Elected on a law-and-order platform, Richard Nixon launched the War on Drugs with a June 1971 press conference in which he declared drug abuse on the streets of American cities to be “public enemy number one.” Or so the conventional narrative goes. But drug historian Emily Dufton says that the true story is much more complicated, and interesting.
In fact, Dufton writes in her fascinating new book, Addiction Inc.: Medication-Assisted Treatment and America’s Forgotten War on Drugs, between 1971 and 1973 the Nixon administration presided over a massive expansion of publicly funded methadone clinics and other treatment services that began to deliver real results in addressing the country’s burgeoning heroin addiction crisis, before largely abandoning the effort in the face of political backlash and public misunderstanding. And that was just the first of many systemic failures in a maddening, decades-long history of missed opportunities and failed approaches to dealing with the opioid addiction problem that plagues blue cities, which Dufton lays out in her book.
So we invited Emily to join us to talk about the history of what has gone wrong with our efforts to treat opioid addiction. That initial, promising early ’70s effort to build an expansive treatment system of methadone clinics was fully defunded once Ronald Reagan took office in 1981. After that, she tells us, the clinic system was largely privatized, and efforts to effectively and comprehensively help people with addiction became secondary to the profit motives of drug manufacturers and clinic operators. This was, she says, the rise of what she terms Addiction Inc., and she points out that today only about one in five Americans with addiction receives medication-assisted treatment (via one of the three approved drugs: methadone, buprenorphine, or naltrexone), which is the gold standard for treating opioid addiction.
As the conversation continues, it turns personal, as Sandeep explains both his deep reluctance to treat his own spiraling addiction in the ’90s with methadone and how, once he overcame the stigma, “methadone saved my life.” And Dufton tells the story of Dana, a close high school friend whose debilitating opioid addiction led to his suicide shortly after his 30th birthday, a tragedy that inspired her to spend eight years researching and writing the book.
As the episode concludes, we come to the disheartening conclusion that the American debate on addiction is trapped between two poles: either punishment without treatment or, as is too often the case in blue cities, tolerance without intervention. Emily then points to the counterexample of Switzerland, which in the 1980s faced an addiction crisis similar to that in the U.S., but subsequently developed an effective, multipronged approach that combines law enforcement with robust treatment interventions to greatly reduce the suffering and social harm addiction creates.
“Other countries don’t have the same issues with medication-assisted treatment that the United States does, and of course their overdose deaths are significantly lower,” Dufton says. “We should be almost embarrassed in the United States about how poorly we treat this issue. But I think we’re just too angry at drug users and simply too ready to transform their forms of treatment into additional forms of punishment to actually change our way of thinking.”
OUTSIDE SOURCES:
Emily Dufton, Addiction Inc.: Medication-Assisted Treatment and America’s Forgotten War on Drugs, University of Chicago Press (2026).
Please send your feedback, guest and show ideas to bluecitypodcast@gmail.com
[00:00:10] Hello and welcome to the latest edition of Blue City Blues, a podcast featuring smart guests talking about the problems facing blue cities and how to fix them. I'm David Hyde with Sandeep Kaushik. Hello, Sandeep. Hey, hey, David. How are you? I'm good. And I wanted to start out by thanking our listeners for helping support this podcast, helping us make the jump to video. You can find us on youtube.com slash at Blue City Blues. So, Sandeep, it has to have that at for some reason in there. It's a little bit complicated at YouTube.
[00:00:40] I'm not sure why. They're sort of following Twitter, maybe. I'm not sure why it has the app. I feel like our listeners can muster the intellectual heft to figure out the app. To get the app. Yeah, slash at Blue City Blues. All right. If you want to help make this podcast grow and continue and get special members only perks, we don't really have any of those yet, but we will have special members only perks. Just go to Patreon.com. There's a theory of perks. There's a theory of perks. Go to Patreon.com slash Blue City Blues. That's Patreon.com slash.
[00:01:10] Blue City Blues. And help out at any level that's right for you. There you go. That's very NPR of you, David. You're reprising your 20 years in public radio. I wanted you to, I thought you might also mention an upcoming event. Yeah, I do want to mention an upcoming event. We're pretty excited at the end of September on the 29th of September to be exact. And if you're a Seattle listener, please do come out and join us because we're doing a live event.
[00:01:40] It's keying off an episode we did recently with Jonathan Weber, a very prominent San Francisco journalist who has a new book out called City on the Edge, which is about how tech, the tech industry completely transformed San Francisco over the last couple of decades. And we're doing a live event with Jonathan, but also with University of Washington's Margaret O'Meara, who's written the definitive history of Silicon Valley.
[00:02:04] And with John Cook from GeekWire, the publication here, to talk about Seattle and San Francisco and how tech has transformed the two cities and what the similarities and differences are. It should be a super fun, interesting conversation that will turn into a live episode. It's going to be at the Nordic Heritage Museum in Seattle on September 9th. I don't know, David, our tickets aren't quite available yet or about to be available.
[00:02:31] I think they should be out by the time this episode comes out or shortly thereafter. And it's a beautiful space at the Nordic Heritage Museum. And one last thing as we get going here. Yesterday, the Seattle Rotary invited us to talk about the podcast. And one of the things that you brought up, Sandeep, was they asked us something like, what have you learned on this podcast after 60-some episodes about blue cities and the problems they're facing and how to fix them? One thing that you mentioned was... The short answer is nothing.
[00:03:04] But one of the things you mentioned was all the episodes we've done on, like, the fentanyl crisis, the war on drugs, the history of U.S. drug policy. So check out those interviews if you hadn't had a chance to hear them yet with Keith Humphries, MacArthur Genius, Lisa Dugard. We also had Andrew Constantino was one that we didn't mention yesterday, Sandeep, a guy who walked the streets of Little Saigon with us. Yeah, an outreach worker here in Seattle.
[00:03:30] Yeah, and then most recently, Michael Powell of The Atlantic on the cities that said yes to drugs. And we've got a great person to continue that conversation about drugs today. Emily Dufton is a historian and the author of articles and books including Grassroots, The Rise and Fall of... Oh, sorry, The Rise and Fall and Rise of Marijuana in America. She's also got a sub stack called Drugs and Apple Pie. And her latest book is called Addiction, Inc. Emily Dufton, thanks so much for joining us.
[00:04:00] Thank you so much for having me. And sorry for my complicated subtitles. Yeah, The Rise and Fall and Rise is a good subtitle. So just to start out with a kind of big question that you explore in your book. Here in the United States, you talk about the fact that only about... I don't know if it's one in five or one in four Americans roughly who are struggling with fentanyl or other kinds of opiate addictions ever get medication-assisted treatment.
[00:04:27] Even though we basically know that that's something that can really help. It can really work for some people. And there are a lot of possible reasons for that, some of which we've talked about on this podcast. But in your book, you explore how the history of addiction here in the United States kind of got us to this point of ineffectiveness. And I wanted to start out with Richard Nixon because this is a really provocative point that you make in the book.
