Transcript: “Capehart” with Rahul Gupta, Director of White House Office of National Drug Control Policy

DR. GUPTA: Thank you for having me, Jonathan. I appreciate it.

MR. CAPEHART: So Dr. Gupta, the fentanyl overdoses are an evolution from the prescription pain meds epidemic from the early 2000s. Talk about that evolution, and where does fentanyl come from and what is the administration doing now to stop it coming into the country.

DR. GUPTA: Well, you know, as a practicing physician for the last two decades plus, I was right there in the trenches when we began opioids, and as a result of what happened was we started to see people started dying because of overdose from opioids, prescription opioids. And as we moved forward to make really good policies to prevent that from happening, the consequence was people moved to the cheaper, more readily available alternative on the streets oftentimes, that was oftentimes injection use of heroin.

And I was a practicing physician and I saw full-time in the emergency room sometimes there would be hardly a shift that I would go through without reversing an overdose from an opioid at the time, for months at a time. And that was so important because I would see some people make it, other people not make it because of the disease of addiction.

But what has happened since is that we began to see a fentanyl being cut, an opioid that is up to 100 times more potent than morphine. So we started to see that mix in with heroin on the streets. And now today we see fentanyl basically overtake the opioid supply of the nation, from an illicit perspective. The reason that’s important is, you know, almost going away are the days when we had organic drugs that we’ve had for thousands of years, like cocaine, marijuana, and others, and heroin especially, where you had crops, farmers, fertilizers, you can measure those crops and get an estimate of what’s being produced. Today, all you need is a small amount of closet, a small closet and the imagination of the chemist to produce these synthetic, deadly substances that come in very small quantities and kill a lot of people, unfortunately, in a very small amount of time.

MR. CAPEHART: So then, Dr. Gupta, who is making it? Where is it coming from?

DR. GUPTA: Well, the entire supply chain actually really starts from precursor chemicals that are shipped from China, oftentimes to ports in Mexico, and the production labs, small, difficult-to-detect labs happen in Mexico, and then they end up in the most vulnerable communities across the border, into the United States. And that’s an important piece to understand the entire supply chain because it is the profits that are driving. It is not the ideology but profits, pure, sheer profits that is driving this particular illicit trade.

MR. CAPEHART: You know, I’m sure you saw this Washington Post investigation from 2018, that found that the Obama administration failed to grasp fentanyl’s threat and failed to organize an effective strategy as deaths soared. It’s been nearly 10 years since fentanyl started claiming the lives of thousands of Americans. Do you wonder how different the opioid epidemic might look today if more immediate action was taken?

DR. GUPTA: Well, I think one of the important pieces forever has been a part of U.S. drug policy is we must recognize the challenge and the threat in front of us rather than to later look in the rear-view mirror, and that’s exactly what we’re trying to do now, because when we do that, we can then innovate policies and strategies that can help us save lives right now.

Of course, this evolution that has happened, it’s important to talk about it because we’re in a very different–what I often say is it’s not your grandmother’s drug epidemic. This is very different. We have synthetic substances for the first time, fentanyl being one of them, meth being another one, and it’s important for us now to be able to take steps, unprecedented sometimes, that will help us, first and foremost, save lives and then get the help people need. So it’s really important for us to stay focused but also understand what can happen in a predictive way and act against it now.

MR. CAPEHART: So, of course, listening to your answer there, Dr. Gupta, immediately my mind went to harm reduction. There are some folks who believe that harm reduction–and that is providing clean needles to drug users as a way of stemming disease–but there are some folks who say that that encourages drug use. Is there any evidence, scientific evidence, that that is indeed the case?

DR. GUPTA: Well let me be really clear. Absolutely not, but let me expand on that as well.

You know, as a physician, someone who has not only seen patients in harm reduction clinics but have distributed syringes and seen the effects, the tremendous effects on human lives in terms of endocarditis infection of your heart valves that often becomes very permanent, lifelong, and very dangerous and costly. Oftentimes we see people dying from fentanyl. Oftentimes we see spread of communicable diseases like HIV and hepatitis, which are also lifelong oftentimes and very expensive to treat.

