Horizon Treatment Services

Hope Amid Crisis: Making Sense of Declining Overdose Rates Ep 06

• Horizon Treatment Services • Season 1 • Episode 7

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For the first time in 25 years of America's opioid crisis, we're witnessing a significant decline in overdose deaths. Dr. Andrew Kolodny, Medical Director at the Opioid Policy Research Collaborative at Brandeis University, joins us to unpack this promising trend while emphasizing that the numbers remain unacceptably high.

The conversation reveals shocking new statistics: approximately 10 million Americans currently suffer from opioid use disorder—roughly 5% of all adults—a dramatic increase from previous federal estimates of just 2 million. Despite reduced death rates, Dr. Kolodny stresses we're still failing those who need help most.

We dive deep into the settlement money flowing from pharmaceutical companies to states and localities, exploring the concerning lack of guardrails protecting these funds from being diverted away from addiction services. Without proper oversight, history may repeat itself as we saw with tobacco settlement funds that often went to unrelated expenses rather than addressing the health crisis.

Dr. Kolodny outlines what real progress would look like: dramatically improved access to outpatient treatment with medications like buprenorphine, available on demand regardless of ability to pay. He shares several compelling theories behind the declining death rates—from improved treatment access to changes in the drug supply itself—while emphasizing how crucial it is to understand which interventions are actually working.

This eye-opening discussion challenges conventional wisdom about border security, fentanyl trafficking, and addiction treatment while offering a roadmap for continuing positive trends. If you're concerned about America's opioid crisis or work in healthcare, addiction services, or policy, this episode provides essential context for understanding where we stand and what must happen next.

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Speaker 1:

Horizon Treatment Services, inspiring hope and healing since 1976.

Speaker 2:

Dr Andrew Kolodny is one of the nation's leading experts on the prescription opioid and heroin crisis. He's co-director at the Opioid Policy Research Collaborative at the Heller School of Social Policy and Management at Brandeis University. He received his medical degree from Lewis Katz School of Medicine at Temple University and he's been in practice more than 20 years. Andrew, thank you so much for being here. I know we had a wonderful talk last year, probably close to the same time, and we've got that first talk on our website. With all of the news about the decline in overdose deaths from the opiate situation, I wanted to call and see what are your thoughts on this. Is this reason to be relieved?

Speaker 1:

I would say that the data is showing pretty significant decline in overdose deaths, particularly involving fentanyl, over the past year. Month after month, we're seeing a drop. I think that that's something to be hopeful about. It's a very promising trend. Of course, there's nothing to celebrate, because the number of deaths is still extremely high. It's unusual because for the past 20, 25 years, pretty much every year, overdose deaths went up. Every year, we would hit a record for the number of Americans dying from a drug overdose, and then the next year we would break that record again, and we saw that happening every year. In 2018, there was a bit of a plateau and there were some who were hopeful maybe finally we'll turn the corner, but we didn't, and then back in 2019, it continued to go up significantly. This is the first real decline that we're seeing since the beginning of the crisis, so it is certainly reason to be hopeful and has many people asking the question hey, what's going on? Why are deaths coming down? Many people asking the question hey, what's going on? Why are deaths?

Speaker 2:

coming down Well. I like to hear that it's reason to be hopeful, but I also saw, as you said, that the numbers are still egregious and we don't want to, you know, rest on our laurels with this whole thing settlement dollars and how that has been distributed and is being distributed across the country California's high impact abatement activities in particular. We're seeing a lot of money distributed. What do you think about the way that this money is being utilized? What are the guardrails?

Speaker 1:

We don't have many guardrails. Some states have passed legislation to try and tech this money because of concerns that, like we saw with money that came from tobacco settlements, that much of it was not protected. Here there's a concern that we want to get it right this time we want to make sure that this money is used to address the opioid crisis. So we are seeing in some states efforts to claw back the money, and what I mean by that is, in some states the state legislature is saying, hey, we get to appropriate. So the attorney generals are the ones who filed these lawsuits.

Speaker 1:

The attorney generals settled with the defendants and brought the money into the state, and the attorney generals often have in their plans that the money should be used for addressing the opioid crisis. But attorney generals don't appropriate. State legislatures appropriate. State legislatures spend. And in some states the legislatures are saying, hey, you may have brought that money in, but we get to decide how money gets spent. And there are many who are concerned, myself included, that some states might not use this money to address the opioid crisis. They might use this money to fill potholes or lower taxes or do something else with it other than address the opioid crisis.