[00:04:53] This is a president who we think of, we remember if we remember Richard Nixon as one of the things he's known for is having launched the kind of ineffective, punitive war on drugs. And you say that that's not entirely right. I say that that's actually wrong. So in the complicated subtitle of my new book, it's called Addiction, Inc., Medication-Assisted Treatment and America's Forgotten War on Drugs.
[00:05:19] And it's precisely this war that you're talking about that I argue is actually one of the most effective responses to drug use in the United States ever launched, especially in federal history. And we've completely thrown it down the memory hole over the past 55 years.
[00:05:33] And so it was my task at hand, I guess, to spend the past eight years researching and writing the history of medication-assisted treatment, which is the use of one of three FDA-approved drugs, either methadone, buprenorphine or naltrexone, to treat opioid use disorder, which is the most current name for opioid addiction.
[00:05:52] And you're right. It begins on June 17th, 1971, when President Richard Nixon, law-considered a law-and-order president, launched a brand-new arm in the war on drugs, which actually opened and funded hundreds of federally subsidized nationalized addiction treatment clinics nationwide from about 1971 to 1973. Yeah. And so it's fascinating right here.
[00:06:19] This is you're providing a kind of fascinating revisionist account, right, of Nixon and his administration's sort of approach to drug use. We think of them as a law-and-order Republican administration. And there was certainly a lot of that, right? And when he comes into power in 1969, there is definitely a lot of law-and-order stuff that they pursue related to trying to increase penalties and arrest their way out of the problem, basically.
[00:06:47] But this other aspect of what they did, right, starting in 1971, where they set up all of these basically methadone clinics, you know, that they fund around the country, is really, really fascinating. And I suppose the question you have is why would this law-and-order Republican president do something like that? And so there's a question of the context of what was going on at the time, right?
[00:07:11] There's an explosion of heroin addiction in the United States in the late 1960s and early 70s. A lot of it is driven by GIs and the Vietnam War. They're going over to Southeast Asia where heroin is readily available and cheap, and many of them are coming back addicted. And then there's, you know, also an increasing supply coming from Europe and other places, right, the French Connection stuff.
[00:07:39] So talk a little bit about that, that environment in which Nixon and his administration somewhat surprisingly decide to go down what we might call this liberal pathway of opening up a bunch of, like, treatment clinics. I know. Surprise! Richard Nixon launched, you know, funded hundreds of treatment clinics. I do feel really lucky that I'm, like, hitting this at a moment of Nixon maxing, right? Like, who knew that this was going to come around?
[00:08:08] So it's a beautiful form of historical kismet. I've gotten in touch with the Nixon Foundation repeatedly, and I'm like, I've got this book that kind of resurrects his reputation, but they have no interest. They're just selling merch on their Instagram channel. But I would love to talk if they're open. But you're right. Like, the context is so crucial here, right? Because, as you said, which is very true, when Nixon was elected in 1968, he ran explicitly on a law and order platform. That was probably the most important thing to his very, very meek success, right?
[00:08:37] He kind of slips into the presidency at the election of 1968 by, like, the slimmest margin. But, of course, in 1968, the country very much was also on fire. So it was not unreasonable for a president to run on a law and order platform because this was after the long, hot summer of 1967 when there were hundreds of racial uprisings. This is after the racial uprisings after Martin Luther King's assassination in April. I mean, this, you know, Washington, D.C. was kind of laying in tatters and still smoking from the numerous fires.
[00:09:06] So it's not unreasonable for this to happen. But once Nixon does come into office, he decides to treat Washington, D.C., which is this sort of unique territory within the U.S., because at that point, it's the only 68 square miles that are completely under federal control. So the president really kind of can do whatever he wants. And he chooses to use D.C. as what he calls a national laboratory for new experiments in crime control because crime was skyrocketing in the city in the late 1960s. Like, it was pretty intense. So he hires a thousand new cops.
[00:09:36] He installs new streetlights. He starts pushing people through the court system more quickly. He hires more judges. And, of course, there's a lot more bodies filling the city's small number of jails and the prison. But it doesn't work, right? Crime continues to escalate through 1969 and 1970. But things really transform in the spring of 1971 when these two congressmen are sent abroad on a global trip to see what's going on with the global heroin trade.
[00:10:04] And they realize that there is indeed a global heroin market where, like, the poppies that are grown in the Middle East are sent to Marseille to be turned into heroin's fluffy white powder. And then that drug is trafficked to the United States in, like, ski poles and, you know, underneath car seats and stuff. Like, we've seen the movie with Gene Hackman. Yeah, Popeye Doyle's out there, like, fighting the good fight, right? The French Connection. Go watch it.
[00:10:31] But by the time it reaches the U.S., it's heavily adulterated. It's not very pure. It's, like, between 4% and 6% pure. And, of course, it's very heavily expensive. And yet, nonetheless, its use is growing. And the problems in the United States are increasing as more people are using. And crime is escalating. And people see a correlation to that. But then over abroad in Vietnam, where these congressmen also travel, they realize that the heroin problem is even more pronounced among the enlisted soldiers in the U.S. Army.
[00:11:00] Because there, within the Golden Triangle itself, the poppies can be grown. They can be transported. They can be transformed into heroin. And they can be shipped directly to Saigon or out in the bush, wherever these soldiers are, and sold to them. It's, like, 97% pure. And it's really cheap. And these guys are facing death every day. So, like, what else are you going to do, right? So, heroin use starts to escalate. And by the spring of 1971, there are fears that between 15% and 30% of enlisted soldiers are using heroin and or addicted to it.
[00:11:30] And 1,000 of those soldiers are being shipped home every day because they've come to the end of their deployment. So, many of them are coming back with their addictions intact. And essentially, it released a media firestorm where there were, like, dozens and then hundreds of stories warning of the impending doom from Southeast Asia when these addicted, quote-unquote, GI junkies were going to come back, go into withdrawal, and, like, shoot up your Sunday picnic, right? Like, everyone was – the stories were horrifying. We were all going to die.
[00:12:00] And that's what prompts a transformation among the Nixon administration where they're, like, oh, my gosh, heroin and crime are skyrocketing here in the U.S. And we have a whole lot of addicted soldiers bound home from Southeast Asia. We've got to do something fast. And specifically because it was veterans who – like, arresting veterans is kind of bad optics, especially when the Vietnam War is going poorly anyway. They had to do something different.
[00:12:24] And so they pivoted to treatment primarily because of the recommendations of a psychiatrist from Chicago who would go on to actually become the director of the office that the Nixon administration establishes to direct this federalized treatment program's sort of organization. And his name was Dr. Jerome Jaffe. Let's hear more about kind of the origins of this treatment. But I was just kind of thinking when you were talking about how – just what a different time it was.
