Overdose Deaths Just Had Their Biggest Drop In History, with Keith Humphreys, Stanford Professor

Speaker A: And we were looking at this delightful but also mysterious phenomenon that we had 25 years of virtually unbroken increases in death. And we were trying all kinds of things that seem sensible and deaths keep going up. And then in the middle of 2023, you see this sudden reversal of deaths dropping. Why would that be? Well, it couldn't be something we were doing all the way along. I mean, it's important as treatment is as important as.

Speaker B: Hi, and welcome to season three of Neural Compass. I'm Mark Jacobstein, president and co founder of Jiminy Health. I am really excited today to be here with Dr. Keith Humphries, uh, PhD, who is a professor at Stanford, one of the world's experts on addiction, an OBE which, uh, we'll have to talk about at some point, how you became a member of the British Empire. I'm quite curious about and advisor to at least three US Presidents, perhaps more. One of the funniest things, actually, Keith, I should admit, uh, when I was researching you that came up, uh, with Claude, is that you are apparently a remarkably sharp dresser by Stanford professor standards. I'm always curious what the AI would say about me. I suppose I have to ask. In any case, I'm really happy to have you here today.

Speaker A: Well, very glad to be on the show. Thanks for having me.

Speaker B: Mark, maybe we'll start with. I mean, most of your work has been centered around addiction and treatment of addiction throughout your career. And if you don't mind, give me a little bit of the backstory on why this was something that interested you and sort of how you got here.

Speaker A: Well, to be honest, I got in by a, uh, happenstance, really. Uh, it was. That's how I started. I was a college student. I knew I wanted. I was majoring in psychology. I knew I wanted to do something in mental health. I had no idea, idea what. Uh, and I was flipping burgers at a Wendy's on Trowbridge Road, meets Lansing, Michigan to pay my rent. And, uh, you know, it's not a pleasant job. And. And uh, you know, speaking of dressing, you did not wear attractive clothes. I was in one of those ridiculous outfits with a funny hat. And a friend of mine came in looking fantastic in office clothes and, uh, relaxed and said she was graduating and, um, was leaving a job as a research assistant in the medical school. And she said, if you want, I can recommend you, uh, for the job. And I said, oh, well, I was making three $3.35 an hour, which was the minimum wage. And I asked her, what does this job pay? And she said $4.40 an hour, and it's a project on addiction. And I said, wow, I'm really interested in that. Which I had never even thought about being interested in. I was interested in the fact that that was a dollar and five cents more an hour. And, uh, you know, I can do the math. That sounds like a great job. And so the coincidental thing is that she had said, it's depression, schizophrenia, uh, you know, family therapy. I would've said, yeah, no matter what. So that. That was luck that got me into it. But then, of course, I might not have liked it. So why did I like it? And there are a couple things. One is the human part of it is very compelling. So I. In this job, I was. I was interviewing people as they were entering the addiction treatment system. And, you know, it is, um, you see everything that is interesting about life in the experience. People are addicted. You know, you see, um, struggles with control, search for meaning, love, death, sometimes, uh, conflict, uh, recovery, redemption, all that. And so I found that all very, at a human level, pretty fascinating. And then there was the intellectual puzzle, which is also interesting. Why do people do this? Why does Homo sapiens, for example, prioritize snorting a powder over eating food when they haven't eaten in three days? Why is it that we are capable of getting into a disordered state where you think everything evolution would have told us, um, in terms of take care of relationships, get warm when you're cold, eat when you're hungry, uh, all that could be thrown aside for the sake of molecules that have no nutritive value at all. And that is a fascinating thing about addiction. So there's two things together. It had the heart and it had the head. And that is what's kept me doing this for. Oh, my gosh.

Speaker B: That's an amazing origin story. And I have to tell you, it's probably the first time I've heard somebody talk about just sort of truly like the. The role of luck in finding what turned out to be your life's work. Uh, which is. Which is. Which is wonderful. And obviously you've had an incredible impact. Let's zoom in on some of the things with addiction that have been really important. One of. One of the things that, um, you wrote some important articles about over the last few years. I think in 2024, put out, um, some information on the decline in overdose deaths. Uh, starting 2024, overdose deaths were down 27%, the largest single year decline ever recorded. I think most Americans have no idea that this happened. And you, I think Helped to put together some of the studies on, like. So why did this happen? If you walk. Walk us through why you. Why, why you think it did, and. And maybe how you feel about the future and sort of where we're headed.