You know, if we have good strategies that are based in evidence and science and are cost effective, we should deploy them. That’s exactly what this administration has done for the first time. You know, President Biden has been very clear–let’s make sure we’re saving lives and getting people with science-driven policy to help the need. And issues like naloxone, syringe service programs, fentanyl test strips for people to know that there’s fentanyl in their own drug supply are some of the most lifesaving strategies, but they also help connect people, help us meet people where they are and connect them to care and other services.

So it’s really important. I think one of the important pieces that often gets lost is in the 21st century we need to be moving and helping people where they are, not waiting for them to come to us. And me, as a physician, I can tell you that. With all of the aspects of health care system, one of the things we lack oftentimes is meeting people where they are and helping them, and that’s exactly what we’re trying to do.

MR. CAPEHART: Well more on that point, I want to bring up California, because back in August Governor Gavin Newsom vetoed a bill that would have allowed a few supervised injection facilities to open in that state, on a trial basis. This is a Democratic governor of a blue state, of a true-blue state. If he’s vetoing such efforts what’s it going to take to have state leaders be more open to these types of harm reduction programs, or in the words that you used, meeting people where they are?

DR. GUPTA: Well I think it’s going to be science, research, and data, because we must be following those aspects. And it’s important that we understand the science, and I’ve said this before that we want to make sure that we’re looking at the research of any emerging harm reduction practices and the clinical effectiveness of that.

Now specific aspects, as you know, that particularly there’s litigation in courts in regards to some of these aspects, and so I’m going to leave it there and not get ahead of it. But it is important that we follow the science, we follow the evidence, and go where it takes us, with the aim to save lives first.

MR. CAPEHART: Dr. Gupta, the recent surge of fentanyl overdose deaths has hit Black and Native American communities particularly hard. What specifically is the administration doing to help those communities?

DR. GUPTA: You know, from day one, President Biden was very clear that we must take a lens of equity and justice when it comes to addressing so many programs but especially drug policy. And one of the facts that is really important to understand is, you know, for the longest time, Jonathan, you mentioned what began as a prescription opioid epidemic. You know, Black Americans often were not prescribed pain medicines at the same scale, and that was partially due to the stigma within the health care system against pain for Black Americans. But also what happened was now the risk has become even greater for our Black and brown communities because it has become about counterfeit drugs, illicit fentanyl.

You know, today 2 out of 5 times the chance if someone is taking a fake or counterfeit pill that you’re going to end up dying from a fentanyl overdose, potentially. Now those numbers are worse than playing Russian roulette with your life, if you think about it, and that’s where we’re seeing some of the highest increases in the Black community. In fact, it is Black Americans, when you just look at the data, over 50 that are bearing the most brunt. So it’s not even one age group that is staying consistent across all races.

So it’s really important, and that’s one of the things we’re looking at, because the other side of this is also not good news, which is when you look at the treatment data, Black Americans and brown Americans tend to seek treatment much more delayed in timeline for addiction than others.

So it’s a double whammy of sorts, and that’s why it’s been very important for us to not only expand harm reduction approaches but also treatment, addiction treatment infrastructure, so we can get the same opportunity in an equitable manner to all people across the country.

MR. CAPEHART: So Dr. Gupta, is that delay among African Americans, that delay in treatment, is that because they themselves delay getting into treatment or is that a question of access to treatment and not having the access to treatment in a timely manner?

DR. GUPTA: Jonathan, great question. Both, and so many other factors, meaning first is stigma. Stigma in addiction is so important because it pervades through communities, individuals, families, neighborhoods, as well as through the health care system. And stigma often, for Black and brown communities, prevents both the individuals from seeking care but also the health care systems engaging individuals at an early stage.

Second is access. Third is insurance coverage and the ability to be aware of what your coverage is. And that’s why things like Inflation Reduction Act become so important to increase the access to health insurance, provide people with the coverage, and be aware of that becomes important.

