By: Rob Henderson

This interview with Dr. Sally Satel was conducted before her discussion at the Buckley Program’s dinner seminar on Wednesday, April 5th. This transcript has been condensed and lightly edited from a longer interview.

Dr. Sally Satel is a resident scholar at the American Enterprise Institute and the staff psychiatrist at a methadone clinic in Washington D.C. She is a practicing psychiatrist and lecturer at the Yale School of Medicine, and the author of numerous publications, in both scholarly journals and such popular outlets as The Wall Street Journal, The New York Times, the Washington Post, and National Review. Her books include Brainwashed: The Seductive Appeal of Mindless Neuroscience (2013) and PC, M.D.: How Political Correctness Is Corrupting Medicine (2001).

Rob: Thank you for being here Dr. Satel. You’ve been a prominent figure in discussing the opioid epidemic in the United States. First, what are opioids?

Dr. Satel: Opioids are drugs that are derived from opium, which is a precursor of morphine. And then there are semi-synthetic opioids. And those are most of the painkillers, oxycodone, hydrocodone, that doctors prescribe. Heroin is a semi-synthetic. And then there are the synthetic opioids. Most notorious now is fentanyl, which is a narcotic. Methadone is also a synthetic. Fentanyl is about 100 times more potent than morphine and fifty times more potent than heroin.

Rob: Is that something to be concerned about?

Dr. Satel: Medical fentanyl is legal. It’s an extraordinarily effective painkiller. I was on fentanyl after an operation, and I can tell you that it works. But the illicit fentanyl is made in China and shipped to Mexico and then trafficked into the U.S. and often mixed with fentanyl.

Rob: Can you describe some of the problems that have come about as a result of widespread opioid use?

Dr. Satel: Well, to use one marker, about 33,000 people died in 2015. You can largely trace the problem back to prescribed painkillers. It started in the early 90s, when doctors began more liberally prescribing them. Now, it was well intended. It was an outgrowth of an effort to loosen the restrictive an attitude toward prescribing opioid painkillers to anyone not suffering from terminal cancer. “Opiophobia” was the name given to a fear of prescribing these medications lest the patient become addicted. Advocates for pain treatment were vocal about this. And then the American Pain Society made pain a fifth “vital sign” in addition to blood pressure, temperature, respiration, and pulse.

Rob: Pain is more subjective than those others.

Dr. Satel: That’s right. And it also elevated pain in importance in terms of it being a basic, fundamental marker that doctors should assess. It’s something you really can’t objectively measure. Maybe you’ve seen the analog pain scale in a doctor’s office with the little faces ranging from one to ten? If you are in the hospital and identify your pain level at four or above, you will receive a pain medication. In the past, these painkillers were limited to patients with cancer, terminal illnesses. But, as part of this movement, people with chronic pain were considered appropriate candidates too. True, some of those patients did need opioids, though others could have been treated by other means. The more opioids prescribed, the more these medications got into circulation and were abused, often by non-patients. As far as who is abusing these medications, there’s a narrative that’s taken hold that is not quite accurate, namely that  if your doctor gives you three Percocet because you’ve had a wisdom tooth removed you’re at real risk of addiction. That’s not really true.

Rob: Is everyone person susceptible to addiction or are certain individuals more likely than others?

Dr. Satel: Certain people are more vulnerable than others. People with a history of addiction in their family, for instance. There are some predispositions. Most people call this an epidemic and others say the label is a little histrionic, but I think it’s accurate. It started out being dominated by these painkillers, like Percocet, Vicodin, and OxyContin, a condensation of the word “oxycodone” and “continuous.” The virtue of OxyContin was that it lasted 12 hours, a long acting drug in contrast to Percocet and others that are immediate release so they’re taken every four hours. It was meant for chronic pain, it was never meant for short-lived pain that  resolved in a few days. Too many dentists, for example, would prescribe a month’s worth of painkiller for an extraction. Practice is now changing to prevent this kind of careless prescribing.

About 2007-2008 it grew worse because of illicit trafficking from Mexico accelerated. Around 2010, doctors, health departments, and law enforcement started address he problem of painkiller abuse and fraudulent prescribing more aggressively. Have you heard of “pill mills?”

Rob: No, what are those?

Dr. Satel: A pill mill is basically an operation staffed by an unscrupulous physician. It’s basically a drug dealing operation. People come in with “pain,” and they pay cash, and walk away with medication that they sell to others. They often purchase OxyContin. The reason OxyContin is so desirable is that it lasts 12 hours because it is released slowly from the tablet. That means it contains a lot of Oxycodone. If it is chopped up and snorted, it causes an intense effect. It was very much in demand. But then the DEA started cracking down on pill mills. Responsible doctors too became more cautious prescribing them. Most states established prescription monitoring programs so pharmacists could track how often patients received painkillers. These surveillance efforts started around 2010. Moreover, OxyContin was reformulated so it wasn’t easy to chop up and snort or inject. That made it less attractive to people.