Speaker 2:

Well and that's interesting because I think that is a great concern and I've heard a lot of conversation about that there are, like I said, areas that it's really encouraged to be spent. We've got creating new or expanded substance use disorder treatment infrastructure, which would be a wonderful thing to see. I think we are seeing some programs popping up or revitalizing their services, expanding their services In terms of accountability to the money being spent in a fruitful way. Are you familiar with the tracker the global settlement tracker that was developed? Are you familiar with the tracker the global settlement tracker that was developed? Are you familiar with this?

Speaker 1:

Yes, I am.

Speaker 2:

What do you think about that? How effective is that?

Speaker 1:

I think it's certainly helpful to be watching. I think it may make it harder for the money to be misspent if there is national attention on how these funds are used, if there are journalists covering this, and so, yeah, I think the website the Global Settlement Tracker, I think is very helpful. The more attention, the better. I do think that, even though in some states where the money may be protected, there are still difficulties with spending the funds, and figuring out how to use these funds is a bit haphazard. Instead of, for example, a centralized state effort to make sure that the funds are used appropriately, it's been decentralized so that you have counties, or at least a significant portion of the funds are decentralized, so that you have county task forces and counties that are also involved in how to spend the funds.

Speaker 1:

And it worries me because I think that the way to address a complex public health crisis is with a coordinated strategy. It's something that's been lacking from the federal government from the beginning of this crisis. The federal government really wasn't doing its share, and so states and counties were left struggling, and I do worry that we're in a situation where you've got county task forces who are trying to figure out how to use these funds. Of course they're well intended, but they don't always have the expertise on how to best use these monies, and what we don't want to see is more money for more of the same, and so in states that have drug and alcohol treatment providers that may already be operating particular programs, you don't necessarily want to just give them more money to do more of the same If the same hasn't really been working. What I really think is necessary is building out a system that doesn't really exist yet.

Speaker 2:

Yeah, well, I would agree with that. I think that it needs to be really thoughtful and, as you said, a coordinated effort at a grand scale. For those who aren't familiar with Dr Kolodny and I were just talking about in terms of the Global Settlement Tracker, this is something that was owned and operated by Christine Minhee. That is, bringing attention to the ways that different folks are spending this money and trying to create some public awareness so that there is a level of accountability where it hasn't been necessarily federally imposed or locally imposed. So you just mentioned, dr Kolodny, that you think that you would like to build it out in a certain way. What would that look like, that you would like to?

Speaker 1:

build it out in a certain way. What would that look like? What I think really needs to happen for overdose deaths to come down more significantly and of course, we can talk a little bit more about why deaths have started to come down but one of the things that I think would have the most significant impact on reducing overdose deaths would be to improve access, dramatically improve access to outpatient treatment with medication. In particular, I think buprenorphine is first line, and what I think really has to happen that hasn't happened yet is that it has to be much easier for someone who has opioid use disorder to access effective treatment. Again, in many cases with medication like buprenorphine, that has to be easier for them to access than it is for them to buy fentanyl Absolutely. And until we get there, I think deaths are going to remain at very high levels.

Speaker 1:

We know and we talked about this last time when someone wakes up who's opioid addicted, they're already in withdrawal, particularly when the dominant opioid is fentanyl, which is so short-acting. And if someone's going to be really sick soon, unless they use and they know where they can inexpensively buy fentanyl, but it's expensive and complicated and difficult to access treatment, people will just keep using providers, even the ones that take lots of insurance or have a sliding scale for self-pay, or people who are uninsured. Often there's an intake process. They have to be financially cleared. There's a psychosocial that may have to be done. The people aren't able to just walk right in off the street and say, hey, I need to get on buprenorphine, I'm going to be really sick soon. Instead, we make them jump through too many hurdles and basically we need treatment on demand available regardless of somebody's ability to pay for it, like we do with HIV and Ryan White funding streams that make that possible. We're not there yet for the opioid crisis, even though we're 25 years into this epidemic. That's what I really think needs to happen.

Speaker 2:

Well and I think that we've seen glimpses of that working right.

Speaker 2:

For instance, we at Horizon Services are in the process of implementing MAT services at our detox and residential primarily detox, I think centers, and so that's been quite a process and I think that's being recognized more in different areas.

Speaker 2:

I know jails are beginning to start making treatment available prior to people leaving or else upon leaving, because, as we know, folks who are leaving jail, if you're arrested and you're brought in and you've got a heroin problem or opiate problem and you come in and then the guys when I used to work in the jail would call it a tolerance break. You know their time inside was a tolerance break which just meant that you know they were going to get good and high when they got out and used again and high when they got out and used again. Unfortunately, before we were offering medication to get folks safely off of these drugs, folks are relapsing, you know relapsing upon release because they go back to how much they were using. How much does treatment in the jails and mat services at detox facilities, how much is that going to help and how much are you seeing that actually being implemented across the?