[00:12:50] I mean, you mentioned Nixon maxing today and modern conservatism. I mean, conservatives back then actually believed in the positive power of government in some ways, right? Nixon launches the EPA. So they're not just, you know, seeing government as the problem and the enemy. And that's in some ways a big part of your story because that eventually ends up changing. But I wanted to kind of have you give us a little bit more of the history of where these new technologies, these new techniques kind of developed and emerged kind of leading up to this point.
[00:13:21] The medically assisted, yeah, treatments. I mean, up to – so what's interesting about all of this sort of erupting in 1971 is that you're right. There's these new technologies that are forming. Well, there's one specific new technology that's coming on board at that time as well. Up to this point, opiate addiction had been a problem in the United States for, you know, going on over – well over 100 years, right?
[00:13:44] From sort of like the post-Civil War introduction of the hypodermic needle, which really spread morphine addiction kind of quite nationwide with the easy accessibility of morphine and other opiates. There were no laws against them, right? And then the introduction of Bayer's heroin in 1898. So like we had had a long experience with opiate access and rising rates of opioid dependence at the turn of the century.
[00:14:06] But it kind of chills out as the United States goes into what's called the classic era of narcotic control when drugs were met with one response, and that was law enforcement. And like by the 1950s, if you were caught with heroin, you would be incarcerated for an incredibly long time. I mean, there was discussion of like the death sentence, mandatory life sentences, things like that. There was – you know, people were very opposed. And it was also considered to be a lifelong affliction. Like you would never get rid of it. This monkey's on your back forever. Good luck.
[00:14:34] But of course the only response was abstinence, right? You would be detoxed and then you would be expected to, you know, ultimately never use opiates again. That was the response for, you know, about 100 years or so until the mid-1960s when these two pioneering doctors in New York City developed what we now understand as methadone maintenance treatment. Their names were Dr. Vincent Dole and he was at the Rockefeller Institute in New York and his partner, Dr. Marie Neiswander, who is a psychiatrist in New York.
[00:15:03] And they started working with the growing opioid-dependent population in New York, mostly driven from Harlem. And they started testing drugs on them to see kind of how long each drug lasted in the human body. And when they tested methadone on two known heroin users, methadone is a synthetic opioid. It was developed in Germany by the Nazis in about 1938.
[00:15:25] And it has this really long sort of lifespan in the brain where it actually worked for these two volunteers to decrease their withdrawal symptoms and satiate their opioid hunger for a day, for a full 24 hours. So Dole and Neiswander think, well, what if we started giving heroin addicts a daily dose of methadone? And that way they wouldn't be going through that sort of like peak and valley of withdrawal and euphoria that, you know, consistent opioid use kind of gives you.
[00:15:54] And we sort of treat them like a daily vitamin. If they would have methadone in the morning, they could go about their day and they could transform back into law-abiding, you know, tax-paying citizens. It was a cure. Now, of course, this is apostasy to the larger sort of, you know, like sort of orthodoxy of ideas about heroin addiction and treatment at the time, which is, of course, no, this is a lifelong affliction and abstinence is the only cure. But Dole and Neiswander kind of become like these crazy stars.
[00:16:22] Marie Neiswander is in Vogue magazine and methadone maintenance at a time when crime and heroin use are rising nationwide is suddenly seen as this potential solution.
[00:16:31] And it's something that the Nixon administration, interestingly, grabs onto in 1971 and decides to absolutely explode from a really small, like a couple of clinics here in their effort where in 1970, there were only 9,000 people on methadone maintenance in the United States and Canada combined to suddenly explode it with like funded with massive amounts of federal money and open over 450 methadone clinics nationwide by the mid-1970s.
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[00:17:55] That's bluecitypodcast at gmail.com. And send along show ideas, guest ideas. Sandeep and I would really appreciate that as well. Okay, back to the show. Yeah, and you're right.
[00:18:12] Like initially, this massive infusion of medically-assisted treatment, basically opening up methadone clinics and getting heroin addicts onto methadone, shows some real promise and success, right? Like there, you know, crime rates go down, overdose rates go down.
[00:18:31] Like there's, you know, in 1973, Richard Nixon is out there, you know, basically kind of almost declaring victory in the heroin crisis, right? Where he says we have turned the corner on addiction. But it turns out to be an ephemeral victory. And this whole initiative is pretty short-lived, right?
[00:18:53] I mean, you know, by the time Reagan takes office in 1981, it's gone. So what happens? And if everything's going so great by 1973 and now you've got tens of thousands of people on medically-assisted methadone, you know, maintenance programs, why does it all fall apart? Why does it all fall apart? Darn, you know, it's like, whoa, we had this moment where things were really different. And it really does kind of just crumble into a million pieces.
[00:19:23] And there's a lot of different reasons for that. But I also should say that the office that organized this response, they didn't only fund methadone clinics. They actually funded like probably two-thirds of the clinics that they funded were these sort of more traditional abstinence-based therapeutic communities, detox programs in hospitals, counseling, drop-in centers, sober homes. Like they funded it all. But methadone is certainly a part of it and probably, well, by far the most controversial part of it, right? Because, I mean, it is controversial, right?
[00:19:53] This is called substitutions theory. You are giving an opioid to someone who is addicted to opioids. And that is, for many people, a bridge which is just way too far, right? You can't go across it mentally, emotionally. There's a lot of pearl-clutching from a variety of audiences. It's not just the conservatives who are like you're coddling criminals rather than like where's the law enforcement Nixon we know and love? Who's this strange man funding treatment?
[00:20:19] To actually the majority of black communities were really opposed to it because, again, like it's like it's the neighborhoods in like Columbia Heights and D.C. and like Newark. It's like the black neighborhoods that are lying in rubble right now. And rather than rebuilding these neighborhoods and, you know, like putting money into better schools and jobs and housing, they're getting free narcotic clinics. Like methadone was very suspicious among black communities in the early 1970s.
[00:20:47] The Tuskegee syphilis experiment had just been revealed. Like there was not a lot of trust of the federal government handing out a free opioid. It was very controversial. And then, of course, there's Watergate. So everything the Nixon administration touches is deeply suspect. So the clinics themselves kind of start to – they generate a lot of controversy and they also generate some really strong federal restrictions in 1973. Because it wasn't only federally funded clinics that were distributing methadone.
[00:21:17] It was also private doctors who were just selling the drug with no controls. So, you know, diverted methadone started being attributed to numerous overdoses. Some of them were very, like, you know, big headlines. A two-year-old girl dies from drinking her mother's methadone-laced juice and things like that. So they're clamped down upon with really strong federal restrictions, which are actually still in place today over 50 years later. So only federally registered methadone clinics are allowed to distribute this drug. Stigma and nimbyism is rampant.
[00:21:46] They're kind of pushed to the edges of neighborhoods anyway. And then the federal money starts to decrease, especially once, you know, not only after Nixon leaves, but then you have a period of major recession under Ford and Carter. There's not a lot of money for methadone. And as soon as Nixon – or excuse me, as soon as Reagan comes in in 81, they're, like, the first thing on the chopping block. Because they're targeting – like, they're a public health benefit for drug users. Yeah, what is this hippy-dippy shit, right? Right, like, not that. Yeah, we're not doing that. It's a population. So they're just – they're cut off.
