuse or they’re struggling with a psychiatric problem. Now those people definitely are at increased risk for abusing these drugs. But, otherwise, happy person, I mean, they can’t be that happy if they just broke their leg, but you know what I mean, is statistically going to be okay.

And there are government data showing that most people who have already abusing pills, they get them from their doctor, like 22% continue to get them from their doctor, most by them on the street or get them from friends or dealers, things like that. And as I said in this toxicology, screens are all these other drugs. It’s often the people who are victims are people who are not new to drug use. And that’s important because the consequences has been, I mean, exaggerated so much the risk of these medications, doctors have to watch, there’s no question. They have to monitor patients, but we’ve gotten so afraid to prescribe that now people with chronic pain, I kind of mentioned earlier and was the worst headache of your life times twenty every day of your life. They’re not being prescribed sufficient pills.

So that is unintended consequence of our inadvertent exaggeration of the danger of these medications, the failure of doctors, well-meaning as they are, to monitor who was at risk for developing an addiction, and then it led to this backlash. Prescribing has dropped precipitously and it did deserve to drop, there’s no question, now the pendulum has swung the other way. So, that’s a situation where we are. And just now finishing up about the small town I was in, the average age was much lower, more like twenty is to forty. But now the people there, you have largely switched over to heroin because pills are much harder to get. And also, now methamphetamine, which is a stimulant, is also a big problem. And as I mentioned earlier, fentanyl is a huge problem because all these drugs are often combined.

So, fentanyl is often added to heroin as you can imagine because it’s so potent. It’s so easy, relatively speaking, to traffic because it doesn’t take up that much space. So fentanyl is ubiquitous and it can be sprinkled on heroin to make it more potent and even added to methamphetamine, which probably explains why they’re overdosed, so many overdoses with methamphetamine. Because in and of themselves, they can kill people, but not at the rate that opioids do, which shut down your breathing. And then also there’s a problem with counterfeit pills. So, if you buy pills on the street, you may think you’re getting Xanax[?], which is a Valium type drug, or a Percocet. It’s actually fentanyl that’s been pressed into the shape of a pill. I mean, these are machines. They’re really expensive, like thousands of dollars, but they can press a powder of fentanyl into the shape of a pill and even use the markings on it. So like next time, if you take a pill, even if it’s Tylenol[?], you’ll probably see Tylenol or some letter or some number embossed on the pill.

These machines can do that. And they can use dye to make the pill. If you know your pill is usually yellow, it could code it yellow. So, that’s very deceptive and those pills could be really deadly.

Juliette: Oh, on the note of doctors prescribing less because of this fear of overprescribing people getting addicted and stuff. It’s weird because, I mean, I don’t know, I don’t monitor this a ton and this is more recent, because I’ve had a lot of friends getting wisdom teeth removed and the doctors are like, that’s painful, you should probably get a prescription of XYZ and it’s not the super hard stuff. I don’t know, I don’t even know what it is. But their parents are the ones who were saying no, because they’re afraid that their children will get addicted. And so there’s kind of becoming a new problem because of the fact that people, especially parents, don’t trust the doctors anymore to know whether it’s okay to prescribe it to someone or their patient or a child. Then they’ll say no and then their kid is in extreme pain.

So one of my friends had like jaw surgery, got his jaw broken in a few places and was only allowed to have Tylenol because his parents did not trust stronger medication.

Sally: Yeah. No, that is a huge, huge problem. I’ve heard that kind of story a lot. It’s complicated how these exaggerations started. As I said, the media were a big part. But the media, they didn’t make this up, they got it from certain physicians who just completely exaggerated the risk of these medications, and I don’t blame parents. If they read this in the paper, how would they know that these claims aren’t exaggerated? Now, of course, if your friend had a problem with, let’s say, he drinks too much or had abused drugs before, that is not a reason for a doctor not to prescribe these medications, the opioids, but it is a reason to watch the patient much more carefully. That’s true. It’s not a reason not to do it. But this is the fallout from this exaggeration, and I almost like wish the parents, if they’re listening, would call me.

I don’t know if you have show notes, but there’s an article that I wrote that’s called The Truth about Painkillers and it goes through all this. And I’ll just say where it is so people can easily find it. It’s on the National Affairs website, National Affairs website. And it’s just called The Truth about Painkillers and it’s by me, Sally Satel, and it’s also on my own website, which is, But, I have to say that I’m not the first person by any means to call attention to the fallout of this exaggeration and completely unsubtle treatment of this issue. But I think, I like to think it’s a good synthesis of what we know. It’s a fairly lengthy article so I hope people would find that interesting and it would quell anxieties. But I have to tell you also, Juliette, that doctors now are terrified of prescribing because their state medical boards are looking over their shoulders.

