Dr. Volkow sits down with Heart of the Matter host Elizabeth Vargas to discuss the growing complexities of fentanyl-laced drugs; the state of mental health in our nation; what the pandemic can teach us about allocating resources to communities in need; and her deeply personal story.
Nora, welcome to Heart of the Matter. It’s good to have you here. Good to be talking to you. We just finished our panel discussion. I thought you guys were great.
I thought the panel was fascinating and it was a really important topic. So I’m glad you did it. So thanks a lot.
Well, it’s important and you and other panelists talked about the fact that right now, in this country, with the statistics being what they are about mental health and substance use disorder, it’s like we’re in a major emergency here. This is a huge crisis.
It is huge in terms of the number of people that are affected, but also the other issue is that it’s very challenging and that it’s something for which we don’t process the time when it’s going to end. And which highlights why it’s so urgent to intervene now because otherwise it’s just going to get worse.
Why? Tell me what you’re seeing.
What we are all seeing actually, because we’re living it in our own lives. Certainly the COVID pandemic, all of the stress that has come with it, the social isolation, has led to an increase in number of people suffering from depression, anxiety, loneliness and this is manifested among other things. For example, for an increase in suicidal behaviors among teenagers, for example. We’re also seeing very significant increases in intentional overdoses, that is people that took more opioids because they wanted to kill themselves. And we’re also seeing a pretty dramatic, the largest increase that we’ve seen in overdose deaths. Again, when you have that level of risk taken it is exacerbated by situations of distress. So we have multiple sensitive points that highlight that this is something that we cannot neglect. And that we’ve known that this mental health issues were one of the most challenging one and is recognized by the World Health Organization as what nations in general are going to be contending the most with into the future.
Wait, the World Health Organization has said what?
The World Health Organization has recognized mental illness, including substance use disorders, as one of the medical conditions that’s going to play the most important role in terms of why decreasing quality of life and cost to society. So these are diseases of the future that are already here at a very high level.
I was going to say, how can this be a disease of the future? We just set a record in this country for the number of drug overdoses. 100,000 in the last year, drug overdoses. We’ve seen those numbers, Nora, go up and up and up every year. Is it going to go up again next year?
If we do not act, it will go up again. Absolutely, it will go up. And I spoke about the notion of diseases of the future in just a rhetorical way because obviously they are very, very prevalent right now. They cause tremendous amounts of challenges. But I said, diseases of the future because in terms of years lost of life and culture costs, we have other diseases that cost more, like cardiovascular disease or cancer. In the future, the importance and the preeminence of mental illness and substance use disorders is going to take an even larger part of our cost in healthcare and for suffering. So we’ve seen in the COVID pandemic the largest numbers ever in overdoses surpassing anything that was even close before. And we’re not seeing any signs that it is going down and it actually reflects two factors.
And again, why I’m saying we are going to see further increases if we don’t act. And that is because not only is there more distress, so more people are using drugs in order to escape their conditions and the pain, but we’re also seeing during the COVID pandemic massive globalization in the United States, if I can use that term for globalizing in the United States, of the distribution of fentanyl. So fentanyl emerges initially in the Northern Eastern parts of the United States and then it starts to slowly progress to other states during the COVID pandemic that just accelerated. And we know that one of the reasons that it accelerated is because actually the drug seizures have just been going up and up every single year. So they are at – the Office of National Drug Control Policy, which reports these numbers, is seeing greater and greater number of seizures with fentanyl and the content of the fentanyl is higher.
The other issues too that they are reporting is that during this period, cocaine, methamphetamine – very high probability of containing fentanyl. The dealers are mixing these drugs with fentanyl in order to get a greater profit. And in the past – also during the pandemic – another new emerging trend is that illicitly manufactured prescriptions – and you were mentioning them – that look exactly like an another or that could look like a Valium or could look like a Percocet.
It’s actually fentanyl.
Yes, it’s actually fentanyl or they’re mixed with fentanyl. And so someone that may just, as you told that very tragic story of a student that had pain and takes a Percocet, and it’s an illicit one with a fentanyl and they die. And that story is one that we’ve heard many, many times, and that reflects actually the increased contamination of illicit drugs in the United States with fentanyl. And that’s not going to get better unless there’s actually a very proactive education and there’s less demand. But it’s tricky because it’s not just – in the past, we could say, okay, heroin is the one that was initially laced with fentanyl. So you could say, “don’t take heroin, be very careful because it’s likely to contain fentanyl, heroin.” But now people that don’t like opioids go and get with their dealer, cocaine batch, and they overdose and die. They don’t know that it had fentanyl.