The fact today is less than 1 out of 10 Americans who need treatment for addiction aren’t getting it. Less than 1 out of 10 in the United States of America. That’s the state of affairs today. We are where cancer was about 100 years ago. So we have to work to create the addiction treatment infrastructure, try to work on stigma, and especially with a lens of equity, both in public health and the medical side but also on the criminal justice side as well.

MR. CAPEHART: That’s a great segue to a question, an audience question from Molly, from my home state of New Jersey. She asks, “Treatment is just the first step. How does long-term recovery figure into the way addiction is addressed?”

DR. GUPTA: Molly, that is such a great, great, important question. When I travel across the nation one of the things is I meet with so many people in recovery, and, you know, treatment I often say, as a physician, is just not about treatment. It’s about recovery and support services.

One of the things I hear most about is housing, for example, housing, economic opportunity, a job, transportation, things like food security, things like childcare. These things become so important in a driver.

I’ll tell you, just yesterday I was with someone who was trying to get a drug dealer off the street, and they found them a job in a facility. And the drug dealer actually quit the job after a few weeks, and the person asked, “Why, after all this hard work?” And they said, “Well, because it was costing me more on Uber and Lyft to get to my work than I was getting reimbursed for, so I better go back to my old job.”

This is the challenge that we face as a nation every day in terms of what support services and wraparound services we need for people, tens of millions of Americans in recovery today.

MR. CAPEHART: Your answer is a nice segue into the other audience question that I have this time, this time from Julie Schwab in Wisconsin, who asks, “Housing is a crucial part of recovery support when an individual leaves drug rehab, detox, jail, prison, homeless shelters, et cetera. When will there be funding for recovery housing? When will HUD create a supportive recovery housing category?”

DR. GUPTA: That’s a great question, and I’ll tell you, I am working very closely with the Department of Labor. In fact, housing is one of the most important pieces that I hear from Americans every single day. We are working with HUD. In fact, there was a recent release of a significant amount of dollars that include people with substance use disorders to be able to get housing. I hope folks are able to check that out or share that information as well.

But it’s also important that when we talk about both jobs and housing in terms of getting the support people need it is really important, both transitional housing but also permanent housing.

Some of the housing regulations are of the past, and that’s exactly what we’re also trying to make sure that are updated because it turns out sometimes people need to move to a different location and have the support structure behind them to be able to create that.

So we are working on it. There are lots of changes that have happened. We’re working with states and local jurisdictions to make sure that our policies support the people that we are all serving.

MR. CAPEHART: Let’s talk about the big price tag that is needed to address the opioid epidemic. Four years ago, on this podcast, under a different name, when Trump was in office, former assistant surgeon general Susan Blumenthal told me that at least $45 billion would be needed to address the opioid crisis. The price tag is surely higher today. So what kind of investment is the Biden administration willing to make?

DR. GUPTA: Jonathan, let me first state the cost of this crisis. Just a few weeks ago the Joint Economic Committee of Congress put the cost in 2020 dollars of the opioid crisis to be $1.5 trillion, in 2020 alone–$1.5 trillion, with a T. Now in 2020, that was the GDP of Russia. We are losing the equivalent of GDP of Russia every year because of this. Not only that, the National Bureau of Economic Research shows that up to 26 percent of a labor force participation loss compared to pre-pandemic levels because of substance use disorders.

So if you look at that challenge, we have to make sure, as President Biden has said, we will provide the resources and the help to communities, what it will take for us to beat the opioid crisis.

Now we have just announced about $1.6 billion for communities across all states and territories to be able to access treatment, prevention, and recovery support services. That builds up to the $5 billion in American Rescue Plan that was already announced earlier. The amount of funding that is going out is very helpful to communities that I speak with.

Now the president also asked Congress, in his budget proposal, to increase budget by $3.2 billion for drug control budgets. The reason that is, is because 75 cents of every dollar of the increase goes into providing communities supports for prevention, treatment, and recovery support services. It’s really important that we as a nation are able to match and exceed the expectations of people across in communities with the resources–it’s not just talk–because the cost overall is so large of doing nothing or doing not enough.

