TROJAN-ISH (10/05/21)
Season 1, Episode 1: Drugs
What’s on your mind Trojan? Let’s talk about topics that our campus is interested in. In each episode, we’ll invite folks who can make your navigation at USC just a little bit easier to understand and to get involved with. Welcome to Trojan-ish. I’m your co host Min Ho.
Today we’ll explore drug use the opioid epidemic, fentanyl and preventing overdose deaths by administering the life saving drug Naloxone. And joining me is my co-host and collaborator Danielle Gautt Licensed Clinical therapist and faculty member in the Department of Psychiatry and Behavioral Sciences in the Keck School of Medicine of USC.
Hi, Danielle. Good to see you.
Danielle: Good to see you.
And our guests today are Ricky Blumenthal professor in the population and Public Health Sciences Department of the Keck School of Medicine of USC, the school’s Institute for Health Promotion and Disease Prevention, and he’s also with the Institute for addiction science at USC. Also joining us is Shannon Knox, Director of Training and Education at community health community health project LA, where she oversees the community partnership side of the county program, O E and D. overdose education and Naloxone distribution. Our third guest is Sheila Puck Dimon of USC graduate student government and a researcher herself in the field of addiction studies and mental health. So welcome to the program. We’re very glad to have you all here with us today. Professor Blumenthal if we can start with you. You’ve been studying drug use for more than 25 years, and you’re a longtime expert in the field. What can you tell us about what’s changed generationally between today’s environment and drug use in the past?
RICKY BLUMENTHAL
Sure. So we’re in the midst of for pretty dramatic changes in drug use patterns nationally, in the last 10 years. It began actually 20 years ago, when the prescription opiate, dispensing really began to increase. And then 10 years ago, in response to that, there was changes in the formulation of prescription medications, and then a steady decline in prescribing that resulted first in a transition into heroin use for some people. And then from heroin. The heroin supply, beginning about three years ago, I’m sorry longer that beginning about five or six years ago began to get contaminated with fentanyl. It was late to get to the LA area that that’s happened more recently in the last three or four years. And now we’re seeing same sort of prescription opiates, heroin, fentanyl contamination, and now fentanyl use and then also increases in methamphetamine use now. So in my studies, which are done in collaboration with community based organizations like the one that Shannon works at, we’ve been collecting data from community residing people who inject drugs for 20 years in Los Angeles. And we’ve seen these dramatic changes. So about five years ago, we saw the uptake and fentanyl contamination. We’re in the field now. And we’re seeing lots of people just using fentanyl, and then lots of people trying to stay away from fentanyl. And then we’re also seeing this uptick in methamphetamine use among all populations. So when I first started doing this work 25 years ago, you very rarely saw someone use methamphetamine and heroin. And now what we see is, you know, about two thirds of the participants in my study, use them together. So they’ll combine methamphetamine with heroin or fentanyl, and use it as a single, a single shot. So there have been dramatic changes in the drug use pattern. And that changes the risk pattern or the health consequences of drug use and presents a real challenge to our homeless providers like the ones that the one that showed them
That work in the perfect segue into Shannon’s area. Shannon, can you tell us a little bit about your work?
SHANNON KNOX
Yeah, sure. So Community Health project Los Angeles has been a syringe exchange in in LA, providing sterile needles to injection drug users, or people who inject drugs since 1992. So we’ve been doing this for a long time well before needle exchange was legal. And now we also do community diversion. partnerships with the county where we help keep people out of the system and we also have my program o end overdose education alloxan distribution, which was a county initiative to try and curtail overdose death. And coming off of what Ricky was saying, you know, what we’re seeing with the increase in mathematics I mean and fentanyl and heroin. I mean increasing drug use in general, is that we’re seeing a huge increase in overdose death, we’re at the height of overdose death epidemic in the United States. We’ve never seen more deaths than this COVID-19 has had a horrible impacts on that.
So what we do, our current interventions for this issue is, you know, trying to flood, Los Angeles with Naloxone or Narcan. It’s a opioid antagonist that reverses opioid overdose. Of course, fentanyl and heroin are both opioids. So we try to get as much Narcan out there as possible, do as much overdose education as possible. And also, you know, we provide harm reduction services that engage people who use drugs, such as syringe exchange. And we also provide like, pipes, and whatever whatever people ask for that they need to stay safe is what we tried to provide people in LA with.
