Factually! with Adam Conover - America’s Other Epidemic with Vikram Krishnasamy, M.D.

Episode Date: October 7, 2020

Physician Vikram Krishnasamy joins Adam to discuss his work fighting the opioid epidemic at the CDC, for which he won the 2020 Service to America Medal, and why he decided to devote himself to public service. Learn more about your ad choices. Visit megaphone.fm/adchoices See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

You know, I got to confess, I have always been a sucker for Japanese treats. I love going down a little Tokyo, heading to a convenience store, and grabbing all those brightly colored, fun-packaged boxes off of the shelf. But you know what? I don't get the chance to go down there as often as I would like to. And that is why I am so thrilled that Bokksu, a Japanese snack subscription box, chose to sponsor this episode. What's gotten me so excited about Bokksu is that these aren't just your run-of-the-mill grocery store finds. Each box comes packed with 20 unique snacks that you can only find in Japan itself.

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So if all of that sounds good, if you want a big box of delicious snacks like this for yourself, use the code factually for $15 off your first order at Bokksu.com. That's code factually for $15 off your first order on Bokksu.com. I don't know the way. I don't know what to think. I don't know what to say. Yeah, but that's alright. Yeah, that's okay. I don't know anything. Hello, welcome to Factually, I'm Adam Conover, and you know, America knows the impact of disease now more than ever, don't we? It's destroyed our collective year with more than 200,000 people dead and at least 7.25 million Americans infected with COVID-19. Disease is the central fact of 2020. I think we can all agree with politics running a close second for now, could overtake it if we are that unlucky. But the truth is, COVID-19 is hardly our only epidemic right now, because for the last 20 years, we've actually been facing an opioid crisis that is so bad it's led to the decline of American life expectancy, something that hasn't happened in a century.

We've been going up, up, up, living longer and longer for the last hundred years, and now we're going down in part because of the opioid crisis. The death rate from overdoses has gone up six times between 1999 and 2017. It has sextupled, for you crossword puzzle doers out there in just less than 20 years. And that's resulted in nearly half a million deaths and thousands more in opioid related suicides. It is a true epidemic that is costing us countless lives. So how do we get here? Well, the story starts with well-intentioned doctors in the 80s and 90s who started recognizing pain as something that their patients were struggling with, as being a rising condition that was really impacting people's life. And an idea grew without much backup that opioids were only addictive when used recreationally, that if you use them to treat, say, chronic back pain that ruins your days and haunts your dreams and makes your life a living hell, well, you wouldn't get addicted. That would just make your pain feel better.

Now, this idea was dead wrong. But in the mid-90s, the pharmaceutical industry, led by opioid villain Purdue Pharma, started aggressively pushing this supposed wonder drug, a time-released pain management miracle known as OxyContin. Ignorant American doctors who were misled by the marketing bought that company line, and it was far easier to get our crappy American health insurance to pay for pills than it was to get them to pay for physical therapy. So these pills started being prescribed in droves. The result? Fast forward a few decades later

and nearly 70% of all American overdose deaths involve an opioid. So, what do we do about this corporate-created crisis? Well, in the 80s, America took a zero-tolerance approach to drug abuse. Drugs were a moral bad that all good citizens, all upright folks avoid. Drug dealers and even some users we thought needed to be sent to jail to fix their problem because it was their

choice and their fault that they got hooked. And racism played a starring role in the drug war of the 80s and 90s too, of course, because when it was black and brown people using and selling drugs, our society was happy to lock them up en masse, helping build the scaffolding of what we today call mass incarceration. But today, in 2020, we now know a lot more about addiction and how it works. And frankly, because the opioid crisis now impacts a population largely white and often rural, our politicians have finally realized that a, quote, war on drugs is really a war on our own people. That's what it was all along, but they finally have caught up to that fact.