[00:22:15] And they essentially have to privatize to survive. And they do have to survive because they have hundreds of patients who show up every morning for their dose. And you don't want to just turn them back to the black market. So they have to stay open so they start to privatize, to remain, to keep the doors open. And, of course, this ultimately leads to the heavily privatized methadone system we still have today. It was birthed by Reagan's absolute abandonment of what Nixon had started a decade prior. So I wanted to linger one more second with the Nixon administration.
[00:22:45] How much of the success of the methadone programs under Nixon involved legal diversion, pre-trial diversion, or other kinds of diversion, where basically folks were given the opportunity to go into treatment as opposed to going to prison or that kind of thing? Well, I mean, they were all voluntary. All of these clinics were voluntary. And I don't know if there was necessarily like a pre-trial diversion system set up. That feels like a product more of like the 90s rise of drug courts. I think this is still too new.
[00:23:14] But there actually was – I speak too soon because there was something that the office that Nixon started – it was called the Special Action Office for Drug Abuse Prevention, or CEODAP. It just rolls off the tongue. But so something that CEODAP actually did institute was called TASC, the Treatment Alternatives for Street Crime Program, which is essentially that, right? It took people who were convicted of drug crimes and diverted them instead to the free and voluntary treatment system
[00:23:40] as a means of keeping them out of – or without – you know, outside the confines of the law enforcement system. So yeah, I spoke – no, it was there. Yeah, it was totally there. I read the pamphlet. They're in the Library of Congress. In its origins, yeah. So as you write in the book and quoting you, quote, the fiercest opposition to MAT to medically-assisted treatment is philosophical, right? Unquote.
[00:24:03] And I vividly remember this, right, from being a kid in the 1970s, being in high school in the 1980s when Reagan comes to power. And maybe my first encounter with this was, you know, we've probably all – I'm going to get canceled by mentioning Woody Allen, but we've probably all seen the movie Annie Hall, right? 1977, huge movie.
[00:24:28] And there's a famous joke in that movie, and I'm going to just play this. It's a six-second clip. I used to be a heroin addict. Now I'm a methadone addict. I remember that from watching that movie when I first watched it in, I think, you know, like 1980-ish when I'm in high school. And it had a profound impact on, I think, shaping my sensibilities and a lot of American sensibilities.
[00:24:52] But that was sort of the prevalent attitude that we're just substituting one addiction for another, right? There's a real stigma. There was a real stigma, still is, but really there was – back then it was pretty intense, that stigma around methadone. Well, I'd like to know about your experience because you were a methadone patient, right? Like how – Yes, yes. And yeah, I mean, yes. So I – you know, I'm not exaggerating when I say methadone saved my life, right?
[00:25:20] I was – as I've said many times on the podcast, I was addicted to heroin all through my 20s into my 30s. For much of that time, I was kind of managing it sort of, kind of, you know, I was sort of functional. But my last three years in Washington, D.C., it kind of fell off the cliff, you know, play with fire, burn your fingers. Yeah, yeah.
[00:25:44] And yeah, my life unraveled and all of the things you would expect to happen happened to me, including – this is the height of the war on drugs. And, you know, I got arrested. I was having all sorts of medical issues. My addiction had spiraled out of control. I was selling everything I owned. You know, I mean, it was the whole deal. I didn't end up homeless, but I was getting there.
[00:26:09] And I tried NA, you know, Narcotics Anonymous and those – you know, I tried the abstinence stuff. I tried to kick a thousand times and it never worked. But I had a real – I had that stigma about method – why would I want to do – try this methadone thing?
[00:26:26] You know, and – but finally I got so desperate that I did and it was a real psychological break for me and it kind of – it was only because I was in the depths of the most profound imaginable despair, right, that I was willing to do something like do this thing where I have to go to this place every day and get the – you know. And they told me it would take 18 months, which seemed like an impossibly long amount of time.
[00:26:55] And what – I was like, what if I have to go on a trip? Like, what am I – you know, like, you know, all these sort of questions running through. Like, why would I do this? I'm chaining myself to this place. But I was so desperate I did it and yeah, it did save my life, right? I mean, it changed my life. And so absolutely, absolutely, yes, it's a very personal experience of it.
[00:27:21] And anyway, but yeah, that stigma was certainly very real back then and I think still exists and I think it's been an impetus for a lot of the kind of post-war on drugs sort of thinking about how we need to de-stigmatize these sorts of treatments, which I think is true. But Emily, yeah, I don't know. You know, I mean, speak to that stigma question, right? Where do you think that stands? It's hard to say, right?
[00:27:50] I think it's still very – I mean, it still exists, obviously. But also methadone is growing right now. I mean, as – I mean, it might stop now that like Medicaid is going to be dramatically reduced. Like the number of enrollees is going to be dramatically reduced. And the fact that like, you know, our current opioid problem, which was launched about 30 years ago with prescription opioids, continues to unfurl with not like a huge major response, not like we saw in the 1970s. And I think it does have a lot to do with this stigma.
[00:28:18] You know, these restrictions on methadone use are really burdensome. You know, as you said, you have to go every day. And for the most part, methadone clinics are only open quite early in the morning. This is supposed to serve a working class population. If you have to get to work at 9, you're going to be at the methadone clinic at 5. But for the most part, people have to be at this clinic every morning to dose.
[00:28:42] Like lining up outside pre-dawn, doesn't matter the weather, about six days a week, right, in the beginning of treatment. And this will last for months, potentially years. At one point, it actually took up to two years of like dedicated, consistent showing up every single day before you could earn, I think, up to four or five days of take homes a week.
[00:29:02] So obviously, this is extraordinarily different from most prescription drugs that people take where like you go to CVS, you pick up three months worth and you take it in the morning with your water when you wake up. Like you don't have to go anywhere. Like if it's Christmas morning, it's your kid's birthday, you have a work trip. You still have to go to the clinic. And it's very difficult to actually sort of transfer your prescription from one clinic to the next. Like I've got to go to Austin for work. I can transfer my prescriptions. Like no, you can't.
[00:29:28] I mean up to I think just recently, like people still had to fax their stuff to the federal office to try to get these prescriptions transferred. It's a very clunky, strange system that's been sticking in its current iteration for about 50 years. And I think that's really contributed to the stigma. But for the most part, of course, the stigma comes from the fact that I think the United States, besides being awash in drugs, remains incredibly uncomfortable with drug use.
[00:29:54] Even if it comes to sort of therapeutic benefits of it, which are pronounced and clear, you know, not only within the literature and the studies, but in other countries, right? Like other countries don't have the same issues with medication assisted treatment that the United States does. And of course, their overdose deaths are significantly lower, you know, mostly because of it. So we should be almost embarrassed in the United States about how poorly we treat this issue.