No, the case that I was talking about. It was the case of Ed and Mary Ternan, who were on our podcast, talking about the death of their son, Charlie, who took a single Percocet that he had bought over social media. And that turned out to be actually pure fentanyl. But when you talk about the fact that the World Health Organization sounds the alarm that this is getting worse. It’s as bad as it is right now, as bad as it is today, it’s going to get worse. And one of the reasons it’s going to get worse is that we’re not just talking about people who got hooked on Oxycontin and then turned to heroin and are overdosing on fentanyl because they were doing heroin. We’re talking about people who go to a party and try cocaine or people, students who have pain in their back and purchase a single Percocet, or even as you mentioned, an Adderall. It’s everywhere. It frightens me to think about what these numbers are going to look like in a year, two years, five years out.
Well, I would like to think two things. One of them is that we’re going to hit the message and we’re actually not going to ignore it. And we’re going to act upon it because the numbers, like for the first time ever, we’ve seen more than doubling on overdoses among adolescents for fentanyl. Adolescents. And these teenagers are likely to have overdose because exactly the same story that you told. They get an illicitly manufactured pill for whichever reason – there are multiple reasons that it would take it, and they overdose and die. But the other aspect too, and this is the one that was mostly concentrated by the comment on the World Health Organization, is mental distress, and that mental illnesses are becoming more challenging, and this has to do with a lot of things that are happening, right? One certainly, COVID, has made major contributions, but what we’ve also seen too – before that migrations of people that actually have to go to one place or the other places enormous challenges in mental health. And the economic difficulties are also one of the factors that contributes to more adverse outcomes with mental health.
So these issues associated with new epidemics or the migration that we are observing because of changes in the globe through temperature changes, that is creating and imposing challenges that downstream are generating mental distress. And that’s where it’s coming up at. And two, we’re not putting the resources, we’re not highlighting it as this is something that we need to work with, right? We’re obviously, and I’m very glad that we’re doing this. We’re highlighting cancer as a strategy. There’s a moonshot for cancer. And that means resources. That means facilitating research. That means creating insurances that will allow people to get properly treated. But we’re not doing that with mental illnesses and we need to do it.
Why aren’t we doing it? Given the numbers and the fact that, especially, you would think, one of the panelists said, this is the time we need to strike. Now, this is the time because after the pandemic, so many more people are suffering from anxiety and depression than said. People are finally coming forward to admit they’re suffering. We’re seeing the overdoses and substance use disorder numbers go up dramatically. If not now, when? And why aren’t we, in spite of that, given all those realities, dedicating the resources? You’re a person and in control in government, in that sense, are you getting the support and the funding you need?
Well, I am, I mean, one of the agencies, we do science. So we provide evidence that hopefully can help change policies, but also provides the treatments and the prevention interventions, evidence-based, that can be used by others. But there are other agencies that regulate access and give their resources to provide for those treatment. So we already have, as I mentioned, evidence-based interventions for mental illness, for substance use disorder, both for treatment and prevention, but the resources are not allocated to implement them. So the question is, why is there not? And as a society, we have always this whole issue of, and as individuals, that an immediate reward is more valuable than a delayed reward.
And that is interestingly, just by saying it sort of, the more in distress you are, the more likely you’re going to go for the immediate reward, as opposed to delaying the gratification, even if that means a higher reward. So, in addition, typically you basically forgo delayed rewards for an immediate reward because you’re in a terrible state of distress. But as organizations and societies, we also work like that. And when we are in a situation of distress, which is basically favor things that are immediate and not long term. And many of the interventions that actually can provide resilience and prevention of mental illnesses are not something that you can implement and have a response the next day. It’s going to take downstream, say 5, 10 years.
What are those things?
For example, prevention, intervention, very, very simple. One of the factors that contributes to higher risk for children and adolescents for substance use disorder and mental illness is being an impoverished family.
Poverty contributes and leads.