We now understand that addiction is actually a medical issue. It's a health problem. And when you're trying to deal with a health problem, you use different policy tools to address it than you do a moral one. For instance, you might focus on harm reduction that hopes first and foremost to stop people from dying as its very first goal. And then, for instance, you might seek replacement therapies like methadone treatment or etc. rather than moral instruction or imprisonment as the penalty for drug abuse. Addiction, we now know, and I hope most people are beginning to understand,

is not a personal failing. It's a public health issue, just like COVID or diabetes. And that means that to address it, we need to look less to law enforcement and more to health inflourishment, treatment, something like that. It's a health problem. We need to use health tools to deal with it. Okay, that's the point. So if we want to know how to deal with the opioid crisis, instead of talking to law enforcement, we need to talk to people who work in public health. And I'm so happy to say we have got one of those people here today. His name is Vikram Krishnasani, and he is a medical officer where he helps to fight the opioid crisis at the CDC in Atlanta. Now, the phrase CDC, when you hear those words, right now you think you got some complex feelings, right?

They've been in the news most recently for their tangle with coronavirus and with, let's say, the complex political situation they're in. And like I said, you may have a lot of feelings about them in that department. But I wanna be really clear about something. The CDC

is a critical medical institution in America that we will continue to need. And so many of the staff members there are incredibly smart public servants who are doing their damnedest to improve America's collective health every single day. And Dr. Krishnasamy is one of them. And he happens to be incredibly knowledgeable on this issue and to have done amazing work. He's actually the recent winner of a prestigious Service to America Medal, or SAMI, which is kind of like the Academy Award for Public Servants in recognition of the incredibly impactful work that he has done. So without further ado, let's get to the interview.

Please welcome Dr. Vikram Krishnasamy. Vikram, thank you so much for being here. Hey, thanks, Adam. It's a real pleasure. So you work at the CDC. It's a busy time at the CDC generally. Tell me a little bit about what you do there, just so we get a picture. What's life look like for a CDC person right now? Yeah, great question. I think right now, times are a bit strange and different for us at CDC. I have been full-time telework for

several months now outside of my CDC office. But normally, I have a day job at CDC where I typically work on addressing issues related to drug overdose, specifically the opioid crisis. And I've been doing that for the last several years now. Got it. Well, yeah, I mean, it's funny because people, you know, we think of CDC right now, everyone thinks of COVID-19, coronavirus, but there are so many public health challenges that are facing us right now. And like one of the biggest ones that I've almost forgotten about since coronavirus started

is the opioid crisis. Tell me a little bit about that. Can you give me a little bit of sense of the scope and what that looks like to you at the CDC? The opioid crisis is huge. It has killed hundreds of thousands of people over the last 20 years. And for every individual who dies of an overdose, there are many more people who may not have died of an overdose. And then think of all of the friends and family and moms and dads, brothers and sisters who are affected by an individual who may have an addiction to opioids. So the scope is just huge.

I mean, there are around 2 million people who suffer from an opioid use disorder, which is our fancy way of saying opioid addiction, and others who may not even be diagnosed. So the problem has really escalated over the last 20 years. It's become one of the big foci of the current administration in trying to determine how do we deal with this crisis, the current drug crisis, and do things in a better way than we have before. And what are the causes of it? I mean, I've actually even done a couple years ago, we did a segment about this on my show, Adam Ruins Everything. It's a seven-minute long segment, and I know our knowledge of it has progressed since then. So I'd love to hear from someone who really knows what has caused that rise. Our knowledge has progressed quite a bit.

And there are a number of factors that have weighed in and caused the current opioid crisis. Number one is we didn't recognize the addiction potential early for these medications. Number two, drug companies peddled these medications to physicians and really encouraged their prescribing these medicines so that we could take care of pain. And on another note, pain really became one of the areas where we began to focus in on in the late 90s and early 2000s to say, hey, how do we best control that pain? And opioids were one of the medications that were pushed to help control some of the pain that folks in the U.S. were experiencing.

And then all of that was compounded by illicit drugs. So think about fentanyl and heroin that were also on the market and people had pretty easy access to. You put all those things together and you have what we're experiencing now, which is an enormous crisis that we're trying to address here at CDC. Wow. There's a lot to unpack there. I kind of want to go through step by step. This is great. So pain, I read about this, that like we've actually almost preceding the opioid crisis, there's been an epidemic of pain in America. Is that correct?