[00:30:18] But I think we're just too angry at drug users and simply too ready to transform their forms of treatment into additional forms of punishment to actually, you know, change our way of thinking about it. So Emily, part of what you talk about is the way in which this early experiment in the Nixon administration, I'm calling it an experiment because it doesn't really last very long, unravels and becomes something else, this privatized system in many ways. So what happens? What's the story there?
[00:30:49] Yeah, so it's pretty crazy. Say it up, the Special Action Office for Drug Abuse Prevention, it doesn't last very long. It lasts about three years. And in 1974, it transforms into the National Institute on Drug Abuse or NIDA, which still exists today. Dr. Nora Volkov is the director of it. She's been director for like 20 years. But when it transforms into NIDA, its focus is mostly on research. It's not going to like fund these controversial clinics anymore. It's very much tamed and it's demoted.
[00:31:18] It's not like an executive level office with the director reporting to Nixon himself. It's like this, it's totally been shoved down in the bureaucracy of Washington. But it does have one constitutionally mandated responsibility, which is to continue to develop new treatment drugs. Because everyone's like, well, methadone, we don't really like it. It's really controversial. It's okay as a stopgap measure. But surely we can create new and improved, you know, chemistry for better living because that's what we do in the 1960s and 70s.
[00:31:46] It's like it's just, it was a period of real development in psychopharmacology. So NIDA does this. It's responsible for funding the development of three more treatment drugs. So NIDA was directly responsible for funding naltrexone, which your listeners might know as Vivitrol. Now it's a 28-day shot of naltrexone. But naltrexone is an opioid antagonist. So it blocks the brain receptors. And it's basically like a vaccine against opioid use.
[00:32:15] So if you're on Vivitrol, you have to be fully withdrawn from opioids. But if you're on Vivitrol, your brain is blocked from absorbing another drug's effects for like a month. So it's kind of like a more of like a prophylactic against drug use. And it comes out in the next... You can't get high. You can't get high after... Yeah, yeah, yeah. And this is like NIDA's like first success. It comes up with this. It's first released as a daily pill in 1984. And it's great because like the Reagan administration is a very abstinence-oriented administration.
[00:32:41] And a drug that you take to not be able to get high fits seamlessly within the Reagan administration's ideology. So they're like Vivitrol or excuse me, naltrexone is great. It's called Trexan as a pill in 1984. We love it. But basically once NIDA is involved with developing it, they're like hands off. They give it to DuPont Pharmaceuticals, which co-developed it. And they're like, good luck. And no one buys it. And it's kind of a commercial dud.
[00:33:08] And then NIDA is involved with the development of another drug called L-alpha-acetylmethadol or LAM. And they're able to get this drug across the finish line with another private company in the 1990s. But by that point, privatized methadone clinics are so powerful as a kind of private commercial industry that they don't like LAM. Because LAM is like a three-day long methadone. You only have to take it once every three days rather than every single day.
[00:33:37] And methadone clinics were paid, of course, daily by the patients coming in. They're like, we don't like this LAM thing. They kind of rejected it. And it dies a quiet death itself a couple of years later. And then in the early 2000s, this new drug that the federal government helped develop comes on the scene. And it's called Suboxone.
[00:33:58] And Suboxone is a really unique drug because it's made with four parts buprenorphine, which is a partial opioid agonist, which means it fills the brain's opioid receptors. It prevents withdrawal symptoms, but it only does it partway. It kind of has like a built-in ceiling effect. So it's safer from a public health perspective because it's less likely to result in overdose.
[00:34:19] And there's one part naloxone, which is an opioid antagonist similar to naltrexone, which means that if you try to like crush a Suboxone pill and inject it to get high, the naloxone will reverse the high and you will actually go into withdrawal. So it's like a built-in punishment, which is its own sort of like, you know, kind of strange Michel Foucault orthodoxy thing there. Something karmic.
[00:34:46] But like once again, basically like the federal government plays this really big role in the development of buprenorphine, right? It's actually responsible for passing the Drug Addiction Treatment Act of 2000, which allows buprenorphine to escape the same federal controls that keep methadone within those federally registered clinics. And this new drug, because it's safer, is allowed to be prescribed by a private physician and distributed from private pharmacies.
[00:35:11] So federal, like federal lobbyists, federal officials, NIDA people, they're deeply involved in the development of buprenorphine with a private pharmaceutical company called Reckitt Benkieser Pharmaceuticals. Federal officials get it across the finish line. They legalize its private prescription. They get it FDA approved. And then they give it to Reckitt Benkieser Pharmaceuticals to say, here it is. There's this new treatment drug. Now you guys are in charge of marketing it. Figure it out. We're kind of washing our hands of the whole thing.
[00:35:41] And Reckitt Benkieser Pharmaceuticals does market this drug at first very poorly and then by the early 2010s with an aggression that is matched only by Purdue Pharmaceuticals marketing of OxyContin. And it leads to a whole big can of worms. You actually, yes. I mean, this is one of the most amazing, you know, kind of anecdotes in your book is you tell the story that, you know, Suboxone comes on the market. It's not really doing, it's not going anywhere. People aren't using it and stuff like that.
[00:36:11] And then all of a sudden, Purdue Pharma, which is the manufacturer of OxyContin, right? And they have this, you know, they aggressively market OxyContin as there's a huge explosion as a, you know, kind of pain treatment. Huge explosion of usage. And then there's a backlash, right? In the early 2000s against Purdue. And you say they lay off, they end up laying off hundreds of their salespeople that get snapped up by this other company.
[00:36:36] And once they hire all these sort of aggressive salespeople, you know, the use of bup and Suboxone goes through the roof and suddenly it becomes a big best-selling drug and a huge moneymaker. Totally. It's like when I first heard about this, I was like, for real? Like, it's a huge experience. Period. It's too good. It's too good. But I actually became close with one of the whistleblowers on the case. She was one of the people who noticed that this was happening.
[00:37:05] A former Purdue salesperson. She had been hired to sell OxyContin in the 90s. She wasn't super comfortable with everything she saw going on. Like, when she was first hired, this was right after Purdue had said, oh, you know, maybe we mismarketed it, but then we changed the literature and we changed the coding and it's safer now. Go ahead. But she started seeing the problems starting to mount in, like, the late 90s, early 2000s.
[00:37:28] And as Purdue started coming under major legal fire, like, hundreds of thousands of lawsuits were being filed against this company for turning people into, quote-unquote, accidental addicts, they start shedding sales staff like nothing, right? So hundreds of people are being laid off. And this little company, Reckett-Bunkies for Pharmaceuticals, which only has two products. It has Suboxone, which is, you know, this new medication. You can get it from a private doctor. You can get it from a private pharmacy.