Speaker A: Yeah. So that paper was led by Casey Vangalov, uh, of the University of Maryland. It was a team of researchers, which I was one, and published in Science this January. And we were looking at this delightful but also mysterious phenomenon that we had 25 years of virtually unbroken increases in death, and we were trying all kinds of things that seem sensible, and deaths keep going up. And then in the middle of 2023, you see this sudden reversal, both the United States and in Canada, of deaths dropping, and they've continued to drop, by the way, to, uh, the most latest data we have, to the end of 2025. So we're like 40, 45% below. Why would that be? Well, it couldn't be something we were doing all the way along. I mean, it's important as treatment is as important as overdose rescue medications like naloxone is. We were doing that all the time. So what happened in 2023? And that's what we were trying to figure out. And, you know, what we did was, um, we looked at drugs that had been seized by law enforcement, particularly fentanyl, which is the synthetic opioid, which is by far accounting for most of our overdoses in the United States, and saw that the purity and availability of that drug was dropping dramatically. So law enforcement was making fewer infuser seizures. And when they seized it, both in pattern and pill form, the strength of that drug was declining, uh, really rapidly. Parallel to that, we looked at Reddit groups where there's groups where people talk about their drug use and finding drugs, and there was this huge surge in people using words like drought, uh, you know, weaker withdrawal. I, uh, can't find drugs. I'm quitting drugs because it's, you know,

Speaker B: this was literally the. The drugs were simply not as strong and as a result, not as deadly,

Speaker A: not as strong and not as available. So, you know, so that suggests a supply shock. Something must have happened to the drug supply. Then the question would be, well, where, um, did that come from? And to look at that, we looked at the United States and Canada. Those are the two. Uh, other than Estonia, a small European country, there's only two countries, US And Canada have really serious methadone, I'm sorry, real serious fentanyl problems. And we looked at the timing of the sort of drops in overdose and drops in Other indicators of the problem and show that that happened around the same time in the two continents. And why does that matter? Because the way the fentanyl trade works is precursor chemicals, which is sort of like the drugs you use to make the drugs, uh, start in China and they go to China, uh, Canada directly, and then Canadian traffickers convert those to fentanyl. Whereas the US Were out as a triangle. The, uh, precursors go to Mexico, Mexican cartels, China and fennel, and ship them north. So if this supply disruption had been due to, say, a Mexican intervention, you would have seen a drop in the US but not in Canada, because Mexico has nothing to do with Canadian drug trade. But since it was in both places at both times, the most plausible explanation, and it's just plausible. It's not like we have direct data on Chinese government action, but the most plausible explanation is China put pressure on those producers, and that was felt in downstream drug markets across all of North America.

Speaker B: There's so many interesting things to unpack there, including, actually, and this may be, uh, a field from your area of study, but I'm curious as to why fentanyl isn't a problem anywhere in the world but Canada, the United States, and Estonia of all places. Like, why is it a problem in Estonia and why isn't it a problem and, say, in the rest of Europe, for example?

Speaker A: Well, you know, this is, uh, one of the effects of prohibition. You know, if, if Amazon could sell fentanyl, it would be available everywhere on earth at a touch of a button. But, you know, one of the functions of, of prohibiting certain markets and prohibiting the production of certain products is diffusion of those products becomes dramatically less efficient. So, um, Estonia, for whatever reason, developed a fentanyl market, had it for 20 years. You can ride a ferry from Estonia over to Finland in 25 minutes. And yet it's never crossed. Um, and you see that a lot in illegal markets. In a legal market, it would be advertised all over, it would be distributed publicly, and it would have spread everywhere because from a seller's viewpoint, fentanyl costs about 1% of, uh, what fentanyl or heroin does to produce because there's no plants involved, there's no agriculture, there's no farms, there's no shipping. It's all whipped up in a lab. So, um, you would think that that would create a huge incentive on the supply side to make more fentanyl. But it hasn't spread because it's illegal. And that is something we get. And the much blind, you know, people complain about prohibitions, the One thing they forget is prohibition really limits the spread of illicit drugs.

Speaker B: So actually I'd love to use that as a segue into something I think has been very important in your career is our discussion of the role of policy and law in the treatment of addiction. And this is something people have talked about for a long time. Lots of experiments we've been on, famously in Portugal, et cetera. And I think the results, as I understand it, have been much more mixed and nuanced than sort of people were hoping. And I'd, uh, love it if you could sort of talk us through some of the things that your work helped to uncover as far as sort of the nature of public policy and the role of kind of community and law, uh, and its effect on addiction.

Speaker A: Let's start with some terms. So legalization typically refers to the legalization of the production and sale and advertising of illicit drugs. That's a separate problem, decriminalization, which generally means reducing penalties on the users, the person who just has a little drugs because they are going to use them themselves. Um, and in. We do, you know, if you look at legalization facts, you can see like, you know, the tobacco industry is an example of legalization policy. I mean, when you have a legal industry, you know, in a modern capitalist world with the global commerce, you can, those drugs will always be far more available than any other drug. Tobacco kills more drugs by a factor of 10 than every single illicit drug put together.