Like what kind of pain? And that can be debilitating too, right? You're absolutely correct. There are millions of Americans that suffer from a mild to moderate pain. And a subset of that are there are millions of folks who suffer from severe pain on a daily basis. And that in itself is debilitating. And we have to find good options to take care of pain, to help people cope and get back to living their normal lives. But these drugs. OK, so let's talk about the corporate side of it for a second. I know you work for the CDC. You probably don't want to go too hard on them, but I would go as hard on them as you want. These companies, you know, push these drugs. They advertise them really relentlessly to doctors. You know, they would. I remember they they sent them all kinds of merchandise and things

like that. Like this was a really, hey, let's get these drugs out in the market. They pushed them really hard. Did they know about the potential for addiction when they were pushing them in a way that was, you know, inappropriate? I think that depends on who you ask. What I will say is that the addiction potential has become very apparent over the last 20 years, and if not earlier. And as these medications have become more frequently used, we have seen an increase in overdoses. And so that to us is really an area of concern. Now, I want to ask you about the doctor piece of it, because that's a part that gets a lot of a lot of attention a lot of blame often we have this image of the you know the profligate doctor who's just you know dr feel

good dr hookup right um as being like a big big part of the problem i've also read and and by the way on on our show we advanced that narrative as, because that was a big part of the narrative that was going on at the time. A couple of years later, I became more aware of coverage of, hey, you know, maybe that was an oversold narrative. And like, because of the pain epidemic, you really did have people who were suffering from pain who like really needed a lot of these prescriptions. And, you know, maybe some doctors were like scooped up, you know, and, and like had their, had their licenses revoked or arrested. And, and a lot of their patients, you know, were sort of tarred as, uh, drug abusers when in fact they were people suffering from extreme pain who now had no way to get a prescription and now are living with more pain. So I've seen both sides of those store of that story. And I'm curious how, how you see it. How,

how do you, how much blame do you put on specific doctors? is how you see it. How much blame do you put on specific doctors? Yeah, Adam, that's a great question. There are a number of factors in play here. I myself am a physician. I'm an internal medicine doc, and I prescribed opioids in the past. And there has been a sea change in how we prescribed those opioids over the last five to 10 years. What I will say is that there was a lot that we just didn't know in the 90s and early 2000s. And with the emphasis on prescribing to take care of pain, there was a real pressure to make sure that we took care of pain. And that led partly to the result of an increase in the number of opioids that were prescribed. Because we didn't have great guidelines, because we didn't know a lot,

you can't really penalize physicians for doing what they did more largely. I mean, the vast majority of physicians don't operate with a bad intent. They want to take care of their patients. They want to do a good job and they want their patients to get better. Of course, there are always a subset of physicians who may not act in that way. But I would say, I mean, myself included, we had our patients' best intentions at heart and we wanted to do what we could to take care of them. Yeah. It's a tough position to be in as a doctor, right? Like to have someone come to you and say, hey, I really need this medication. Maybe it's your first time seeing them. And they're saying, I've got really bad pain. And you're sitting there going, well, am I, am I feeding an addiction, but writing this prescription? Does this person really need help? I mean, it's really complex.

Adam is really complicated. And I think the bigger question here is, let's say you have somebody who you want to, you want to provide medication to, you want to take care of their pain, but you're also concerned that they may have an issue with addiction or dependence or a substance use disorder. It's really important to also look at that piece and try to help that person out in a way to get them into treatment if possible. And that is a totally different, it's a paradigm shift from where we were 20 years ago. That just wasn't something people were thinking about back then. Yeah, it wasn't nearly as common as it is now. Well, tell me a little bit about the work that you do at the CDC trying to tackle this.

I don't like to call problems intractable because it makes it sound like they can't be solved, but there's a lot of different dimensions feeding into this. There's the corporate piece of it. There's the addiction piece of it. There's the pain piece of it. And the numbers have been rising. It's really devastating. How do you go about trying to resolve this? We have a number of programs in place to try and get at the root of the opioid crisis and try to provide some interventions to address the problem as it stands. I want to take a step back and say that this is a problem that is larger than CDC as an agency.