[00:37:56] And they also have Subutex, which is a pure buprenorphine form. But because it's pure buprenorphine, it's only allowed to be distributed in certain controlled environments like hospitals and emergency rooms and things like that. So not a huge part of their sales. But they have one product and they know that their best potential audience are the exact same people who were using OxyContin beforehand. So they start to hire all of these laid-off salespeople from Purdue and marketing directors and, like, all of this laid-off staff.
[00:38:23] And so they migrate away from Purdue Pharmaceuticals and toward Reckett-Benchiser Pharmaceuticals, essentially to start selling the hose to put out the fire that they started when they were selling OxyContin, you know, a couple of years prior. Okay. So, Emily, so there's more to this. What happens next? Right. So the years go on. Reckett-Benchiser Pharmaceuticals starts really aggressively selling this drug. And they also start to come under generic competition.
[00:38:52] So they really turn it up. They participate in something called product topping where, you know, Suboxone used to be a tablet. And you have to take it under your tongue because if you swallow buprenorphine, it's neutralized by the liver and it won't work. So it has to be under your tongue. It used to be a tablet. But as generic buprenorphine starts to come down the pike, Reckett-Benchiser Pharmaceuticals pivots. And they turn it into the form of Suboxone, which is available today, which is like an under-the-tongue, like, sort of film strip. It's like Listerine film strips that used to be around a while ago.
[00:39:21] So it's the exact same product. But as they're going through their new FDA approval, the FDA is like, this seems really fishy. It doesn't seem safer. And it seems like you're only changing your product to get another 10 years of patent protection because you currently own the entire buprenorphine market. We're going to report you to the Federal Trade Commission, and they're going to start investigating you.
[00:39:41] And then other federal officials start investigating the company as well because by this point, it's engaging in the exact same fraudulent marketing activities that Purdue Pharma was participating in before with OxyContin. They're fudging all of their data about safety. They're arguing that the new film strips are the safest ones possible and no state Medicaid systems, which are starting to cover buprenorphine now, should invest in these generic buprenorphine forms.
[00:40:06] And they essentially get caught by 2020 for fudging their data so completely and sort of forcing state Medicaid systems, specifically the one in Massachusetts, to start reimbursing exclusively Suboxone film that they're found guilty of federal misdemeanors. They're fined $2 billion. It's the largest federal opioid settlement at the time. And the CEO of Recepemke Pharmaceuticals spent six months in jail during the peak of COVID.
[00:40:33] It was this enormous punishment that was brought down on this little company. And Purdue never suffered the same circumstances, right? They never – like when they actually came under department – like federal investigation in 2007, they were left off with a slap on their wrist, whereas Recepemke was forced to pay an enormous fine and spend jail time for the CEO. But no one paid any attention to it because it was 2020 and we had other, you know, more pandemic-y things on our mind.
[00:41:00] So when I started researching this book and I was like, I cannot believe the story of Suboxone. I can't believe that essentially the federal government developed what is a really effective medication-assisted treatment for opioid use disorder, gave it to a private company. The private company turned into a pure profit-making machine until the federal government essentially shut the whole thing down. At this point, Recepemke Pharmaceuticals had to dissolve its marketing team. No one is allowed to go and actually market this drug anymore.
[00:41:25] So it started off as this major federal public health intervention and it ended up becoming basically a commercial triumph and then now a commercial sort of dud. It's a fascinating story. Fascinating and depressing. Why do the kids hate capitalism again? Imagine. And obviously this story that you're telling about, that you just told us about, about the kind of trajectory of Suboxone is part of the kind of broader argument of your book, right?
[00:41:54] Where you say that, you know, title of the book, Addiction Inc. You write that the system we have created sort of now is, and I'll quote you here, quote, a patchwork of private commercial clinics selling medications once available for free and providing treatment in environments patients say are cruel, inaccessible, exploitative, and profiteering medically-assisted treatment in America is good business. Right?
[00:42:53] Again, a great organization. Again, a great organization. I spoke at their keynote a couple of years ago as a kind of success story for, or whatever. But I also know the story. I'm on the board of the, basically the largest homeless services provider in Washington state. And they have a very significant behavioral health program.
[00:43:13] They have 250 people, homeless people, who are on sublocate, which is the long-acting 30-day shot of buprenorphine. Right? And every one of those sublocate shots, that one month of sublocate, that shot costs $2,000. Right? You know? And, you know, it's funded through Medicaid, right, for homeless folks for the most part. So there is sort of federal funding that comes in.
[00:43:42] But nonetheless, like, these are like for-profit, highly, highly expensive drugs. Right? So speak to that. Made by the same company that made Suboxone. They pivoted to sublocate when they could no longer market Suboxone. They're like, well, we need something to earn money off of it. Right? But, I mean, so it's a very difficult sort of field to wrap your head around because it is so complicated and it's made up of so many different factors.
[00:44:09] There are a few really wonderful nonprofit programs across the United States. I visited a lot of them, actually, and I was able to talk to people who run them and people who are patients. I mean, when the vision is there, people are capable of making really wonderful programs. I visited one in particular in St. Louis that really blew me away. It had a ton of different services. It offered buprenorphine and naltrexone. It had a relationship with the methadone clinic nearby. It offered counseling.
[00:44:35] It offered telehealth services to serve those care deserts out in rural Missouri. It offered food. It offered housing. It offered work. And it was mostly funded by state opioid settlement funds and the state money just for the drug problem that comes down. So there's a lot of availability and accessibility in certain areas. But then if you go to other care deserts across the United States, it's very difficult to actually get access to services even when people are desperate for them.
[00:45:01] And that's, to me, a real disappointment and kind of a sad outcome for what began in 1971 with this vision of making treatment accessible, attractive, low threshold, as an alternative to basically law enforcement efforts kind of writ large, but also towards other – like the public health response, which at that point had really been non-existent.
[00:45:24] But the idea of offering universal health care, too, of all people, like heroin users, I mean, it's not a surprise that that idea didn't – you know, it kind of lost its luster pretty quickly. But even as our drug problem has escalated over the past five decades, our response to it has stayed this minimal and small – I mean, there was a decent influx of federal funds that came through during the pandemic. The Biden administration was very supportive of this stuff. But we're seeing a reversal on that already with the Trump administration.
[00:45:53] And, you know, we're worried about future Medicaid cuts and, you know, decreased access. We have had a very small drop in overdose deaths last year. But who knows if that will continue? And, of course, the drug supply is always changing. Opioids aren't our only problem anymore. And we don't have any capacity to treat people who have struggles and use disorders with other substances. So it's not a great outcome. Yeah, meth is a huge drop, right?
[00:46:20] There's no medically assisted treatment that really at this point seems to have proven efficacy when it comes to methamphetamine addiction, right? No. And we should have seen this coming, right? Like pretty much after every prolonged period of opioid use in the U.S., like meth rebounds pretty fast. So I think we're going to be dealing with a meth issue for probably another decade or so. And it's probably going to continue to increase, which sucks because, yeah, we don't have any response to it. The best thing we can do is – oh, I'm forgetting the term for it. But it's like a contingency management.