Speaker B: But there are costs and alcohol would probably be on that list.

Speaker A: Yes, yes, yes it is. Yeah, but there are obviously cost, prohibition, I mean any, any anything you prohibit, no matter what it is, you know, there's enforcement costs. You, you know, if you, there can be injustice, all those sorts of things, you know, that, and that's important to weigh all those in account. Decriminalization is less radical because you're still saying it's not legal to manufacture, sell and so on, and you're reducing the penalty on users. And sometimes I think, for example, if you go back, uh, you know, in the 50s, you know, where people were put in prison for a decade literally for using marijuana, you say, wow, that's a lot worse harm from the punishment than from the drug could ever do. Um, and so that, that's wonders people think about, you know, you know, decrim is, uh, you know, can make those more sensible, uh, trade offs. For example, California in 2010 converted possession, ah, of cannabis from a misdemeanor to a ticket, essentially like a parking ticket. Um, so what Oregon did was uh, you know, more Radical in that they said for all drugs of any sort, uh, possession was completely legalized. They also, for in small amounts and they also defelinized large possessions. So if you had a truckload of cocaine, it was only a misdemeanor. So that was a decision that probably, um, you know, accelerated the drug trade. Because what a deal if you're, if you're a drug dealer. Um, they, they claimed they were doing what Portugal does, but um, they really weren't because the way Portugal works and I spent, I should say I've spent a lot of time Portugal. I know the people designed their policy, um, they decriminalized, but they did not, uh, legitimize or stop discouraging drug use. So if you are using drugs on the street in Portugal, police office can pick you up and take you to what's called a dissuasion commission, which does pretty much what it sounds like. Who can pressure you into treatment. Like they can say, well we've done an assessment, we think you need treatment, you're a taxi driver, um, we're taking away your license unless you go to treatment. So, so they have that in. All of that was taken out by the Oregon advocates. They wanted no pressure whatsoever. The other thing that's different is Portugal is a conservative society by far compared to the US in general and certainly compared to the west west coast. Um, Portugal was a dictatorship in living memory. It is a Catholic inflected, communitarian society with very strong families. You, uh, know many people like if you go to Lisbon, you will meet people who, not only do they live there, but their mom and dad live there and their brothers and sisters live there and their parents live there. So there's a lot of watching and social constraint when you have a lot of social constraint. And social constraint is something we all encounter far more often than we encounter the law. Um, you have a certain amount of sort of protection, uh, around drug use getting out of control. Whereas in the west coast United States, here we are, we're individualistic, we're capitalistic, we're do what you want to be. You don't owe anybody anything.

Speaker B: Most people who are here are not from here. I mean some of the things that are super very interesting here are some of the double edged swords of the mobility, for example the United States, which has led to extraordinary opportunity and economic mobility, um, and people being able to get out from under, say stifling situations or a family situation, that's no good. It also means that people live a long way from where they were born and Away from some of, maybe some of the positive effects of social constraints that are a function of being in, in. In a neighborhood where everybody knows you. Yeah.

Speaker A: Very, very well said and exactly the case. I mean I've lived out here, you know for over 30 years. I love it out here. The, you know, the, the freedom, the individual, uh, individualism. Stanford I think has that culture and it's very nice culture so you can be creative. And it's why you know the music scene, the art scene, the Silicon Valley, all our entrepreneurs, why you know that they, you know, lesbian and gay rights and you know uh, it's a lot of people go to the Castro who grew up in small towns who could not be who they were there. And then they came here and they could. So there's plenty of good things about it. But that same kind of thinking and culture is a lot uh, uh, you know, goes from being a good thing to a bad thing. When we're talking about fentanyl use, you know, um, which kills a lot of people and is not really you expressing yourself, it's you being know losing your, your self control to a drug. And that was forgotten by the folks in Oregon. So you know they're um, forgot that you know if you take away, you already didn't have the cultural constraints and now you're moving the legal constraints. There were basically none. And so you know Oregon had the fastest growth of overdose of any state in the country. They as property crime was dropping and violent crime was dropping in the United States. It was going up uh there and uh, the other thing that's hard to capture with statistics but I would just tell you I went to Oregon. I go to Oregon a lot for some uh, some collaborations up there. Just the quality of life. Like you know, if you're just in a neighborhood in Portland say and you just wanted kids came home from school and uh, you just wanted to go to the park with them and like you can't. The park is an open air drug scene. And by the way you're going to have to step around a bunch of tents on your sidewalk and there's someone using drugs at your, you know, at your kid's school and all that sort of thing. Those things aren't necessarily what show up in crime statistics ordo statistics but it does change what it is like to for example try to raise a family.