It takes multiple agencies at all levels of government coming together to be able to address the crisis. So at the federal government, you're thinking NIH is doing basic research and has other programs in place. The Food and Drug Administration is looking at other treatment modalities. And then you have CDC, who is looking at the public health arm. And then you have local health departments and hospitals and physicians who are tackling this on the ground and really trying to figure out, hey, how do we move forward and are seeing this every day? I think one of the larger questions that we have at CDC is how do we get good data and

how do we identify and track and understand the number of people that are affected, both as the number of folks that are overdosing and the number of people that are dying? And then also understand what types of drugs people are using. Where are they getting them and how are they using them? Are they using heroin and fentanyl, or are they using prescription opioids? So there are a lot of questions here and a lot of work that has gone into and is going into addressing the crisis. So let's break down those different agencies a little bit. The NIH, you said they do research. It's a research organization, right? Yeah, it's a biomedical research organization, Yeah. And the CDC covers public health. Just just break down that distinction

a little bit for me. Yeah, it can be it can be very confusing. And so so thank you for asking me to clarify. We hear all these alphabet things like, OK, I know that has something to do with medicine. Why do we have two of them? Why isn't it just one agency, right? So yeah, if you can enlighten folks on that, I think it might be helpful. Yeah. And there is a long historical context that I won't get into. And so the CDC was really founded back in the 50s to fight communicable diseases, especially malaria. And so we have come a long way since then. And there is a whole portfolio of diseases and public health conditions that we continue to fight. So think about heart disease, stroke, malaria, HIV. In the center that I work within CDC, we focus on injury prevention, where overdoses and drug use fall.

And so what we really do is think about what are the approaches that we can take from a public health standpoint to really prevent some of these end outcomes that people are experiencing. So how do we prevent people from overdosing? How do we prevent people from becoming addicted to opioids in the first place? And some of those examples here at CDC are, one, guiding physicians to prescribe those opioids in a better way so that they can decrease the risk to their patients. Another way is to prescribe and to distribute a medication called naloxone, which is an antidote to these opioids and can actually save lives. So these are the kinds of things we think about when we try to figure out how we save lives over the long term in the opioid crisis. Yeah, it's kind of the fact that there's an antidote for opioids is incredible to me. Like, it's not something that we think of as having a having a cure in a way where I mean, it doesn't

cure you from addiction, but it can prevent deaths. Yeah, absolutely. Naloxone, frankly, saves lives. And we have the numbers to back us up. We have empirical evidence that that's the case. And really the challenge is how do we get naloxone into the hands of everyone who has a prescription for opioids, who may be using heroin or fentanyl, so that they can save themselves or have a bystander save them if they do overdose? or have a bystander save them if they do overdose? Yeah, we, you know, I do work in homelessness around Los Angeles. We do engagement with, you know, unhoused folks in our community. And one of the things that we have started doing is distributing naloxone under the brand name Narcan, if that matters, just to like say, hey, you know, because people die of overdoses in our neighborhoods. And, you know, it's, yeah, it's a nasal spray.

And if folks know how to use it, it can be lifesaving, which is, yeah, I mean, really critical. Yeah. You're looking at around 70,000 people who die of a drug overdose every year. Really? Yeah. And two-thirds of those are related to opioids. And then you think about how many more people must have overdosed before they died or before someone dies.

And so those numbers become huge. And you can really see the importance of making sure that that naloxone is distributed widely in the community so that people have access to it to prevent someone from dying. widely in the community so that people have access to it to prevent someone from dying. Well, tell me a little bit about the work that you did that caused you to get this Sammy Award. For folks, I talked about a little bit in the intro. It's a very prestigious award given to public servants in recognition of remarkable work that you do. And, you know, a lot of people have gotten this award of saved billions of dollars or, you know, a lot of people who've gotten this award have saved billions of dollars or, you know, saved hundreds of thousands of lives in such and such a way. I'm curious, what is the work that you've done that led to this award? Yeah, well, first, I want to thank

the Sammys for calling attention to the enormity of the opioid crisis. And I'm grateful that they're doing that and for recognizing the work that we've done. The area that I work in specifically relates to what happens when a clinic, a physician, some other type of medical provider is prescribing opioids outside of the bounds of medical practice. So in a nutshell, prescribing opioids that are way too high of a dose without the specific safeguards in place to protect patients. That is not often the case. So I want to make sure that people understand that this is not something that every physician does. These are certainly providers who are outliers. That's the word I was going to use, outliers. These are like the ultimate Dr. Feelgood. These are the people who are really, really behaving irresponsibly or perhaps criminally. Yeah, definitely. And what

happens is, is that federal law enforcement or state law enforcement, think FBI, HHS office, the Health and Human Services Office of the Inspector General, or the Drug Enforcement Agency might be bringing a case or trying to determine what's going on in these clinics that are negatively affecting patients. And so what happens is that you might have patients who are in chronic pain and getting high volumes of pain medications, such as opioids, from these physicians