Speaker 1:

country it is happening.

Speaker 1:

I haven't seen good data where we're measuring improvements there, but we are seeing improvements and it's extremely important.

Speaker 1:

We know that one of the biggest risk factors if not the biggest risk factor for an opioid overdose death is for someone to have been recently discharged from jail prison deep.

Speaker 1:

That's one of the highest yeah, yes, it's one of the biggest risk factors for an overdose, and so the more that you can ensure that people aren't walking out of jail without medication on board or detox facilities that really do inductions and send people out stable on medication instead of think, the more we'll see reductions in deaths, and there are many right now interested in trying to better understand why deaths are coming down nationally. For the past year, every month, we're seeing a decline in deaths in most states. In Seattle and in Washington and Oregon and Seattle and Portland, we haven't really seen the same drops that we've seen in many other parts of the country, but for those who are trying to better understand this, one of the theories is that we're seeing a decline in deaths because of improvements in access to treatment. I don't know if that's really the best explanation, but it may be. There are other explanations that may better explain the trends, but it's certainly it's one of the reasons we might be seeing a decline in deaths.

Speaker 2:

You know, I've seen some theories that I found I don't know if offensive is the word, I was surprised by them being in print one of which was a suggestion that you know it may be declining because those who are susceptible to overdose have already passed away, and I think that just really speaks to the lack of understanding of how this all works.

Speaker 1:

you, know, and actually I mean, I think that that is not. That is, you know. Nobody knows why deaths have come down significantly. So anyone who tells you they think it's A or B or C is just speculating. But it's not unreasonable to speculate that because fentanyl killed so many people with the disease of opioid addiction, there's so many people with opioid use disorder that have died that the pool has shrunk, the pool of people who can continue to die from opioid overdoses. And so I would agree with you. It's a very disturbing, disturbing explanation. But if the people with severe OUD, if 80% of them, died off because of fentanyl I doubt it's that high, but it wouldn't be that high because we now actually have better prevalence figures for a reduced disorder but still, if a significant number of people with OUD die from their disease, that could help explain why deaths have come down. I don't really think that's the main answer. And there are still people becoming newly addicted to opioids, not at the same rate as they would have been 10 years ago.

Speaker 2:

Right yeah, and you know I have to concede that, hearing you talk about it just now, I think I see that statement differently. I think I understand better what was meant by that. So let me just ask more than that was just. You know, people can't get addicted to opiates anymore because everybody who did died, which sounded a little lackadaisical to me. I guess there is merit in the idea that what caused the problem in the first place was people being, you know, overly prescribed or you know having access to these drugs and becoming addicted. And then fentanyl, just cutting that off. Cutting off certainly does explain, I guess, how quickly the lives of those extraordinary numbers of people who became addicted could have ended abruptly with the surge of fentanyl.

Speaker 1:

Yes, yes.

Speaker 2:

So I can see that differently Now. Thank you for sort of mapping that out.

Speaker 1:

Sure, sure. You know the number of people who develop a disease in a year. That's called the incidence of a disease, or the incidence rate, and the number of people in a population who have a disease is the prevalence. So, for example, if we were talking about HIV the number of people who became newly infected with HIV in a given year you would call that the incidence with HIV in a given year. You would call that the incidence. And if you were to talk about how many Americans have HIV, that would be the prevalence For HIV. We actually have good incidence estimates and good prevalence estimates. I can't tell you what they are, but for the people who work on HIV, they can tell you X number of Americans contracted HIV in 2024. It's an estimate, but it'd be a pretty good estimate and they could also tell you how many thousands of Americans currently have HIV. Those numbers are available For opioid use disorder. We don't have those numbers.

Speaker 1:

Again, we're 25 years into this epidemic and when it comes to surveillance, public health surveillance of this problem, we're still not up to speed. What we can do is estimate a bit and because we know that the vast majority of people who became addicted to opioids over the past 25 years. Their addiction developed from prescription opioids, not heroin. It's fair to say that, as the prescribing was exploding, the number of people getting newly addicted to opioids every year was going up and up and up, and it's also fair to say that, now that opioid prescribing has been trending in a more cautious direction, the number of people getting newly addicted is declining. The incidence rate is going down. That said, we are still overprescribing, which means that every year there are still many Americans becoming newly addicted. Now, fentanyl killed so many people with opioid addiction that it may have actually been killing people faster than we were seeing develop opioid addiction. But again, we don't have good surveillance, so we can't really answer these questions.