Speaker B: Yeah. Sand in the gears of the quality of life. Um, it's interesting because there's been a, you know there was a minor league version of this in San Francisco as well, where uh, folks whose politics were probably generally quite liberal started to experience the impact of, of in some ways the first and most important role of the state is to keep you safe. And if uh, you and your children safe and if you don't feel that then you're going to see policy changes. I'm curious and perhaps there's no way to sort of tease these out as to whether or not you feel like the role of the, the social connection. Some of the things you described about Portugal as a historically conservative uh, state where people largely live in neighborhoods where they grew up. Lot of um, implicit social pressure was more important or this sort of dissuasion and almost coercion to say, get into treatment and uh, probably difficult to tease that out, uh, statistically but perhaps. I don't know if you, if you have a sense.

Speaker A: Yeah, I think the social controls are way more important. I mean if, if, and I feel that way about everything. I mean if you look at something like drunk driving, which is um, used to be considered a source of humor. If you, you know, if you, if you look back, you know, there's a, you know, um, if you watch a TV shows and things like that and, and sort of winked at and now you're a pariah. If you leave a party drunk and say, you know, one more for the road, well that, that is something more people will encounter. The look on their friends faces, you know, the disapproval of their families, then will be arrested for drunk driving. You know, you know, we don't, we don't interact with the law that much. You know, when you add up all the arrests, well, you know, the proportion of crimes compared to arrest is. The rest are trivial. Uh, share that. But whereas how often do we have to think about what does my family think, what do my neighbors think, what does my boss think? All the time. And, and so those will explain a lot more about substance use, social norms, cultural norms, your day to day things than the law. The law is kind of like maybe the backup. But you know, mostly, you know, you're. The reason you do the things you do is going to be the people you, you spend the most time with.

Speaker B: Yeah, it's interesting you say, I will say I've said this before on this, on this podcast. I think the most important heuristic for almost all human behavior in almost all situations is what are other humans doing. And, and there's a good evolutionary reason for that. If people aren't eating, if there people aren't eating the thing, it's probably poisonous. If people are dressed a certain way, it's probably appropriate for the weather or the social situation or for some reason. And so the simplest, least cognitively challenging thing to do is to behave like people around me. Um, and I think we've all experienced that.

Speaker A: But, yeah, I mean, we are a mimetic species. And the other part to it too is, of course, that's about resource gathering and sharing. So, you know, since we used to have a time of more scarcity of things like food, cooperation was essential. And you couldn't damage your social ties that much. You could literally. You would literally die if you were cast out of the, know, the tribe. And, um, that's. No, that's no longer the case. Um, and, you know, you see, that's one reason why, you see, if you go up, you know, like I volunteer in the Tenderloin, you see people, um, who have, you know, are away from their families and using drugs on the street. In one sense you'd say that's. That's a function of terrible poverty, but it's also a function of enormous wealth relative to what there was a thousand years ago. Somebody like that would just simply not have been alive. That you couldn't survive without social, uh, support and bonds, uh, through most of the history of homeless state games, you can today.

Speaker B: So maybe as a segue there, some of the other work that you've done has been around the efficacy of organizations like, uh, Alcoholics Anonymous. And it strikes me as interesting, I mean, somebody, uh, a psychologist, who presumably also believes in some of the other methods of, say, treating our mind and brain, whether that's therapy or, um, SSRIs or various drugs that we have and ways that we treat, um, anxiety, depression, addiction, et cetera, clearly sort of seem to interweave with kind of the. The social components, uh, like, how do we live? And AA has always struck me as sort of right. Right in the. Right in between. Right. Like AA is. There's a clearly a sort of a social and group component. I don't know how much of the notion of, say, disappointing your peers or maybe seeing sobriety modeled by your peers plays into this versus just the general impact of what seems like a quasi therapeutic approach of understanding what is troubling you and getting at root causes, et cetera. So maybe I'll start with actually, you know, if you don't mind describing some of the work you've done. And I know some of this is from earlier in your career, but around the efficacy of AA and, um. And. And then maybe if we can try to Pull it apart.