MIN HO
Thank you for that. question. Question on this topic? Why is it that we’re seeing so much increase in use? You mentioned COVID-19. Let’s, let’s talk a little bit about availability of drugs. And also, you know, the economics of it, right? Or is it cheaper to go to certain drugs than others? If you look at, you know, the introduction of, or the wide availability of prescription medication in the last 10 years? How has that impacted what ends up being distributed in street use and recreational drug use?
RICKY BLUTHENTHAL
You know, it’s a complicated tale. I mean, part of what I tried to suggest, but probably didn’t say, clearly enough, is that the transition from prescription opiates or heroin was precipitated by by pulling back the prescription opiates. So Well, it wasn’t a natural progression, you had had 10 years that people using and some misusing prescription opiates without an uptake in heroin use. And that was one of the regulations around prescription opiates change that then the transition to heroin occur. So there’s a dynamic relationship between, you know, legal, legal, drug dispensing, and illicit drug use. So that’s one thing to keep in mind. And then on the back end, and this is not a thing I’m an expert in, but I’ve talked with enough DEA agents to understand the basic premise, which is that in drug trafficking, the more potent and less weighty the product is, the more valuable it is. And so you know, just keeping that in mind, like if you’re a drug trafficker, you’re more likely to traffic heroin, then cannabis, because heroin is worth more per wave, then cannabis is similarly, fentanyl is worth more per weight than heroin is because it’s substantially more potent. So that’s probably what’s happening in terms of changing in the illicit drug supply.
Also, to follow up on that as volume to Ricky, so like you can, you can make more potent synthetic opioids like fentanyl, smaller, you can’t really shrink weed, you know what I mean? So that goes along with the potency and the ability to ship this, the more potent the drug, the easier it is to ship and make profit off of.
MIN HO
So let’s talk a little bit about drug testing strips, and have they made a difference? And in keeping people safe, and how to use them.
RICKY BLUTHENTHAL
Well, Shannon, do you want to address that?
SHANNON KNOX
Sure. I’ve gotten so many emails this week about fentanyl test strips and I’m actually making a pamphlet about it because I want people to understand a little better. So fentanyl test strips do test. I think the last study that I read was like 21 to 24 out of 28 analogs of fentanyl, right, so spinosa synthetic opioid, there’s multiple different like chemical variations of it. And they don’t pick up on all of them. But they do pick up on most there. There are some drugs that are more molecularly, similar to fentanyl, like methamphetamine and also vitamin C, which sometimes people cut crack with can give you false positives. But it’s a good tool to remind you to be safe. I think that it’s most helpful for like people that are using coke or something because imagine this right, so a lot of people that are living in addiction, and they get they get a bag of coke or something and they see their spending on it. And they want to flush the $80 bag of coke or do they want to risk it and try doing it right so I find fit and I’ll test apps to be a good reminder to be safe, but I feel like a lot of people will still do their drug if they really want to do it. And that’s what We really advocate for Naloxone, having using with somebody so that they can respond to you when you overdose. But I find fentanyl test strips to be pretty expensive and not the they’re not the most important tool in the toolkit. You know, getting Narcan is way more important to have on him than a fentanyl test strip. Because I tell you what, if I found fitting on my Coke, I’d be like, but how much because those strips are also very sensitive, right? And so I might still do it, but I would be like, Hey, friends, here’s some Narcan, I’m gonna do this drug, you know, and watch me and if I overdose call 911. This is rescue breathing hit me with the Narcan. Yeah, because I think that people that want to do drugs want to do drugs.
RICKH BLUTHENTHAL
Yeah, and then for people who are using other kinds of drugs, like cocaine and methamphetamine who don’t want to use fentanyl at all, then the testing will allow them to, you know, they’d have to dispose of the drug and lose the money that went on with that. But you know, you would then have the advantage of that dying, or you could go ahead and find naloxone, right? Or make sure that Naloxone was available to, you know, to them. And I think one of the thing that’s important to realize about Shannon’s work and the work of our organization and I’m, I am on the board of advisors, so I’m not completely unbiased. But you know, they’re really instrumental in distributing 10s of 1000s of Narcan doses every month, to people who use drugs in Los Angeles County. And so, you know, the next challenge, I think, is making sure not merely that opiate users or people that use opiates have access to it, but that all people who are purchasing drugs, and this contaminated illicit drug market have access to Naloxone.