Speaker 1:

We do have better estimates than we've ever had before, and this is something that's new. Since the last time we spoke. The federal government a few months ago issued a new estimate for how many Americans have opioid use disorder, a new prevalence estimate. The previous estimate had been about 2 million, which made no sense really. People who studied the opioid crisis knew that many more than 2 million Americans have opioid use disorder. But had you interviewed, say, nora Volkow, the head of NIDA, a few years ago, and if you had asked her how many Americans have opioid use disorder, she probably would have said 2 million, 2.1 million. And if you said where'd you get that number, she'd say it's from the National Survey on Drug Use and Health and that's our federal estimate. Well, the new federal estimate is that there are about 10 million Americans with opioid use disorder, not 2 million. That's a much better estimate than we've ever had before. And there are other estimates that suggest that it's about 5% of adults in the United States that are suffering from opioid use disorder.

Speaker 2:

Tell me that number again.

Speaker 1:

About 5% of adults in the US, wow, appear to be suffering from opioid use disorder, which is a huge, a huge number.

Speaker 2:

And that's with all of the awareness and all of the attention and all of the naloxone distribution and all of the MAT services coming up and with all of the stigma about buprenorphine. How do you say it for me?

Speaker 1:

Buprenorphine.

Speaker 2:

That one, with all of that at the surface and people actually talking about it, and we're still at a 5%.

Speaker 1:

Well, the number's not going to. Once people get opioid addicted, it generally doesn't go away. I do think that all of the attention on the opioid crisis, along with the more cautious prescribing, is reducing the number of people who get addicted every year. So I can easily say that the number of Americans who developed opioid addiction who were added to this pool in 2012, was greater than the number of people who became newly addicted in, say, 2024. We don't have those numbers, but it's fair to say that when America was flooded with prescription opioids, more Americans were getting addicted to opioids. In 2024, it's still going to be a large number and much larger than in other countries where opioids are prescribed more cautiously.

Speaker 2:

So I've heard recently about rainbow fentanyl. What is this? Is this different than? How is this different and is it more? I mean, how do you find a drug that's more fatal than fentanyl, right?

Speaker 1:

Yeah, it's not more fatal. The cartels have been packaging it differently in pill form. They've been doing that for a while in counterfeit pills. One of the more popular products is fentanyl pressed to look like an M30, an oxycodone 30 milligram pill with an M on it from Malincroft, the company that manufactures them in different colors, and this got some media attention because there's concern that the different colors are meant to target children More appealing to the youth.

Speaker 1:

That's really true or not that the goal there is to target children? It may just be a way of differentiating your product. There is an interesting question though that's related to this, because, again, this question of why deaths are coming down, and we've now talked about two of the theories, one of the theories being that more people are accessing effective treatment, which is why deaths are going down. For example, more people are accessing buprenorphine. We talked about another theory, which is that so many people with severe opioid use disorder have died from fentanyl that the pool has shrunk for people who can continue to die. That people have been using has become less potent, and there's a question of whether the cartels or the folks packaging up the fentanyl are doing it better than they were before so that they're killing fewer of their customers.

Speaker 1:

But there is some evidence that the samples of drugs available on the street, when they're tested, the amount of fentanyl in them is lower than it was previously, so the pills are less lethal. So one theory is that drug dealers are getting better at pressing these pills and packaging them so that they kill fewer customers. A related theory is that the effort to crack down on precursor chemicals that are used to make fentanyl has been effective and that the cartels are having a harder time manufacturing fentanyl because it's harder for them to get the precursor chemicals, so that they're using fentanyl more sparingly. That's another theory. Or that fentanyl is getting more expensive. Decades of drug policy research teaches us that during periods of time when the price for a drug on the street is high and when the purity or potency is low, fewer users die.

Speaker 2:

Right that makes sense.

Speaker 1:

So it could be that the price has gone up and the potency has gone down, but again, this is still speculation, all speculation.

Speaker 2:

And.

Speaker 1:

I haven't seen good data on price, only some data that suggests that the potency has gone down.

Speaker 2:

Well, thank you for that, and you just said something that I just want to make sure our audience understands. Would you please just explain briefly what you mean by the precursor? Chemicals are a little harder for folks to get.