[00:46:50] Contingency management. I did a story about a local effort here to try to introduce some contingency management. And the folks here that are working on that seem to think that it can do some good, but it's tough for folks that are on meth. Emily, you also tell a lot of stories in the book, but one of them is deeply personal about a friend of yours who was struggling with opioid addiction. And that story helped – or his story helped inspire you to want to write this book in the first place.
[00:47:19] What happened? Yeah, I guess I consider this book kind of a research – like the response to a research problem that was posed by my friend Dana's death. We grew up together in Allentown, Pennsylvania, which is kind of on a nice little triangle between Washington – or excuse me, between New York and Philadelphia. I live in Washington now, but that's not part of the triangle. So Allentown, New York, and Philadelphia.
[00:47:44] And so it became a really wonderful trafficking area for the increasing number of prescription opioid pills that were being trafficked through this area in the late 90s and early 2000s. Like after OxyContin's debut in 96, the pills started coming pretty fast and furious by the early 2000s. And I had this buddy, Dana. He was a couple of years younger than me, but we would do the school plays together, and we went to a really small school.
[00:48:08] So we became good friends, and I sort of witnessed his decline over about 15 years from when he started using opioid pills to when he really reached kind of like the peak of his chaotic addiction. And it was a very distressing story for me because Dana was – you know, when I knew him back in high school, was probably one of the most vibrant and vivacious and funny and smart people I had ever known.
[00:48:38] And his decline and ultimate death really bothered me because he did finally go cold turkey off of the pills. He was shocked into this by the suicide of another friend of ours who had been on opioids for about 15 years, got himself off, and committed suicide by drinking Drano. His death really moved Dana to reconsider his choices. He moved back home to Allentown. He was in Colorado. He went through withdrawal cold turkey.
[00:49:05] He was trying to get his life back together, but he was really depressed. You know, living in your childhood bedroom at 30 and kind of working the same dead-end job, he didn't really see a lot of possibilities for himself. And one September in 2018, he walked into the woods behind our old middle school, and he hanged himself from a tree. And his body wasn't found for over 10 days. And by that point, you know, he's nearly unrecognizable. It was just this awful tragedy.
[00:49:35] It destroyed his family. His parents have never really recovered. And it impacted me. I mean, it was – Dana was one of so many people that we've buried from my high school. I'm kind of like the Xennial generation, sort of in between Gen X and Millennial. And we were really hit hard by the prescription opioid epidemic. And I've lost a lot of friends from overdoses and suicides over the years. And it pushed me to question what could have been done to actually help these individuals
[00:50:03] and why they didn't get the care that they supposedly deserved, right? We call medication-assisted treatment the gold standard of treatment in the U.S. And yet, one out of five people with opioid use disorder actually accesses it. And if they do access it, it's usually in these environments that are punitive and profiteering and clearly insufficient to the problem at hand. So I was really sad about Dana's death. And I was like, you know what I should do? I'm pretty masochistic.
[00:50:31] I should spend eight years figuring out the history of where all these drugs came from and publish a 460-page book about it. And so here we are. Yeah. And a very good 450-page and a very interesting 450-page book. I learned a shitload from reading it. And I already thought I knew a lot about this topic because I, you know, had to have personal interests for obvious reasons.
[00:50:56] So, you know, let's take this because later in the book, you go to Switzerland. And you say Switzerland is the place that is getting it right in terms of dealing with opioid use disorder or whatever, you know, addiction. Right. And you say they're a really good counterexample to what we've done here in the United States,
[00:51:25] particularly because they used to be just like us. They used to be just as crappy as we were at dealing with their addiction problems and made just as many, you know, kind of spectacular mistakes dating back to the 1980s in how they were handling addiction until they figured it out and didn't. So tell the story of, yeah, that trajectory in Switzerland and how they differed from the track that we got on.
[00:51:52] Yeah, I really, I like, I like the idea of Switzerland as sort of like a counter, counter narrative to the U.S. Because you're right, like they kind of had a very similar problem to us and figured out a way to solve it much more rapidly than we have. And so I come, like my family's part Swiss. And when I was growing up, my grandmother was always, she would always say, if it's Swiss, it's the best. And so that was sort of like rattling around in my head when I was looking for, you know, because I didn't want to end the book on like, wah, wah, everything is terrible. This is why we have all these deaths.
[00:52:23] We've abandoned this population to private profiteering and punishment. Oh no. It's like, we have to have examples of things to look forward to, right? If we're, if we're armed with the knowledge of, of where we've succeeded and where we've messed up in the past, perhaps we can build a better path future, a path in the future. But of course it helps to kind of know what that path should look like and what the end goal is. And so I was like, well, how about I look at Switzerland and see if there's any alternatives there or any inspiration?
[00:52:50] Because back in the 1980s, it really was the heroin and HIV capital of Western Europe. Like it was really, we think of Switzerland today as this like beautiful, pristine, perfect little place. And it kind of is like, it feels like a fairy tale walking around there. But back in the 1980s, it was in really tough shape. It's right in the center of Western Europe. It's connected to the rest of the continent by like thousands of trains that run through it every day.
[00:53:16] And it became ground zero for heroin use in this little park in Zurich, right behind the train station. And the drug problem quickly... Needle Park, right? I vividly remember that, you know, I don't know, like 60 Minutes or somebody, you know, there were like all these kind of lurid stories about Needle Park and Zurich, right? Needle Park, right? Those dangerous Swiss. Oh my God. Yeah. But in the beginning, Zurich's response was very similar to like Oregon's or Washington
[00:53:45] state's today, which was very hands-off. They had a socialist city council and they said this tiny little park behind the train station, Needle Park, is a supervised but condoned open air drug site. And the problem with that was that it very quickly spiraled out of control. The police weren't able to kind of keep a lid on it. People started coming from everywhere and either living in the park or just scoring and going back home or whatever.
[00:54:10] But that became a real issue in the mid-1980s with the arrival of HIV, which can spread very easily through human blood or sexual contact. And of course, in Needle Park, you have a lot of needle sharing and prostitution. So it's a recipe for the spread of this very deadly virus. Because also remember, in like the mid-1980s, like if you get HIV, it is a bad scene, right? It's a death sentence. Yeah. It's a death sentence, right?
[00:54:37] Like 50% of adults, if you get HIV, you are dead in 15 months and you are dead from like a painful, awful, you're going to get, you know, pneumonia and rare cancers and like you're going to basically fall apart. It's a death sentence. So the Zurich city government and then the federal government responds by saying, okay, just allowing this to happen, we're only responding with law enforcement obviously isn't working. We have to do more. And so they initiate what's called the four pillar response.