Plus these pills were getting harder to acquire and when you could get them they were more expensive. So some people who abused pills switched over to heroin which was cheaper and easier to find. By 2012, the rate of OxyContin prescription had started to drop, and fentanyl started to take off in popularity. Of those 33,000 people who died in 2015, about 17,536 died from pills, 12,989 from heroin, and 9,580 from synthetic opioids like fentanyl. Fentanyl is very potent, and it is often mixed into heroin or sold in pill form, so people think they’re actually getting an OxyContin or a Xanax rather than something much more powerful.

Rob: Are opioids acquired more often through legal or illegal means?

Dr. Satel: If you’re talking about painkillers, they’re almost always from a prescriber. But there are scams. There are cases in which dealers have paid homeless people to go to doctors, and get pills for the dealer to sell. Also, Medicaid covers the cost of these medications and some patients would get a prescription from their doctor, perhaps they were on some pain, but they would sell part of their supply at a dollar a milligram. The book, Dreamland, by Sam Quinones, details this.

Rob: You mentioned before that there are misconceptions about people’s propensity for addiction. Can you talk a little bit about both the misconceptions and the truth?

Dr. Satel: There’s this great push to democratize addiction. And it’s true that the poorest person and the richest person can become addicted. That’s clearly true. The definition of addiction is the compulsive, excessive use of a substance that’s difficult to stop in the face of adverse consequences. In most cases the patients who are prescribed medication and abuse it —that is, use it for reasons beyond pain relief – are those who struggle with a mood or anxiety disorder or who have had a drug problem before.

Rob: Is the addictive pattern equally likely for everyone?

Dr. Satel: Well there’s a study from Princeton economists Anne Case and Angus Deaton [Winner of the Nobel Prize in Economics in 2015] on this.  They found that poorly educated working class white people are especially affected. Case and Deaton have called them “deaths of despair.” They refer to alcoholism, suicide, and addiction. The life expectancy for this group is declining, whereas for educated whites, African Americans, and Hispanic Americans life expectancy has been rising. A lot of these undereducated people live in the Rust Belt, or rural areas where jobs are very scarce. So there is an economic component, a hollowing out of communities in terms of economic prospects and hope and that makes them vulnerable as a group. In other instances, even people with outwardly comfortable lives struggle with self-loathing, social alientation, chronic sadness, and other painful states.For them, drugs provide relief and they are ambivalent about giving that up.

Rob: Can you talk about the misconceptions and truths about people who suffer from addiction?

Dr. Satel: Well too often, addiction is portrayed as a sort of “zombie” state. The drug controls them completely and they are incapable of change. Yes, if the person is in the midst of a crack binge or heroin withdrawal, that is not a time for reflection. But addicts are not perpetually nodding out or in the midst of withdrawal.  I work in a methadone clinic, and most people had jobs before they came for treatment. They were purposeful during the day, they were able to function. They were able to make the decision to seek treatment. In fact, most people stop on their own. The ones who cannot or do not and who go through many cycles of treatment are typically individuals with a concurrent mental health problem.

But it’s complicated. It’s hard for people in pain to stop for long stretches because they use the drug to medicate their pain. So there were the deficits in life that make drugs attractive in the first place, and using drugs creates more problems in your life and then you have another layer of consequences as a result of addiction. A lot of people do think, “I’d rather continue to feel better.” And when you think about it that way, it’s almost a rational choice.

When we over-medicalize addiction we infer that it’s a condition over which a person has no control at all. I’m not downplaying the compulsive urge to use; it is very strong. Still, users have many lucid moments in any day. They can also respond to incentives and consequences. That is how people usually get to treatment: their boss is about to fire them, their wife is about to leave them, and so on. True, no one chooses to become an addict. But people do choose to use drugs to feel better in the moment and they make decisions to seek that relief. They behave like steep discounters.

Rob: What is your ideal solution for this problem?

Dr. Satel: Universal happiness! And more funding. Well, doctors and researchers have really been trying to find non-addictive painkillers. That would be a major revolution. Doctors are becoming more astute about pain treatment. And Medicare and Medicaid should be more willing to pay for other kinds of treatments. And of course it’s important that the DEA and State Department conduct interdiction efforts to combat trafficking on the incoming side. And opportunities for treatment, you may have heard of this antidote called Narcan. It’s a nasal spray used for drug addicts who are unconscious, and it makes them come to. But a lot of people, after being revived with Narcan, simply get up and walk away. They don’t go to the ER or treatment. We need both more treatment and more creative ways of engaging with people.

Finally, the criminal justice system has a major role. I don’t mean in jailing people but in diverting them to treatment. Judicial leverage is a good way to ensure they remain in treatment long enough to undertake important changes such as achieving employment, re-integrating with their families, a sense of purpose, and so on.

Rob Henderson is a junior in Grace Hopper College and a veteran of the U.S. Air Force.