in a way that's not safe. You might have people who clearly have an addiction problem, and in our parlance, we'll say an opioid use disorder, and are getting these medications in a way that they shouldn't be. Or you might have people who are simply seeking to distribute these medications to others. And so all of these things, I mean, they're not good. And so, you know, and so all of these things, I mean, they're not good. And it doesn't take long for individuals who have been on opioids to have some sort of dependence, to get some sort of withdrawal symptom if they don't have continued medication. And those symptoms are terrible. They are not good,

they're not pleasant, and they lead people to use more to engage in behaviors that might lead them to find more. And so our goal here was really to connect these patients to other treatment providers to be able to identify, hey, what's going on here? How can we best help those patients? So you're saying that even when you've got this worst case scenario clinic that is really beyond the pale, that clinic maybe has it probably has some legitimate patients it has some people who who are really like sure it's got some folks who are distributing and or whatever uh but it also has people who are dependent either i mean either they've acquired a dependency or they're they are maybe just patients who actually

have a lot of pain and like they actually need the opioids that they're being, uh, that, that they were being provided with. And so those patients need to go somewhere. Is that what I'm understanding? Right? Yeah. So what I would say is you have patients who are on chronic pain. I think the jury is still out on whether those opioids are helping those patients with their chronic pain. We're still trying to understand some of those pieces. It's very complex. And the other thing to think about is, is the care that those patients are getting safe? If somebody's on too high of a dose, their overdose risk goes up. And so how do you prevent them from overdosing? And then for those who might have an addiction issue, it's really important

that they get in to be seen for potential treatment for that addiction. And so in these situations, it's important that we find a way to connect those patients to care. And the way we do that, at least from the CDC side, is to make sure that we can connect our law enforcement sister agencies here at the federal government level with state health departments that are doing opioid work over the last five to 10 years and really have those connections to be able to help those patients out. This is really great. Honestly, the question I asked you earlier about doctors, right, came from me after we did our segment on the opioid crisis and on, you know, the corporate malfeasance there involved.

I read an article in Harper's called the pain refugees about folks who were, you know, like on opioids. Their doctor gets busted. Right. And then they're abandoned. And, you know, folks with extreme pain who, you know, the pain is debilitating. They can't work. Their life is, you know, as miserable as if you had any serious illness or disease. Theirs happens to be pain. And then they're like, where do I go? This is the only doctor in town. You know, I'm in the middle of wherever. And you're helping those folks. You're making sure those folks aren't abandoned. Is that the idea? We are doing our best. And I say our best because there are still a lot of problems here in terms of how individuals can access care in the United States for addiction specifically, but also more largely in terms of health care.

OK, so you try to do this by when law enforcement comes in, connecting them with public health or with other health service providers. It strikes me there might be some friction there because law enforcement and health providers or public health agencies work differently. They have different philosophies, to say the least, about how they deal with people in the world. Yeah. How do you do you find that and how do you negotiate it? Yeah, I will say that we all exist in our alphabet soup of agencies. We all exist in our silos to some sense. And so part of our work is how do we break down those silos and pull together collaborations that are effective? we recognized is that there's already some collaboration between CDC and federal law enforcement agencies, such as the Drug Enforcement Agency, DEA for short, and the Department of Justice. And so how do we come together to help these patients that are affected? So we had conversations, and just a big shout out to my colleagues over there at DEA and the

Health and Human Services Office of the Inspector General, who also recognized, hey, there's something we can do here to protect these patients and to help them out. What do we have to do? And one of the ideas that we came up with was how do we get everyone to buy in to connecting with state health departments and providing them with information about an action, an enforcement action against the healthcare provider before that action actually occurs. That is a sea change in how we do things or how things have been done in the past. So in the past, an action might occur. So a provider might be arrested, a clinic might close, and then the state health department might find out after the fact. And then the state is trying to figure out, hey, what do we do here? What resources do we have? How do we make sure that these patients are taken care of? And in this situation, what we were able to do is to connect the law enforcement agents in

the field in the states with the state health department to have this conversation earlier. So two weeks earlier, three weeks earlier than the anticipated action date so that they can determine, hey, what are the things that we need to do? How do we plan? How do we get our structures in place? What's our plan to get notifications out? All of those things to really be able to respond in a way that's helpful. Now, that like that. What you're describing is bureaucracy. You're managing.