[00:55:07] And the four pillars are law enforcement, prevention, harm reduction and treatment. And they put all of those into action together as equal contenders on addressing the problem. So law enforcement does start to crack down, not only on Needle Park, which actually got shut down. They moved down the river to an open air park called Letton. But the police start to crack down on Letton. Methadone maintenance, which again is the only medication available at the time, but they
[00:55:35] make it immediately available in low threshold voluntary clinics, mostly for free. They start prevention efforts and they start harm reduction programs, right? But so the harm reduction programs are essentially safe injection sites or safe use sites. They're called gas and Zima in German, in Swiss German. But they start to like, because not only is, you know, the issue is a problem for the drug users themselves, right? Heroin use or heroin addiction is not a great life. HIV is a real threat.
[00:56:03] But Zurich and other Swiss cities also recognize that harm reduction also has to apply to the society around the drug users, right? Like these open air drug sites were terrible places and they were riddled with violence and crime. And children... Hieronymus Bosch hellscapes, right? You know, that like we see in parts of Seattle these days. Or Philadelphia. I mean, the United States is just like, no big deal. Let's let this keep happening.
[00:56:31] Whereas in Switzerland, much more emphasis on social order. And they're like, this is terrible and it's bad for everyone. So we have to shut it down. So they're very big on supervised consumption sites. I visited one in Basel. It was great. It was a wonderful environment. Because the Swiss recognized drug use is always going to be with us. The point is to mitigate and integrate its effects as much as possible so that that social order that the Swiss love so much can continue to thrive.
[00:56:56] So if you're going to have chaotic illicit use, you put it behind a real big stone wall. You only allow an approved dealers who don't like cause violence or any problems. You treat the rest of the use. So you're trying to ensure that, you know, people who want to get away from that lifestyle have access to it and all the social services that come with it. You prevent it in the larger society. And for any use that kind of escapes any of those confines, that's when you bring in the law enforcement response. So it's a much more holistic wraparound response to drug use.
[00:57:25] And the United States is just like, how could we ever recreate this? We only ever do law enforcement or harm reduction. We only ever do the two. Right. We do one or the other and we don't, we can't figure out how to integrate the two. And compare that to, you know, British Columbia, which also experimented with supervised consumption sites. It's different though than Switzerland, right? Why was it such a failure in BC in ways that it hasn't been in Switzerland? Well, I think because you don't have the other responses in place, right?
[00:57:54] Or think about like in Oregon, right? Like when Oregon decriminalized all drug use, and I think like 2020, they did that with the supposed effect of it being like, well, if you are caught using, you know, on the street or whatever, you just get pushed into treatment. But those treatment programs didn't exist, right? That cart was so far ahead of the horse. I think Oregon was like 49th out of 50 in treatment availability within the states at the time that they decriminalized all drug use. It didn't make any sense.
[00:58:20] What the Swiss do better than places like BC or New York, which has injection sites as well. And again, I say this as a big fan of safe consumption sites. I think that they are an integral part of any sort of holistic four pillar approach to drug use. But when you only put in those and you expect them to be the solution to the problem, you're setting yourself up for failure. In the same way if you think decriminalization is the only response is going to be right, or law enforcement is the only response is going to be right.
[00:58:46] If you put all your eggs in just one of the baskets, they are going to fail. And then what happens in the U.S. is that like if something fails once, we just demonize it. And we're like, well, it's terrible. It'll never work. And we should just get rid of it, right? It's the same response we had to methadone clinics in the 1970s. Whereas what I think Switzerland does well is shows us the potential response we could do if a response, if like the total drug response was coordinated in that same way. And again, I see this happening in some places.
[00:59:15] I think the St. Louis example is a really good one. I see some programs in Baltimore that are really spectacular. But we don't see that in every state. We don't see that from the local to the federal levels. And I think it's because we don't quite have the imagination for it. Like most people don't even know that it exists. So we stick in our silos of like law enforcement or harm reduction and never the tween shall meet. And then we're surprised when it doesn't work. In Seattle, if you said we're going to have zero tolerance for open air drug use or street
[00:59:43] camps combined with this other stuff, the first part would cause a lot of people to say, no, we can't have that. We cannot have a policy. It's the war on drugs. We can't do that. That's the war on drugs, right? I mean, that's the sort of standard progressive response around here. And it does have this weird, you know, kind of libertarian. It drives me crazy when I hear progressives talk about the autonomy, protecting the autonomy of the addicted, right?
[01:00:10] And when the addicted have no autonomy, what addiction robs from people is their autonomy. It makes me, drives me crazy. Like as somebody who went through that, like I had no fucking autonomy. So shut the fuck up about the autonomy shit. I mean, it actually makes me really mad when I, when I hear that kind of that line of argument that is essentially about leaving the addicted to kill themselves in slow motion is essentially
[01:00:39] what we are doing in places like Seattle. And, and, and, and it infuriates me to see that. Right. On the other hand, right. Obviously we couldn't just be sweeping in there and arresting every junkie and throwing them, you know, I lived through the nineties too. And that was, that didn't work either. Right. Like, like, yeah, but there, but as you say, Emily, there are Switzerland seems to have figured out one quick question. Cause a lot of the kind of progressive drug reformers will point to Portugal and say, look, Portugal's
[01:01:06] decriminalized drug use and it's gone well there. And, you know, we should just decriminalize here. Have you kind of looked at the Portugal example? Oh yeah. And Portugal is very similar to Switzerland. You know, again, there, there's there, but there's a lot of stick, right. And the stick not only comes from like the law enforcement field, right. Again, if you're caught using in public, like it's not just going to be like a pat on the head, but like, it's fine. This is Portugal. It's decriminal. Like, no, there's still going to be, there's still going to be effects and consequences to this.
[01:01:36] And you get sent to a dissuasion commission, right. They, that you're, you're kind of put into a system and they push you to. Yeah. I mean, like there, there are consequences to this use. And again, the United States just kind of hasn't put like either the consequence is enormous and like life altering. It's like life in prison or whatever, or the consequences, like there's nothing whatsoever. And because it's so unpredictable and very different, like this, this Patrick of responses
[01:02:03] across the U S it creates like, it creates a lot of problems, which is why I think our drug problem has continued to escalate and spiral over the past couple of decades. Well, and politically we'd rather fight with one another than solve problems sometimes is the way that it seems. It's just like, yes. Anyway, we're very ideologically siloed on, on these sorts of, you know, whether it's homelessness or addiction or street disorder. You guys made a podcast about it. It's great. Yeah. Yeah. Yeah. I wonder why we're so obsessed.
[01:02:32] Uh, yeah. Uh, yeah, I, I, we are, we are at time. Um, this has been Emily Dufton, a fascinating conversation. The book is addiction Inc. I really can't recommend it more highly came out earlier this year, university of Chicago press. Um, uh, and yeah, thank you so much for coming on and, and telling us about what you found about this kind of fascinating history of medically assisted treatment for opioid use disorder. Oh, thank you.
[01:03:02] It's been, it's been a blast and I love this show. I'll keep listening. Um, I love tuning in. Thank you so much. Thanks Emily. That's it for another edition of blue city blues. He's Sandeep Kaushik. I'm David Hyde. And thanks everybody so much for listening.