Poverty is crucial. Low income. And this you can see why there is stress between the parents. They don’t have the time to devote to the children. And so that children get neglected and they don’t get given the opportunities. And those interventions, prevention interventions, that provide, for example, support and training for those parents, as well as helping them economically with some of the issues that are crucial and indispensable have been shown. Those prevention interventions when the children grow up to adults, they have reductions in drug taking, in mental illness, better outcomes. And in some of these instances, they’ve been able to follow it up and see that their children have also better outcomes. But it’s not something that they see at the next day. Something that you’re going to see when these children and adolescents that you do that prevention become adults.
Right. This need for immediate gratification not only haunts the addict because I’ve got to get the quick fix. It haunts policy makers because I don’t want to have to wait five years to see the results of my investment right now. I want to see an immediate result.
It basically influences the allocation of resources. So in thinking about it, obviously we need to do urgent deployment of interventions right now, because every single day that we don’t intervene, there’s going to be 300 people dying from an overdose. Right? And so there is an urgency on what we’re trying to do. And in that respect, we need to actually identify what are the needs that a community is going to get. And this was discussed very nicely in the panel. We need to actually recognize that one intervention is not necessarily the best way of doing things, not all the allocation of resources. So you have funds for treatment of substance use disorder, and you say, okay, I’m going to be dividing them based on the population numbers. That doesn’t make sense. You divide them based on the needs of that population. And so in areas that are already particularly deprived, you deploy that resources, you give priority to those areas, and you tailor the intervention that they need.
You mentioned that we learned some big, valuable lessons in the pandemic and dealing with COVID. That the government learned a lot of lessons. That the healthcare medical industry learned a lot of lessons. Lessons you think that we can use when it comes to fighting the disease of addiction or mental health issues. What are those lessons that we can take from COVID and apply to substance use disorder and mental health?
Oh my God, there are so many lessons.
The top three.
…There are so many, but one of the ones that resonates a lot in my brain is the lesson that we learn of horrible health disparities that the COVID pandemic made evident.
The health disparities, the racial disparities, the economic disparities…
The racial disparities. You saw that people that were Black Americans were much more likely to get infected. And if they got infected, they were much more likely to die. And that became very evident early on. And so what it is telling us is why is it that they are more likely to be infected and why is it if they get infected are more likely to die? Well, they’re more likely to get infected because income inequalities force them to work in unsafe conditions.
And live in crowded…
Absolutely. And live in crowded, unsafe conditions. And then why, if they get infected are more likely to die? Because of their racial, structural racism, and because of lower income, they have neglected their healthcare conditions. So they are much more likely to suffer chronic medical conditions that then puts them at greater risk of dying. So, but if you turn that same lens toward addiction, you find yourself exactly in the same situation.
You see the same thing with addiction?
Absolutely. And one of the things that emerges is no surprise. People with substance use disorders were more likely to get infected and more likely to die if they got infected from COVID. And people with mental illness were also more likely, some of them, to get infected, and if they got infected, they were more likely to die.
Wait, why is that? Why is somebody who might be anxious or depressed more likely to get infected?
Well, many of them actually because of the comorbid medical conditions. So if you have schizophrenia, for example, you are much more likely to have metabolic syndrome. That is when you have excess weight and you have an endocrinological imbalance and this has to do in part with the medications that increase the risk. So they also are much more likely to be smokers and smoking negatively impacts your lungs. And in patients suffering from depression, this is changing, and this is improving now, but traditionally much higher rates of smoking and that in terms put them at higher risk.
So you found that many people who suffered from mental health conditions, because of comorbidities, were much more likely to catch COVID and much more likely to die from COVID?
Yeah, no, it is. What it is sort of saying, when you look at what COVID taught us was these health disparities and what it is telling us, let’s look at the health disparities that we’re observing in individuals with mental illness and substance use disorder. We need to address them and to understand why is it that we’re situated in this position. There’s no reason why they shouldn’t have access to good quality care and support. So that would be one of the lessons that I said. It made it even more clear than what it was. We knew there were health disparities overall, but the COVID made it even so much. So another aspect, which is very different from that one in terms of what it tells us about our social structure, has to do with the aspect of how we deploy and organize resources. And I mentioned it in our panel because obviously the ability that we had during the COVID was inspirational in terms of bringing the best of government with investors and companies to help deploy treatments and vaccines.