MR. CAPEHART: Here’s something I would love to get your reaction to. Beth Macy, who is the author of “Dopesick,” which chronicles the rise of prescription drugs abuse, wrote in an op-ed recently, in The Washington Post, that “If the administration offered free treatment on demand for people who can’t afford it, the way HIV/AIDS treatment was available in the 1990s, the United States would be able to curb the number of people who die from overdose.”

Why isn’t that being done?

DR. GUPTA: Well, we’re working towards that, those types of approaches. That’s exactly right. So let’s look at the drug called naloxone, or Narcan, as people often name it. We know that 3 out of 4 Americans out of the 108,000 that died last year are dying because of an illicit opioid like fentanyl. Now if we have enough naloxone in communities we can save tens of thousands of people right now, and that’s exactly one of the areas we’re focused on, in making sure that happens.

Once we do that, we want to also make sure that people are connected to treatment and we remove the ability, the challenge of affordability, the challenge of access. And that’s where we have provided expanded telehealth services. So today, you know, one of the silver linings in the COVID pandemic has been the expansion of telehealth to approach and reach rural communities, communities that have been chronically deprived of care, as well as others. This is a way to get there.

But, you know, things like health insurance access, things like making sure that there’s a coverage limit on the co-pays are very important, because that’s the way we’re going to get there. We also want to make sure that our policy, the President’s own strategy, calls for universal access to treatment by 2025.

So actually, what Beth has stated is exactly what we have in our strategy. That’s exactly what we’re working towards.

MR. CAPEHART: So we spent the bulk of this conversation talking about opioids, fentanyl. Let’s talk about pot. Dr. Gupta, earlier this month, as you well know, President Biden called on HHS Secretary Xavier Becerra and Attorney General Merrick Garland to review marijuana’s classification under federal law as a Schedule I narcotic. When do you expect that review to be done?

DR. GUPTA: Well, it will be done expeditiously because the President has asked for it to be done expeditiously. But before that I just wanted to mention that what the President has announced is historic in nature. No one before, in the history of the United States, has made those proclamations. First of all, he has asked for pardoning from all federal systems of anyone convicted or arrested for the use or possession of marijuana. This will impact thousands of people.

Secondly, he has called on governors to do the same across the states because that’s where the bulk of those folks are. And thirdly, of course, as you mentioned, he’s called on looking at the scheduling between the attorney general and the HHS secretary in an expeditious way, and we will continue to monitor that process as well.

MR. CAPEHART: Is this the first step to decriminalization?

DR. GUPTA: Well, this is certainly a step that the President believes deeply in. He believes that people should not be arrested or convicted for sole possession or use of marijuana. It’s really important because, you know, when you look at the numbers, we’ve had over half a million arrests in any given year, and guess what? The arrests for the same prevalence of use is four times, nearly four times as much for Black Americans as compared to White Americans. These are the kinds of actions that President Biden has announced will help us look at our justice policies from an equity lens, and it’s an action that is going to impact the lives of Americans.

And so many ask how, why? Well, because here’s why. When you have that ding on your record you can’t get public housing. You can’t get government loans. You can’t get employment. You can’t get a lot of the other services, even child welfare benefits. You can’t even sit on a jury in so many jurisdictions because of that. It takes and deprives the lives of individuals.

When I was a physician, full-time practicing, I saw so many people in my practice that would come, and the lost economic opportunity, a lot of those diseases and suffering will be as a result of that.

So this is going to make a big difference for people’s lives in so many ways.

MR. CAPEHART: You are a doctor, and many times in this conversation you said we’ve got to follow the science. When you follow the science when it comes to marijuana, does it make sense that it is criminalized? Or let me put it this way. There are people who don’t want marijuana to be decriminalized, and say that it is, quote, “a gateway drug to other things.” This is 2022. Does that argument scientifically have any weight?