SHANNON KNOX
And I would especially say I want dealers to have to be giving out Narcan and fentanyl test strips. So if a drug dealer is watching this, contact me, I will get you that stuff. I won’t judge you.
No judgments there.
MIN HO
No judgments. Sheila, Well, let’s let’s turn to you for a minute, I know that not only are you a graduate student here, this really is your field of specialty, looking at mental health and addiction. I know some of your research has looked at use among college students in particular, what can you tell us about you know, any patterns there of drug use? Or, or how they perceive their own risk?
SHEILA PAKDAMAN
Yeah, definitely. So for college students, it tends to be cultural attempts to be social, you know, especially for freshmen who are just entering it’s their first bit of freedom, their first time, they’re usually out of the house if they’re living on campus. So it becomes this like, almost like this mindset of, Oh, this is college, this is my time to party, everyone’s doing it. And then this tends to be the group that is the highest risk for binge drinking. That being four or more drinks in two hours for females and five or more drinks in two hours for males. Binge drinking comes with so many risk factors. It could be either violence, it could be obviously DUIs. And it could be other risk factors such as co co-occurrences. Usually also, with this group, we see a high level of academic stress, a high level of financial stress, and these things can also play into substance use. So it could be more so of a coping mechanism in some people versus a party mentality. And what is really up and coming with this group is simultaneous alcohol and marijuana use, which has definitely seen an uptick specially during the pandemic. And that might just be because of the fact that the alcohol may be a relief to the depression in isolation that came along with the pandemic, and the marijuana might be to offset for them with this age group. And that just all goes into these theories, especially primary, primarily socialization theory, which looks at the different types of patterns, and different than just the different disciplines on why people use drugs. And college students definitely fall into the theory of both cultural social, and, and that’s how it all just comes together. hopefully that answered your question.
MIN HO
That’s great. Actually, let’s let’s talk a little bit about you know, the the life course theory on drug use and how the setting and the environment shapes an individual, how they may perceive drug use, and and actually what drugs they may be exposed to, or tend to gravitate towards.
RICKY BLUTHENTHAL
Oh, yeah, I mean, I, we’ve talked a lot about study, right. So how transit is illegal and illicit markets for drugs, change people’s drug use patterns. Obviously, individual attributes have a lot to do with it. There are a variety of ways of thinking, excuse me thinking about these individual to Some of the most obvious things that put people at risk have to do with experiences they’ve had in life. So traumatic events is a common precursor. comorbidity with other mental health disorders can also contribute to substance use pattern, you know, but I also want to return I think, both to something that Shannon and Sheila pointed out, which is that, as humans and animals, we’re pleasure seekers. And so there’s plenty, there’s plenty of that sort of activity that goes on. And sometimes that involves legal substance substances, and sometimes it involves illegal substances. So I think at the end of the day, you know, from a societal perspective, you know, we have to acknowledge these things are going to happen. And much in the same way we’ve done with drinking, right, where they’re sort of sober, sobering centers, and, you know, I have adult children when they were younger, and they went out to parties, hey, if you get drunk, just call me, I’ll come get you. Like, we can build in social supports and infrastructures to protect people. For folks who are using opiates, whether it be heroin or fentanyl, or using the stimulants like methamphetamine or cocaine, you know, we can put in things like the fitness test trips, and oxygen distribution. And there are even other interventions that we can deploy, like safe consumption sites, that will keep people safe, while they engage in these very, you know, you know, pretty common activities by humans. So, you know, I think it’s important to to, to stop stigmatizing people’s preferences for pleasure. And technology, it’s it’s part of being human. And we want to create circumstances where people can do it as safely as possible.
DANIELLE GAUTT
I really like the way you you frame that as far as humans being pleasure seekers, I’m, I’m curious what, what are some of the, the negative consequences of the more abstinence measures or the measures that really kind of shame those who choose to engage in drug use?