To develop vaccines, to develop therapeutics approved.
In record time. In record time, that was extraordinary. Extraordinary and my view is let’s learn from this success and let’s try to figure out how we can emulate it.
And do the same thing when it comes to treating substance use.
Substance use and mental illnesses. I think that the issue is, we need to recognize that this is key. And I was in a panel with Janet Woodcock when she was the acting FDA director. And I asked her that question. You’ve been involved both with a COVID pandemic and the substance abuse crisis. What is it that would allow us to do what we did for COVID for substance use disorder? And she said to me, “Nora, one of the big differences is the level of resources that was placed in order to address the COVID pandemic.”
Right. The government threw everything at it. We threw so much money at COVID, and we needed to, but nobody’s throwing that much money at mental health. And nobody’s throwing that much money at substance use disorder.
No, it’s very minimal. And I think that elevating the importance actually of it and realizing of course that obviously is great if you have all of those resources, but even if it’s not that same level of resources to elevate and highlight, this is a priority and facilitate many of the procedures. Because for example, one of the things that enabled the solutions that we had was the FDA was willing to actually accelerate the process of approval. Well, that is something that per se does not require an investment of dollars, per se. So I think that these are the ones. And the third one that I would say that jumps in my brain, is that what we learned from COVID. We had an extraordinary solution with the vaccines, and I was saying, oh, is the solution. We have these incredible vaccines because they look really remarkable.
And so to all of us, it was just shocking that people were not vaccinating themselves. So you can generate evidence and you can put the resources because you didn’t have to pay to get vaccinated and the people were not. And so what does that mean? And it means that we need to build trust in the communities. And so just like there was a lot of distrust and whichever way – it would just get worse when it became politicized. But there is also a lot of distrust when it comes from people suffering from substance use disorder for organizations and for the government. Because to start with, they’ve been criminalized and they’ve been stigmatized and discriminated. So the notion of trusting that the healthcare will be providing for treatment is not going to be automatic. And that’s what we have to learn from COVID. We need to invest into campaigns and support systems and garner people that have a voice in those communities to speak up, to be our partners.
Yeah, you’ve really emphasized the importance of people in recovery, the importance of them speaking out and sharing their stories or families who even tragically have lost somebody from not keeping that a secret and writing an obituary that’s a lie and telling the truth. You actually have your own personal story about stigma around the disease of addiction. Your mother. Tell me that story. Cause it’s powerful.
Yeah, no. And, and it’s a story that I just shared with the panel. And I’ve shared it in the past. And I decided to share it because obviously one of the messages to me is that we need to get rid of stigma. And stigma is promoted by silence, because if you are silenced, nobody cares about this situation. It is like it doesn’t exist. So we need to speak up. But we also have to recognize that we have to respect the other in terms of how much they’re willing to share. And I just told the story of my mother, whose father actually I never met, when I was five or six years of age. And he live in Spain and we live in Mexico and she got a telegram that her father had died. My mother and I – and I tried to, but she closed herself in her room and I couldn’t get to her. And the next morning they told us that he had died from a cardiovascular accident.
They told you he died of a heart attack.
Yeah. And then later on and many, many years later, I was a doctor. I was involved with research on addiction that has been all of my professional career. And a very advocate with a very strong mission of bringing the knowledge that can allow to treat addiction as a medical condition. And that also justifies investment of resources and investment of trained personnel that can help it. And at that, my mother called me. And so I flew from New York to Mexico, where she lived as she was dying of ovarian cancer. And she had called me because she wanted to speak with me. And in that conversation that we had, she told me, you know, there’s something I never told you. And she said, you don’t know that – I’ve never spoken about it – but my father was an alcoholic.
And I also have never spoke about it, but in distress, not being able to stop drinking, he committed suicide. So I have not known that my grandfather had been an alcoholic. I had not known that he had died by suicide. And both of those two things are highly stigmatized. So no one spoke about it. And, and it just shocked me. It made me think, what did it mean that my mother, who I was very close to and who was very close to me, did not feel comfortable to tell me this? I mean, her daughter who’s in this field. So if she didn’t feel comfortable to speak to me about it, it was going to be less likely that she would speak with others. Cause it made me think, what is it that I missed in that communication to allow my mother to entrust, to share this, which was a secret, right? These are secrets and we shared them. And, and I guess, and I’ve done a lot of thinking of how can we get those secrets in a way that it’s open because they shouldn’t be a secret. I mean, in general.