Speaker A: Yes, sure. So, you know, as, as I told the story of how I got into this field inhabit stance, I really had no idea what AA was when I started my career, but I started to meet some people in it. And my initial reaction, I don't mind saying, was kind of skeptical. How could that possibly work? You know, you got a, you have a disorder and you're, you got no doctors, you got no social workers, you got no psychiatrists, no, no, no medications. And somehow you're going to get better. Um, but, um, but, you know, I, I. Some friends, you know, I met took me to what are called open meetings, which you're allowed to attend if you're not a member. And I got to watch it. And I'm so impressed by the, the things you see there. Like, you know, there's social support. There's also a lot of practical strategy sharing and there's accountability too. Um, you know, it's not just support, it's also, you know, hey, you know, where were you Tuesday? There was a meeting, you know, um, you know, or your sponsor or senior member who's, who's establishment or helping a newer member, you know, saying. You may say things like, you know, you say your marriage is bad and it's 100, your wife's fault, you know, uh, but, you know, you contribute to this too, right? You know, what are you doing that they. All that kind of stuff and the installation of hope, you know, you, if you look at the role of particularly the storytelling, when people will come up and say, you know, here, here's what, here's what, you know, here's what I was like, here's what happened, here's what I'm like now. And these kind of narratives that they have this sort of structure of, you know, deep descent into addiction. And now I'm in AA and it's going really well. That is inspiring. You know, and if you see somebody sort of looks like you and whoever you define looking like you say, oh my God, you know, their life was every bit as much of a mess as mine is right now in this day. And they look great today. I would like that. Uh, and the people found it, were very conscious that that was the world's best sales tactic is those, those personal stories. And obviously it's worked for them. It's one of the, I think it's

Speaker B: clear empathy works is, I think, is easiest when you can identify with someone and it may be as crude a characteristic as they are the same age or gender or race as I am, but I suspect that, like, lived experience in this particular case is actually even more important.

Speaker A: Oh, yeah.

Speaker B: Yeah.

Speaker A: I mean, I, I feel like, you know, I, I, I don't do clinical care anymore, but, you know, I, I care about the people I tried to help. And I, uh, I think they, I think they knew that, and I think they felt correctly, that I knew something. You know, I mean, I, uh, scientifically trained, like, you know, cognitive behavioral therapy and stuff. But there is some special thing that I couldn't offer them of saying, you know, you don't have to tell me what it's like to be addicted to cocaine. I was addicted to cocaine for 10 years, you know, and you're telling what it's like to get fired because I got fired too. That, that, you know, which, which is an identification, but also is very good for the shame people feel, you know, of, uh, like, well, this person couldn't be looking down at me because they basically were me. Um, and that can, that can help form the, you know, uh, trust, um, in. Yeah.

Speaker B: Period. So how do you think about that and relation to maybe the sort of more formal world of treatment for addiction? So I know you do a lot of work at the va. For example, presumably, um, patients who struggle, perhaps they're coming to you for therapy. Perhaps they're also on meds. Are they also typically in a program like an AA Is that something is sort of, quote, prescribed? How do you think about that?

Speaker A: Yeah, so, I mean, in VA programs, most of them, AA is, is 12 steps, or at least, you know, part of the mix, or at least, you know, presented as an option. Why wouldn't they be there? You know, a, uh, cheap, widely available and often attractive, you know, community resource. Um, and this will be true outside the VA as well. I mean, if you go, you know, if you walk, lots, lots, lots of programs. You'll see, you know, the 12 steps on the wall and all that sort of thing. But, uh, but a, uh. Of course it's not just that. I mean, there's still, for example, in the va there's all kinds of medications available. There are, you know, job training, there are housing supports, there are psychotherapies, family therapies, all that sort of stuff that go along with that. I mean, what. One of the things I've always felt is it's not really my business how somebody recovers from addiction. And I, I, and I've been misunderstood on that before. Like, you know, I, I have two of my most cited papers. One is a systematic review done with a couple colleagues at Alcoholics Anonymous, which show all these benefits. But one of the other ones is the systematic review of acamprosate, uh, and naltrexone for, for, um, Medica, uh, which are medications for, for people who have alcohol use disorder. And I've had people read the A thing. So you're just one of those people hates medications. And I've had people read the medication. You one of those people hates puffs? Like, no, like I don't care. My colleagues in ecology never say, you know, well, this, uh, cancer patient got better, but unfortunately they chose radiation instead of surgery. They just want people to live. I mean, and, and, and so I think it's hurt the addiction field that it has at times had a more like a religious kind of framing of there's only one way to get to heaven. Whereas from a healthy point it was a. There's many ways to get to heaven and there's different heavens for that matter,

Speaker B: and, and probably positive interactions between the different modalities, like your social, your social and cultural environment around you matters. A 12 step program is helpful. Formal CBT based therapy is helpful. Perhaps depending on what's happening in your life, you need medicine. Uh, also. Yes.