RICKY BLUTHENTHAL
Well, you know, stigma doesn’t really help anyone. You know, that we actually have a whole series now of relatively well designed studies that show that stigma against drug use is experienced a stigma against drug users. That’s how they experienced it. And that leads to lower self esteem, lower self efficacy, less social support, people withdraw support from them, right, because they want to bottom out, and that, you know, that leads to devastating health bonds consequences, like I spent 30 years of my adult life watching this happen, and things have only gotten worse. So when I first started, you know, the things that we were worried about were HIV, and abscesses. You know, and now we’re worried about HIV abscesses, infective endocarditis, hepatitis C, overdose deaths, which used to be very fairly, fairly infrequent. And then, you know, we have all this pernicious of legal framework around the use of these drugs, that’s driven people to homelessness. So when I began collecting data in Los Angeles in 2001, about a third of my participants were on house, it’s now 90% of those people who are on house find themselves losing life saving medications, losing access to Naloxone, losing access to social support, access to food, places to bathe themselves and go to the bathroom with no net, you know, obvious change in the in the number of unhoused people in our cities. So, you know, we’ve really created circumstances or circumstance for people who find themselves in a difficult spot is made more difficult by the routine operations of our policies in the space.
MIN HO
What is the biological root of addiction?
RICKY BLUTHENTHAL
Well, I probably shouldn’t answer this question, because I’m not a big fan of the okay. I mean, I, you know, the way that I think the most common one is, you know, chronic use with negative consequences. And of course, the problem with that is who’s deciding what the negative consequences are, and how are they enforced? So, you know, obviously, there’s dependence. So people who use opiates and opiate like drugs, certainly, that can develop a physical dependence, where if they stopped using, they’ll have withdrawal symptoms, a similar phenomenon happens with people who use stimulants, right? So we have measures for cocaine and methamphetamine dependence and there are ways to treat those syndromes or those symptoms. But that’s a little bit different than I think what most people think about induction which feels to me like a big fat that in and I don’t think actually is, I see this channel wants to say something I’d be interested to hear what she says.
SHANNON KNOX
Well, I mean, just to put it in like, terms of, like, what the experiences is to me, you know, addiction, using that word is compulsion to use, right? It’s kind of like, you wake up in the morning, you’re like, I’m not gonna, and then like, half hour after waking up, you’re like, I’m gonna, you know, and then like the rest of your day, you’re doing it again. And in my experience, that’s kind of how it goes. Like, I write myself a note at night, I’m like, No, you’re not gonna and then they wake up and like, Yes, I am. And, um, and then if you’re, if it’s something like, you know, like an opioid like heroin, then yeah, you get really physically addicted. Same with benzos like Xanax, or Klonopin, like drugs are still prescribed, like regularly, you, you can die from withdrawals from that stuff, right? So like, it’s not just a mental dependence on like, not having anxiety, but the physical withdrawal is something you have to really taper off of, if you have a drug that you like to get, like for a party, and then the next day, you’re like, hung over, I feel terrible, and then you’re not using it again, then that’s recreational or like, you know, social use, and, and if you’re not compelled to then use it again, then you’re not in that cycle. And so what I do is when I start noticing, multi day compulsion to do something, I’m like, Alright, stop now, because it’s only going to get worse. You know, what I mean? This is the threshold, I call it the threshold of like, needing to do it every day, I don’t want to do that.
MIN HO
So we’ve talked about a lot of different ways that people seek pleasure, with substance and pleasure seeking as a, you know, kind of like a human need. With COVID, we also touched a little bit about upon relief, right? Um, you know, relief from boredom, relief from isolation.