Medicare and Medicaid sometimes put limits on what they can do. Pharmacists now, actually, sometimes second-guess the doctor and say to the patient, you don’t really need that, which is unfathomable. For what it’s worth, I should say pharmacists are protected by DEA law. Like if you walked into the pharmacy and you were all stumbling and slurring your words and you handed a prescription for Percocet, they do have the right to exert the judgment not to give it to you. It’s like a bartender not knowing a shot glass of someone who’s already have passed out. So, they do have that right. But, there are examples of pharmacists just being completely just aggregating way too much power to themselves in discretion, not even calling the doctor. There are a lot of harsh stories here to be sure.

Juliette: Yeah, I think you describing it as a pendulum is like the perfect way to describe it, because it went too far in one way and now it’s going like completely in the other direction. Okay. So, I mean, with the machines that press powder into pills that are not the actual pills but like different things that are worse or more deadly or anything, that seems like that is not good for the people who were struggling with opioid addiction to like pills and prescriptions. So then it seems like maybe the method of cracking down on prescriptions, I mean, it’s something, but it doesn’t seem like it’s necessarily the best solution if it’s pushing people towards heroin, right?

Sally: Yeah, you’re exactly right. And this is agile[?] tension that the more you crack down on drugs, the more you encourage more potent forms of them to be trafficked, and that is a big problem. But on the other hand, you certainly understand. You don’t want these drugs floating around and then kids could get ahold of them. I mean, young kids easily overdose and die. And also, it makes perfect sense in some way that you don’t want people using them. So, you make them harder to get. But, as you pointed out, there are these unintended consequences which is then people switch to more dangerous forms of drugs.

So, this is what the public health community is strongly advocating. And, I mean, they’re clearly right here, which is as much availability of a medication called Narcan, naloxone, which is a antidote, literally an antidote. So, I am the first person to be on your website to have a real antidote. Because if you overdose, as I say, it’s Narcan and it’s given through nasal spray or through a shot. This is what EMTs use, the emergency guys use, but it’s also sold in pharmacies and sometimes given away for free at public health departments, it will reverse the overdose. The molecules of naloxone will literally throw the opioid molecules off the opioid receptor, of your brain stem, which is your breathing center, which is where all the action is. And you will wake up and you will not be happy because you’ll be thrown into withdrawal, which is what happens when opioids stop. I mean, people go into withdrawal anyway when their heroin is wearing off, but this is an intense form of that withdrawal, but they will be alive.

And so the idea is do you have Narcan literally on street corners, and I think in some places where there is really heavy use, I’m definitely thinking Vancouver, which is British Columbia, and there’s terrible drug problems there. There are literally like little stands where there’s Narcan available, but people are encouraged to carry it with them, use it on their friends, like if you’re with your friend and they’re going to use heroin, both of you do not shoot up at the same time or snort at the same time. I watch the other person go first. So that if, God forbid, it’s much more potent than we expected, I’m there with the Narcan to save you, okay. So Narcan will save you. Fentanyl makes Narcan harder to work because it’s so potent and you might need several shots of it or several sprays of it.

But, anyway, there’s Narcan, and then there’s a great push to get people into drug treatment. And the good news about opioids, as opposed to like cocaine, if that were your problem, is that if opioids are your problem, you really do have good, what’s called, opioid replacement, opioid substitution drugs. And that’s methadone that I mentioned before. Usually, it does come in pill form, but it’s usually distributed, looks like Pink Floyd[?] in a clinic or there’s something called buprenorphine, which is a pill or something. It’s like also a strip. You can put under your tongue. And these themselves are FDA-approved opioids, but they release the medications far longer acting and it’s a substitute. So people don’t go into this withdrawal because when people stop and go into withdrawal, even if they keep saying they want to quit, it makes it much harder that withdrawal is just very, very uncomfortable.

Now some people call it turkeying out, they do. But a lot of people just can’t tolerate it so they keep using and using and using. And if they can start these medications, at least they can stop the cycle and then start treatment, which is a long-term process because it really means you have to redo a lot about your life to get to a point where you don’t feel you need these drugs.

Juliette: Yeah, those sound like possibilities.

Sally: It’s what we’ve got.

Juliette: Yeah.