Speaker A: And, and of course the population, which is, you know, we're talking about, we're 50 million people are very diverse. So, you know, it, what, what catches one person, you know, from. Pulls them out of the, you know, the lake and they're drowning can be utterly different than, you know, what pulls in the other person. So you have a, it's a strength to a care system to have lots of different things. Just like, you know, you know, we wouldn't want like gyms if like gyms had exercise bikes and nothing else like that would be really strange. Right. Um, and, and uh, there was a time when the US treatment system was kind of like that because, you know, was barely anything. So there was, you know, you could go to AA or otherwise no one would help you. Fortunately, now there's a lot more options. And that means from a population sense, you can help a wider range of people because it's not just a menu with one item.

Speaker B: Yeah. The ways in which, of course, we structure reimbursement for those are wildly different. Um, 12 step programs are often free, um, and volunteer driven, et cetera. Um, but, uh, um, well, so speaking actually of, of the way we reimburse for things because this makes me think about incentives, et cetera. You've been a policy advisor for at least three US Presidents. I don't know, perhaps even more. Um, what are the typical questions. What's an administration looking for when they call you?

Speaker A: Yeah, so the most consequential work I did was for President Obama. So the first I took a year off from Stanford and I worked in the White House as senior, uh, drug policy advisor. And the issue there was the Affordable Care act, you know, had been promised in the campaign. 60 million people voted for President Obama. So he had sort of the warrant and, you know, had the Congress with him. And the question is, how do you handle addiction in that. In an, uh, overhaul of healthcare system, are we going to treat it as a health problem and take it out of the kind of mixture, sort of social welfare and criminal justice where it had been. Our view. Our. Our view was very much. And our. Our White House office and the White House in general was, yeah, it should be covered in the same sense. Diabetes is covered or, or hypertension is covered or any chronic, uh, illness. And that is why, you know, the ACA covers you, uh, know, the is. It calls what's, you know, an essential healthcare benefit is for substance use disorder. And also that it embraces, uh, an insurance rule called parity, meaning that, you know, you can't have a rule where you say in your plan, you know, an outpatient visit is $10 copay, unless it's for substance use, your mental health, then it's $25. They got rid of that. And I think to the good. So you get a lot of questions about that, like, how does it fit towards this, fit in the, um, healthcare system? And then there's a lot of questions from the criminal justice side. And that is not because I'm gonna say, oh, it's just because, you know, oppression, war on drugs. Sure, there's, there's definitely been oppressive drug policies, but drug use, uh, drug addiction, alcohol addiction has a lot of, you know, what economists would call negative externalities, you know, effects on others. So a huge amount of violence is driven by substance use. And while we would say the addiction is a health problem, if I'm, you know, if I'm addicted to methamphetamine, that's a health problem. But, but because of my addiction health problem, I beat somebody up.

Speaker B: It's also a social problem, right? Yeah.

Speaker A: Criminal justice. And because there's a victim over there saying, hey, wait a minute, uh, I want this guy to get more than counseling. He, you know, he broke my nose. And so that there's that question of how do you handle that, um, in light of the fact that, you know, yes, it's a person. Yes, they Have a health problem, but also they're a threat to public safety. So I spent a lot of time on this sort of area, which is, you know, kind of jargon is therapeutic jurisprudence. But can you hold people accountable through the legal system, but at the same time not for desire fundamentally to punish them, but a desire to change their behavior through using the leverage you get from criminal justice system to, for example, make them enter treatment or make them submit to regular drug and alcohol tests and have consequences if they continue to use things like that. Those are the two big bands. There's some other things we worked on, like, you know, we mentioned, uh, the fentanyl studies, you know, studies. There's issues around drum flows and foreign policy, uh, and things like that. But mostly I'm talking either, you know, docs or cops, uh, in my work.

Speaker B: Yeah, the negative externalities, uh, piece is obviously profoundly important when you're talking about substance use disorder. The other thing that is always struck me as interesting is obviously addiction is in part a disease of the brain and mind, but as we've discussed earlier, also social strictures and also impacted clearly by the law. Um, ah, other people have made this point that like in Singapore, there is no addiction. Right. Why? Because if you bring addictive drugs into Singapore, you are executed. And it. You. And the interesting thing about that is, as, uh, they pointed out, you cannot legalize away. You cannot legislate away cancer. There is no law you can implement, although you can legislate away some of the things that cause cancer. You could. You could make smoking illegal, for example, and that would. That would eliminate some cancers, but not. All right. Um, whereas they have essentially eliminated addiction and as a result, addiction deaths, um, by. With truly stringent, uh, legal strictures. Now, I'm not sure I want to live in that society, but that is. But it does. It does point out the fact that these things are. Are much more multifactorial, um, as. As we've been discussing.