That story, as sad as it is, it’s not uncommon. There are a lot of families who keep secrets. And I was really kind of shocked on the panel when we were talking about stigma that you said stigma exists, even within the medical community. That patients don’t feel most of the time, that they can be honest with their own doctors about what substances they may be misusing.
That’s absolutely correct. And there’s some very tragic stories that patients will tell you. And that’s both for substance use disorder and mental illness. And this gets exacerbated. As I mentioned during the COVID pandemic, when the emergency rooms were basically at full capacity, where doctors were very, very anxious. And when you don’t understand well what a pandemic is or an epidemic, and people are getting infected and dying and you don’t know how you’re going to contract it. And during the makeup personnel, that’s extraordinary stressful. I lived it because I was an intern when HIV went in New York City and many of the interns refused to go see the patients because they did not want to get infected. And we didn’t actually know how to protect those.
Didn’t know in the early days, how it was passed. And the same thing with COVID in the early days of the pandemic in New York City, we still thought you could touch surfaces and catch it.
So you had this very, very stressed healthcare system. And there your tolerance to be basically willing to be more open and accepting of someone that you have grown up thinking, this person is just doing this on his own. This is his fault. It’s his fault that he’s suffering from this addiction. He chose it. He just doesn’t have the discipline to stop taking drugs. That’s a belief because we all more or less look at ourselves through our own experiences, but that is very myopic because…
How often does that happen? Like how often does a doctor believe that it’s a moral failing or lack of self discipline that somebody is misusing a substance?
I don’t know exactly the numbers, but one of the things that always surprises me is how prevalent it still is. And one of the things too, for example, people say, yes, addiction is a disease. This is among healthcare physicians. And, but, and the moment that they say but, then you know that here is where it comes down. But it’s the person chose to take drugs. But the reality is that how you come up to experiment with drugs is not necessarily completely a choice. And you have different context. And also something that people should think – in most instances, people that end up taking drugs regularly have a vulnerability for that path. And that vulnerability can be the genes that lead you to that compulsiveness in addiction. But also another one that leads to that vulnerability is when you have mental distress.
Right. Depression or anxiety. Most people I meet in the rooms of recovery used a substance to get relief from anxiety or depression.
So is that a choice? I think that it is, that’s why I call it myopic. It’s really not a choice. People are desperate in order to feel better. And that starts in adolescence, adolescents that actually just don’t feel right.
But are doctors not taught in medical school? The AMA has been saying for decades that addiction is a mental disease. Aren’t doctors taught about addiction in medical school?
More now than before, but it’s still not universal. And it’s not at the level of training that is necessary for proper performance, but some of the medical schools absolutely have revamped their training of medical students. And also the same thing is important for nurses. And that is another area that needs to be expanded. And so we need to train healthcare providers, not just doctors, about substance use disorders. What are the factors that lead you at risk? How do you recognize it? How do you screen it? How do you basically, what interventions you can do when you have to make a decision to send someone to specialized care. And that also goes with mental illness. Because one of the ways that you recognize, say for example, a teenager at high risk for addiction, is by screening for an underlying mental illness. So if you have a teenager that is complaining of depression, lack of energy, and high levels of anxiety, that is a red sign that you – basically this teenager, if you don’t treat them, may end up taking drugs or alcohol to treat themselves.
And by the way, the reason this needs to be taught in medical school is it’s not just a checklist. Like are you anxious? Yes/No. Okay. Moving on down the list. It’s like the joke when doctors say, how much do you drink? At your annual checkup. And doctors joke that, whatever the patient says double it, because they know that patients will lie to them. In other words, it takes an effort to ask the questions to get at what really might be going on inside that patient, right? Somebody’s just not going to walk in and say, “I’m anxious, depressed, and thinking about killing myself. And I do heroin every night.”