DR. GUPTA: Well, let me break it down, Jonathan. That’s a great question. First, we know that there have been documented and clearly data is behind certain medical uses for cannabis. We also know, at the same time, that there is plenty of evidence that when we talk about children and their growing brain, the use of marijuana does impact negatively in terms of your areas of where their emotion and learning and decision-making, all those get impacted as well. So just as any substance for growing brain isn’t good, it isn’t good for children and adolescents as well.

But that doesn’t nullify the medical benefits that have been documented in science over the years, and a lot of this is developing science. I mean, there have been bans on marijuana, and that’s resulted in a deficiency of literature and science and scientific research behind it.

So I’m glad that we’re able to see more science develop so we will get closer to the truth that we can. To me, as a scientist, it’s really important to know, hey, what are the effects, both good and bad, so we can make good, sound policy based on that data.

MR. CAPEHART: You’re the head of, as I said before, the White House Office of National Drug Policy, aka, “the drug czar.” You are also the first medical doctor to be in the position. What surprised you most about this job?

DR. GUPTA: Well, I think, you know, working for almost 25 years in primary care practice in some of the most rural areas across the nation and the most urban areas across the world has allowed me to see what the real harms of having, you know, bad drug policies ends up, which is build true harm to people across both the country and the globe. But also, at the same time, we have profit-driven drug trafficking organizations and oftentimes transnational criminal organizations that aim to harm people as well.

So, you know, the most important and surprising piece for me has been that we need to use our data, both on the justice side as well as on the public health side, to make the best decisions possible. And that’s an important piece that I bring to the table because I’ve seen way too many patients that have gone on to have successful lives. I mean, at the end of the day, we’re in 2022, addiction is a brain disease that impacts so much in your body, but your community as well as everybody.

And it’s important that we look at addiction as a brain disease, and help get treatment for people while, for the traffickers, we get justice. And that ability and that opportunity is one that I take very seriously, and the service of American people I take very seriously, and I’m just honored to be in this position, and my ability to make a difference.

MR. CAPEHART: Do you feel like you’re being heard?

DR. GUPTA: Oh absolutely. I think every single day, when we have an American perishing every five minutes around the clock, it is something that I carry in my heart all the time, as a physician, someone who has taken an oath to do no harm. You know, oftentimes I compare that to when I’m saving somebody running at CPR or a code in the hospital, and I feel sometimes that there’s more we can do and we must do.

So of all the things that we’ve been able to do so far, to get naloxone out there, to get treatment expansion, to get telehealth, I think there’s so much more that needs to be done. Because although now we’re seeing a 35 percent increase in drug overdoses around pandemic, to come down to now 6 percent, we’re seeing a flattening, but there’s so much more work that needs to be done across the nation, and that’s exactly–of course, I think the word is getting around.

MR. CAPEHART: Last question for you, and that is this. What health threats keep you up at night?

DR. GUPTA: Well, as I mentioned before, the opening of the synthetic drug systems has really opened a Pandora’s box. We, this nation, this world has never, ever seen a threat that you can create in a small place, and literally be imaginative in nature, and get to it. We’re in a very different stage in the world. It is that which is very important.

Our systems have been–you know, we’ve had the tools of the 20th century oftentimes that we try to apply in the 21st century, in so many areas. This is one area we cannot afford to do so. So it’s a matter of just making sure that we’re building 21st century tools, because the threat has never been greater or never has been more severe.

So it’s really important for us to not only be looking at emerging threats from drugs but at the same time providing people the help and the care that they need, and building that addiction treatment infrastructure while making sure we have policies that are compassionate, caring, and evidence driven.

MR. CAPEHART: Dr. Rahul Gupta, the “drug czar,” or more formally the director of the White House Office of National Drug Policy, thank you very much for coming to “Capehart” on Washington Post Live.

DR. GUPTA: Thank you for having me, Jonathan.

MR. CAPEHART: And thank you for joining us. To check out what interviews we have coming up go to WashingtonPostLive.com.

Once again, I’m Jonathan Capehart, associate editor at The Washington Post. Thank you for watching “Capehart” on Washington Post Live.