Speaker A: Yeah, I mean, you have a specific agent, like nobody gets addicted without the drugs, you know, but people can. Anybody can have a heart attack. Anyone can have schizophrenia, you know. So you're right, that does bring some other policies into the frame and, you know, with thoughts about how to. How to handle that. And that's also true in illicit markets. You know, if you've got, again, like tobacco, you know, we know that, um, there are ways to constrain supply through things like, uh, licensing sellers and, uh, changing the tax structure.

Speaker B: I mean, simply making it, uh, illegal to smoke in restaurants, I think was extraordinary. I was living in New York where when Mayor Bloomberg was one of the first people in the world really to implement some of these anti smoking measures and uh, I can't tell you how much I saved in dry cleaning, but also the impact over time in terms of the number of smokers and as a result the number of people whose lives have been saved. I'm sure somebody has calculated, but it's truly incredible. Um, and they were able to do that without making smoking illegal, just making smoking difficult and socially less acceptable and eventually sort of socially unacceptable. And, and uh, that's been very, very powerful.

Speaker A: Yeah, absolutely. That's why you know, the rate has dropped, you know, absolutely ubiquitous. You know, in the 50s. You and I would be smoking right now, right during this conversation. And now it's less than 10% of Americans, which is an astounding public health achievement.

Speaker B: Fair enough. Um, so uh, if you were, I suppose you may have uh, young researchers in your lab. I was thinking if I was a young researcher coming into the field today, psychologists thinking about the future of uh, addiction, addiction treatment, how to think about substance use disorder, um, and reducing sort of the scourge and challenge of the disorder. Where would you point them? What do you think are the most interesting areas of development in the field?

Speaker A: A big one is we need better therapeutics. There is no medication for stimulants, so method cocaine. There is no medication for cannabis. Um, we have um, we have some meds for the other addictions but you know there's always ways to get better. We have some really fascinating findings that I'm interested in on medications that were made to change the gut and you know, hor hormones in the gut and like in uh, GLP1 agonist, um, you know, uh, for diabetes and obesity. And then you see people in these studies drinking, smoking, using less drugs. That's a really interesting area to cry for. Therapeutically. There's some interesting brain stimulation work you uh, know with RTMs, um, you know that could be uh, productive. So some, some stuff on therapeutics. And then the other one is, you know, I think there's a really big deal is trying to find a third way at the policy level between uh, you know, carceral racist war on drugs, you know, which had in sort of the 80s and 90s and a free for all like they had in Oregon, the libertarian free for all. And you know, activists tend to frame this as you only have two choices. I mean it's a classic radical thing like you know, either, either you're, you know, you're either you're, you know, you're

Speaker B: with us or you're against us or

Speaker A: loyal socialists or the other way around. Um, but the truth is there's not just some big switch. It's a series of dials. Like you have to adjust them and that sort of thing. But you're figuring out those sorts of things. Like, you know, like, for example, they're now figuring out in Oregon they repealed what they did. It didn't work, but they, they had no desire to have a war on drugs. So what do you do instead? You know, you're going to have, you got to figure out what will happen when the criminal justice system has contact with someone who's, you know, shooting fentanyl in the, in the park or is running around, you know, in, in a intersection full of cars, high on cocaine. You have to figure that out. And then you have to figure out, like, how will you structure a treatment system that is attractive enough that people will voluntarily want to go to it? But also, um, when, you know, people are under pressure, you know, from the criminal justice system or their families or their neighbors or their employers, that, that, that system is able to use that pressure constructively as a motivator for change, those kind of things. Then the last one, things everyone forgets about is prevention. I mean, the, you know, it is the, the only, the only thing I can guarantee you about addiction is if, if you don't use a drug, you will never get addicted to it. And after that there's no, I'm not making any promises. I can talk about risk, but that's the only sure thing. So the extent we have succeeded in prevention, like the fact that, you know, huge number of young people now, you know, are not initiating, uh, uh, tobacco in, in, in teen years like we did or, or, or not drinking, um, or not using drugs is, is a much bigger impact on society than anything we do in the treatment space or the harm reduction space. Because, you know, so you know, your, as, as your listeners will know. You know, when the brain is plastic, is it most, you know, it's when we're younger and you know, and that's when lifetime habits are formed and that's where addictions are formed. So if, if you can get through, you know, that, that period and you know, from teen years into your early 20s without using some substance, your odds of ever being addicted to it for the next 60 years are vanishingly small. And so that's a huge payoff from prevention. But prevention is often forgotten or it's misunderstood. People think, oh, prevention is like day error from 50 years ago, which is not the state of prevention at all. Um, but that's something that always needs to be thought about because our normal human reaction is to react to the crisis. So we've got someone in front of who's dying from an overdose. Of course we want to help them, but you also got to think, now, wait a minute, I've got millions of other people who could become that person 20 years from now. What do I do today? So I'm not constantly running from crisis to crisis for the rest of time.