And no, no, no. And in terms of what you see that we can do to bring forward on both sides, right? That doctors themselves, so that they know how to properly screen, but also educate the patients. And so we had a campaign that basically went by the name – “Talk to Your Doctor” – that basically was encouraging patients to speak up if they were drinking more than they were, or they were taking prescription pills to help them fall asleep or for pain that were not prescribed to them, to speak with their doctors. So it is wanting to target both sides of the equation. And, but that does require training of the personnel in the healthcare system and also educational campaigns on patients. Because it also depends very much where you’re coming from. And I think that this came around that also in the panel that teenagers or young people are more willing to discuss their emotional feelings than, for example, older people or certain communities where it is very important that you appear as a strong character, certainly if you’re a male.
And so this could be seen as an indication of weakness. And mental illness by many is seen as an indication of inner weakness. If you suffer from depression, if you’re not strong enough. And we need to change that. And you were asking the question, “well, how do you change culture?” And we can change culture. And we’ve changed it many times. Look at what the HIV has done in terms of how it was discriminated early on, and how organizations of patients and patient advocates lobby and change it. And now, I’ve been in meetings where you have individuals basically saying I am HIV positive. So it was not the stigma or fear. And I think that what was magical tools that helped the HIV movement was having now solutions, therapeutic solutions, that are not a death sentence.
So if you can show, for example, that if you have a combination of antiretroviral therapy, your prediction of basically of survival is as great as if you didn’t have HIV. So you basically changed the course of that illness. So if, obviously, we have that type of an intervention for suicide that was so extraordinary effective in modifying so dramatically, that would help with the stigma. And we do have some very effective medication in mental illness and for opioid use disorder. And to a certain extent, alcohol. The effects size is not so large. Or for smoking. But there are some interventions that do help. And so are antidepressants. They are life-saving in many instances. And we have new treatments like ketamine, and there’s a lot of work and interest in novel modalities. There’s the neuromodulation technologies to stimulate your brain.
Yeah. I’m always amazed that, given the numbers of people suffering from substance use disorders, I’m amazed that some pharmaceutical company hasn’t said, “Hey, this is our moonshot. Let’s figure out – let’s come up with a therapeutic because we could make a ton of money.” I mean, let’s just appeal to their basic instinct of profit. You could make a ton of money because there are a ton of people suffering.
They are. But if you look at that track record, it’s the same thing with pain, right? You sort of as a company, I mean, it’s how many people are suffering from pain? 50 million people. And we want something that is not addictive, that doesn’t produce respiratory depression like opioids. But what has happened is historically the companies had invested a lot of dollars on research and development and it didn’t result in products that went into the market. So they made their analysis and say, where is it that if we invest, we’re going to get a return on investment. And so they closed the development of psychiatric drugs and they closed development for the most part of analgesics for pain because the success history was lower. And in addiction, what happens is stigmatized disease. So the company said – they don’t want to be associated with treating a disorder that is so stigmatized.
So even the pharmaceutical companies are buying into the stigma?
Yeah. Oh absolutely. Absolutely. And the sort of instances where there was a medication that was used, Wellbutrin, which is an antidepressant, that also is effective for the treatment of nicotine addiction. And, but the company, in telling the story, they basically felt that it had hurt them. They changed the name of the drug so that it is not Wellbutrin. So it has a different name. But they say even with changing the name, they actually lost in their business. So they felt that it had negatively impacted them.
So there is a lot of prejudice against going for drugs of addiction. And that is, I hope, sort of changing with the opioid crisis, because it’s become evident that this was an area that is badly, badly needed. And if you recall, it emerged on people sort of becoming passively addicted to a drug because a physician prescribed them. So they were the victim of improper practices. So that led to a different distinction. So they now took categories of people that were addicted. And this is creating a stigma. Those that went in because they were the victims of improper prescription practices. And then the others that went through the group that had been totally stigmatized. And trust me, I hear that. But those are different.
Yeah. Dr. Nora Volkow, thank you so much. Your work as director of the National Institute on Drug Abuse is so incredibly important. And there’s something you said on the panel and others spoke about – if someone comes forward and says, “I’m suffering, I need help,” that took so much courage for that person to do that. And that problem they’re suffering with, it is already enormous. So have compassion if someone comes to you. And good luck.
No, thanks a lot.
You’re going to need it. It’s a huge problem.
But very important. If someone comes to you, don’t ever, ever ignore it. That’s what I would say, but thanks very much for your interest and inviting me to this podcast.
Thank you. Thank you.
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