Sally: But here’s that or not make or have a world where people don’t want to use drugs in the first place. Or, I don’t mean again, use them, I mean use them to excess to the point where they’re ruining your life. And that’s a harder project and that goes way beyond psychiatry.

Juliette: Yeah. That’s a mission that if it ever gets accomplished, it will take a very, very long time to get there. So, okay, a last question before like a wrap-up question. What is the difference between dark genie addiction and dark horizon addiction?

Sally: Yeah, thanks. I made up those terms and you alluded earlier to Anthony Bourdain who’s just that wonderful, tragic man, who had his CNN show, Parts Unknown. He was like part travelogue, part cultural immersion, part cooking, and he killed himself, was it 2017 or ’18, it was awful. But he looked like his life was going well. And during one of his episodes, he met with some people who were addicted to drugs in a small town in Massachusetts. And like the stories in so many other places, the big industries shut down and the economic situation is dire. And then the social fabric starts to fray and people were in this para mode[?]. And so there was a lot of people who were using heroin and pills. I think this was taped in 2014. And until they were all going around the room saying why they use drugs and when it came to Anthony Bourdain, he said, oh, I wish I had the quote in front of me, but I’m not sure quite what it was about me but there was some dark genie inside me, which I hesitate to call a disease.

So that’s where I got dark genie from and it means that a dark genie is something, as he said, inside a person. And all we have to do is look at all these glorious movie stars and like your friends who appear to have everything and yet they drink too much or they’re starting to use heroin or way too much marijuana and you’re thinking, why are they doing that? Why are they sabotaging themselves this way? And it’s because, just to use that shorthand, the dark genie, there’s just some inner pain that they are medicating. But that’s an individual analysis. The dark horizon analysis, that is what I made up, it’s really what’s behind epidemics because it applies to populations of people who don’t see much of a future, that’s where the dark horizon comes in.

Whereas dark genies are about individuals, dark horizons really kind of loom over entire groups of people, because their environment has become very, very despairing because they don’t see possibilities. They look around and they see all the people in their town who had any promise got out already. And so you’re left in a lot of these places with young people who probably didn’t get a great education and who knows how addicted their own parents were. So you’ll have that population and then you have a lot of old folks who were left and a thin middle class, because the kids who are growing up were doing kind of well in school or had a sense of, I’ve got to get out of this small town, they’ve left. So these are depressing places and that’s the horizon.

Juliette: I think it’s just the phrases, the terms, they’re like amazing, like they’re wonderful. They’re very good at explaining two very different situations that are very causal to addiction but also it kind of hints at the fact that addiction is way more complicated than a brain disease or some other explanation. You can’t really simplify it because there’s not one reason, there’s not one solution, there’s not one like general format that it follows every single time.

Sally: Oh, no, exactly. But you got it exactly right. Right, the brain disease thing is just like flattens it down. Fine, of course, the brain has changed, but you’re right. It’s so much more rich and you’re really doing a disservice to a very complicated human phenomenon, human drama when you do that. So, I appreciate your summary.

Juliette: Okay. So, to wrap up, what is one thing you believe that one time in your life that you later changed your position on and why?

Sally: Well, that’s easy. Experts are fallible. That is something that becomes clearer to me all the time, which is that just because someone has lots of degrees or even a high-ranking position doesn’t always mean that they know everything or that they’re willing to change their mind when the facts change. And that’s why to the extent that anyone who works with a problem that could have a database, it’s so important to marshal that data when you can.

But I suppose that’s my answer to your question in terms of stales[?] falling from my eyes, so to speak. But it’s not like I believe in God and then I didn’t or, I mean, I wish I had some sort of cataclysmic disillusionment or awakening. But that was the one that came to mind when I was thinking of your question.

Juliette: Yeah. Actually, I really like that because that’s why I asked this question, because I’m asking all these experts all these questions and then I’m like, well, you must have changed your mind about something.

Sally: That’s a good question, yeah.

Juliette: So, that makes me happy. Well, thank you so much. I learned so much and, I don’t know, I just had a good time so thank you.

Sally: Well, thank you. I really appreciate it.

Juliette: Well, that’s all we have time for today. I’d like to thank my guests once again for their time and insight. I would also like to thank everyone who listens, subscribes, and shares The Great Antidote podcast. If you would like to be on the podcast or if you have a guest in mind, please feel free to reach out to me at [email protected] Bye.


CGO scholars and fellows frequently comment on a variety of topics for the popular press. The views expressed therein are those of the authors and do not necessarily reflect the views of the Center for Growth and Opportunity or the views of Utah State University.