Speaker B: So much interesting work to be done in the next decade. I was just thinking, like, so many fun threads to pull on there. Ah, I know that the preliminary data from the GLP1, like, uh, drugs in regards to addictions to, uh, many different things, are very, very positive and promising. Uh, I think we're still waiting for the Phase 3s to read out, but I would be shocked if we weren't able to find meds that. The way I think about GLP1s is there's nothing in our evolutionary history that prepared us for the abundance around us of things that are sweet and delicious and what have you. So of, of course, almost everyone ends up obese, um, uh, without some way to modulate that, um, you know, that primary pathway. And that's probably true for, like, all the things that we evolved to crave. There's nothing in our evolutionary history that prepared somebody for their first hit of an opioid. To your point about probably best to never try, it also relates to policies vis a vis, uh, people receiving pain meds. Of course, um, inside the US Healthcare system, if they're not in, say, a terminal disease state, um, is something else to discuss, but we are gonna run out of time here. But Keith, I really want to thank you. This was really wonderful. I'll leave you with our final question we ask everybody who comes on the show, which is, you know, the podcast is at the sort of the intersection of mental, behavioral health, uh, neuroscience, and in some cases the influence of AI Uh, on both of those curious about anything you're reading, listening to, watching, um, that people who are interested in your work might find exciting. Um, of, uh, course, one that jumps out at me, for example, is for those who haven't seen, I think it's season two of the Wire, where they have the sort of the Hamsterdam, uh, experiment, where they sort of quasi experiment off the books with this notion of legalizing drugs. Um, and, and sort of the mixed results, uh, is. Is one that I would think of when and based on our conversation. But I'm curious if you have things that um, you're, you're reading or watching or listening to that you'd recommend.

Speaker A: Yeah, well, what an interesting question. I mean, you know, I, I am finding it fascinating to uh, look at the incredible amount of public data that people post about their drug use and where they buy drugs and how they get drugs. And if there are now sites you can see like what drugs cost and where they're used, people are tweeting about these things. And some colleagues and I have been working on this routine led by Russ Altman, showing that you can even use that to predict overdoses. Like if you look at where people are tweeting the most about fentanyl or where they're putting the most Instagram or TikToks about various drugs, you can predict the future. So it, the, and that's really important because most of the systems we have are kind of slow and concrete and all that. And the other thing is it's a way to get honest information that is hard to get from a person. I mean if you ask somebody, you know, do you use fentanyl, they're very likely to say no if they do and then. But not tell you that much about it. But the anonymity of online, you know, has people disclosed a lot more. So it's, it gives you a, if you're, if you're, you know, I'm outside the fentanyl using community, um, it gives me ah, insight into what honestly what people say, what advice they give each other and what myths they spread, what truths they spread. Um, and I find that all just, you know, an incredible thing, uh, that comes out of these new technologies, uh, that we have. Of course there's some problems that come from it, but this is something of letting us understand each other, which is

Speaker B: an epidemiological leading indicator. That's amazing. Uh, very interesting. We'll have to, we'll, we'll turn a hackathon loose on that and see if uh, maybe some, some interesting tools for, for uh, for folks like yourself who are helping to make the addiction problem better can uh, can intervene. That's, this is wonderful. Thanks so much again for the time.

Speaker A: Thank you. Really great to be on the show. Be well.

Speaker B: Cheers. Thanks. The thing I keep coming back to from this conversation, it's Keith's point that social norms do more work than the law ever could. The reason drunk driving became unacceptable wasn't the arrests. It was the look on our friends faces. If we want to fix addiction, loneliness and the broader mental health crisis, we may need to think less about policy levers and more about the fabric of communities we're building. In the next episode, I'm sitting down with Dr. Deb Howery, former chief medical officer of the CDC Emergency Physician and one of the country's foremost experts on public health, injury prevention and what it actually takes to protect people at scale. If Keith gave us the community view, Deb gives us the systems view. Neural Compass is brought to you by Jiminy Health. To find out more about Jiminy Health and how our clinical grade AI solutions are helping to shape the future of behavioral health, visit J I M M I n I health.com and then make sure to search for Neural Compass in Apple Podcasts, Spotify or anywhere else your podcasts are found. Make sure to click subscribe so you don't miss any future episodes. And on behalf of the team here at Jiminy, thanks for listening.