RICKY BLUMENTHAL
No, I mean, I think people yeah, I mean, boredom is a danger, right? People seek meaning in their lives, and if their life feels meaningless, then they’ll turn to other other means, of, of engaging, right, then, you know, I mean, let’s be frank, I mean, you know, alcohol kill, you know, up until recently, alcohol, still kills way more people on an annual basis than any of these other substances. And a lot of drinking is related to, to boredom, for sure. And then also, you know, anxiety, wanting to socialize and not feeling able to do so effectively without having this disinhibitor. So, you know, it’s all, you know, like I said, I think it’s the desire to use is pretty universal. You know, the configuration of what Shanna described as compulsion is really different for all of us. You know, and you might feel compulsion for one drug and not another, you know, and we need to be aware of that, and then a lot of it depends on what what else is going on in your life. You know, so if you have a life that’s rich, and meeting and social support, you’re all things being equal, you’re probably going to be less likely to develop a compulsive use pattern, because you have other things going on there, simulating, engaging, and, you know, if you don’t have those things, then you’re going to become more vulnerable to to it. And that’s why you see an age grade. Typically, there’s an age graded behavior pattern to substitute, which is, you know, it’s high when you’re young. And then it usually diminishes and then when you get my age, you start it goes back up, because you’re sort of is this all there is.
And we’re back to boredom again.
SHANNON KNOX
And another thing too, is that, you know, the highest paying job basically, you can get in the whole recovery world is like sober companion, right, that’s when you’re paid a lot of money to hang out with someone who’s trying to stay sober. So that’s like something to think about with COVID, too, is everyone’s isolated, and really like what keeps people from, you know, keeps people accountable to themselves, not using sometimes having a witness that’s making them do things. I really want people to understand that there’s a lot of hysteria going on around fentanyl right now. And there’s a lot of mythological misinformation out there saying things like, you know, that you can overdose by touching it. It’s really, really extreme circumstances that you would touch, fentanyl and overdose. And also it doesn’t aerosolized. Like if it gets in the air, that doesn’t really happen. It’s, like, poof, turn into like this invisible thing that you’re then going to breathe in. And the reason I want people to understand this is because it’s actually like, causing people to be afraid to respond to overdoses, right if someone’s overdosing on fentanyl, and there’s no fentanyl right there that you’re gonna then send wort or smoke, and then go help that person, you’re most likely not going to overdose, you’re not going to overdose, you can respond to fentanyl overdose and not be worried about it.
I mean, I think people, I always thought of what Shannon said that one of the things I think that she illustrated This is know yourself in the context of whatever drug you’re going to be using, and really taking account. So, you know, like I said, pleasure seeking is perfectly normal. But you don’t want to put yourself in a circumstance where you’re unnecessarily vulnerable to something catastrophic happening. So I think knowing yourself as part of that, and then being around good people, who, if something goes sideways, are going to be willing to respond. And you know, we’ve all read stories just around the alcohol use, right? of, you know, you’ve your friends, obviously, you know, drunk out of their mind, and then people don’t care for that person. Right. And so I think, you know, and I’m a parent to college age children, but I’m also like a, you know, a drug policy guy. So you know, why would I want to say is that a lot of the negative impacts that happen with drug use have to do with who’s around you. So if you know yourself, and then you have good people around you, you know, it’s possible, you know, it’s a lot safer to do you know, to do some of the pleasures that you might you might want to using these substances.
MIN HO
Thank you for that. Sheila, do you have one or two things that you’d like to share? Well,
I would say don’t be afraid to reach out to someone, if you feel like you need to talk to someone about something or you feel like you may have a problem, because there’s so many resources on campus. And then there’s also so many community resources that you can tap into. I think a lot of students stress about confidentiality, or like will this get back to, you know, the dean or something or my parents, don’t worry about that. Put your safety and your health first, there’s plenty of resources.
MIN HO
Right, including our own Naloxone Distribution Program, Naloxone, SC, which is student run. And Naloxone is also covered by your student health insurance. So you can go to the pharmacy and actually pick up some canned for yourself and keep it in your environment and keep it on you. Danielle, any words of advice for our students as well.
DANIELLE GAUTT
I’m just really taking in everything that all of our guests said today. As always, I think it’s important to really check in with yourself I think someone on the panel said knowing yourself, right and having an idea of who’s around you your environment, and also not being afraid to reach out for help. We’re here to provide support and counseling and mental health services 24 hours a day, seven days a week, if it’s after hours, we have a 24 hour line that we are also here to provide you support. And all of our services are confidential.
MIN HO
That’s right. We’re all here for you and we are confidential in counseling and mental health services. I’d like to thank our guests for today. Ricky, Shannon, Sheila, thank you so much for joining us. It’s been a real pleasure. And we hope your work continues and your work gets out there. Fight on.