Speaker 1:

Sure, sure. So not that long ago the dominant opioid on the black market was heroin. And heroin is expensive to produce because to make heroin you have to grow opium poppies, which takes a lot of land and resources and it's labor-intensive. And then you have to extract opium from the poppies, which is also very labor intensive. You have to. It's generally the way that that's done is to extract the opium from each individual puppy head Flowers, lance the opium oozes out and then you scrape it off of the puppy head and you have opium. And then you have to turn that opium into heroin. Heroin is a semi-synthetic opioid, so it's a chemical process where you turn the morphine molecule that's in the opium into a heroin molecule. And then you know heroin is not a very bulky drug, but it's 50 times bulkier than fentanyl. So fentanyl is 50 times stronger than heroin. So you then have a bulkier product to try and smuggle across a border.

Speaker 2:

Oh, wow.

Speaker 1:

Fentanyl, on the other hand, has been very easy and inexpensive to manufacture. You don't have to grow opium poppies. The way that the cartels were making fentanyl was to get precursor chemicals from China and they, you know, bought their chemists the recipe and you could produce with China, so that the cartels in Mexico would have more difficulty accessing the precursor chemicals. And my understanding is that the Chinese government was cooperative in that regard, and so if the cartels can't access the precursor chemicals or if they've become more expensive, that makes it harder for them to produce.

Speaker 2:

I see Boy people have to be really committed to this whole process and all of the dangers. What do you think is going to be the impact of fentanyl in the country when the borders are less porous?

Speaker 1:

if you will. My understanding is that the bulk of the fentanyl that comes into the United States comes across. It comes through at border crossings. It's not, you know, people carrying it on their person sneaking across a porous border. It's coming on trucks at border crossings. So I don't know that making the border less porous will help in that regard, but maybe other efforts will help keep it from coming across the border.

Speaker 1:

I do think there are some who would completely disagree with me that interdiction efforts, supply control efforts, efforts to try and keep fentanyl out of the country are worthwhile. They would say it's completely not worthwhile and the answer to the whole problem is to legalize heroin, legalize fentanyl, legalize cocaine and methamphetamine and that's the answer. I think they're wrong and they're very wrong. I think the lesson of the opioid crisis is that when America was flooded with an oversupply of legal prescription opioids, millions, supply control, which means you're for the war on drugs and you're for law enforcement or you're for demand reduction, which demand reduction through prevention and treatment of opioid addiction and interdiction efforts can be. Even though you can't keep fentanyl out 100%, the more effective the interdiction efforts are, the more you can see that the price is higher on the street or the potency is lower, and that can reduce the number of people with addiction who die.

Speaker 2:

Yeah, and you just said too that it could come from different ways the stopping the supply, the stopping the demand but we spoke briefly too. We don't need to go into this. Folks can listen to our first talk if they want to hear more about this. But just the various components of stopping this thing right the prevention efforts, the outreach efforts, the education efforts, the increased amount of outpatient services, math services, all of these different things there's so many pieces to this puzzle. I just was really looking forward to hearing from you and seeing what you thought about all of this, and I appreciate the time that you've taken to talk with us today. Is there anything that you would say, beyond what you've already said, in regards to how we might keep it from another uptick and how we might continue the downward, the decline?

Speaker 1:

It's a great question and it really speaks to how important it is for us to understand why the deaths are coming down, and I mentioned different theories.

Speaker 2:

But we just don't know.

Speaker 1:

We need to find the answer to that question, and it is an answerable question. If one puts together the data, interviews, the people on the front line of the problem, it is possible to better understand why the deaths are going down so significantly. And we need to know the answer to this because if we're doing something right that explains why the deaths are coming down, we need to do a lot more of it.

Speaker 2:

Right.

Speaker 1:

But right now it's just a lot of guessing and nobody really knows, which is unfortunate.

Speaker 2:

Yeah, it is, but I love your theory. I love the final theory. If we're doing something right, we need to do a whole lot more of it right, nice and simple. Keep it simple. Well, thank you again for all the work that you've done advocating for this, and thank you so much for your time today. It was really nice to see you again. Maybe it'll go down so much in the next two years and I'll call you again.

Speaker 1:

Sounds good. Let's hope that happens.

Speaker 2:

I hope so Thank you. Dr Kaladni.

Speaker 1:

Thanks Jen happens?

Speaker 2:

I hope so. Thank you, dr Kaladni. Thanks, jen. All right, bye-bye. Please visit our website to learn more and to connect with us on social media.

Speaker 1:

Our website is wwwhorizonservicesorg horizon treatment services inspiring hope and healing since 1976.