What you're doing is you're changing the way the bureaucracy works. You're saying like, OK, before you go bust the guy, hey, give a phone call to, you know, the state public health and, you know, fill out this form instead of that form or, you know, or let's work on a process here. It's just sort of people, you know, it's you're altering workflows essentially. And that's not something I ever thought of as being a public, part of public health work. Yeah. I'll say that I have a desk job. I work in an office. I have a desk job. I see patients every so often. You still see patients as well as a doctor? I do.

It's very meaningful for me. It's how I've been trained, and I continue to do so. I, of course, have not been able to do so in the last couple of months because of working on COVID-19. And I provide my time pro bono to a clinic that sees underserved patients, patients without health insurance here in Atlanta. And in doing that, during COVID-19, the clinic has had to close because of not having the measures in place to be able to protect people. What a shame, because that's the kind of clinic that we most need to be open, frankly, is serving underserved people.

It's a safeguard for the community. So, you know, I'm trying to work with them to do some telehealth in the near future. So we're working on it. But yeah, I mean, my day job is very much based at a desk. If I'm not doing some kind of emergency investigation related to an outbreak somewhere. And so I like to think of it not as red tape, but as pulling people together. And really pulling people together in a way that is effective and establishes long-term relationships so that we can do this work more effectively in the future. Well, yeah, I mean, I like the way you put that, pulling people together, because it

makes me think about how much of the response to any problem is a question of organization. I learned that a lot from, I talked to a lot of folks in the labor movement. They always stress organizing. You know, you got to get people together and have conversations and work out a process, et cetera, if you want to get anything done. And you're sort of describing the same thing that like, wow, the real challenge is maybe not that, well, I don't want to say what is the real challenge, but a big challenge is not just the drugs or the medicine or, you know, even say with something like COVID-19, the virus itself,

it is organizing the people in order to address the problem in an effective way. That seems very true, but also counterintuitive. This is absolutely about organizing people in every sense of the word. So we're trying to organize people at the federal level. There are people trying to get organized at the state and local level. You've got provider groups. You've got insurance groups. You've got addiction treatment professionals. I mean, you've got, there are all sorts of people involved here, all sorts of sectors and stakeholders. And the only way we're going to deal with the opioid crisis is by pulling people together

to address every issue along the way. Man, it's just such a profound, such a profound insight to me. Cause it's like, you know, literally if you need to, I don't know, get something done in your community or your family, you need to, you know, if you need to do a yard sale at your house, you're like, Hey, you need to, someone needs to take all this stuff out of the yard. Someone needs to make little signs. Someone needs to do like solving any problem. You need to give everybody a job, get everybody on the same page.

It's like this fundamental thing of getting stuff done. And that's still the problem at our at a larger level. It's fundamentally the same thing, just a much bigger scale. Maybe this is a very basic insight, but it's kind of blowing my mind right now. No, it's it, I think you're exactly right. And I'm happy to open the doors on what we do. So thank you, Adam. This is about pulling people together. And if you think about any one issue within the opioid crisis, whether it's treating folks who have addiction, whether it's distributing naloxone so that people have access

to it, whether it's making sure that there are enough treatment providers to provide treatment to all of these individuals. All of those things take a number of organizations coming together to make sure that their resources are in place to be able to do that. So let's take naloxone as an example. You've got to be able to get the drug. You've got to be able to pay for the drug. You've got to be able to figure out where you should put it. I mean, all of those things require multiple agencies to be able to do that. Yeah. Just every single step of that. How do you then get the drug into the hands of the people who need it? Like literally who is handing it to the folks? I guess the insight I'm coming to is like every, every problem is a logistics problem. In

addition to whatever kind of problem it is, it's also just logistically, how are you, how are you handling this? How are you pulling people together? That is so cool. Well, look, I have a lot more questions for you and I want to ask you specifically about your, your personal story and how you came to this work, but we've got to take a really quick break. We'll be right back with more Vikram Krishnasamy. Okay, we're back with Vikram. So Vikram, you were trained as a doctor. What brought you into public service?

What was the moment where you were like, hey, that's where I want to spend my time? I am the child of immigrants. So my parents came over here in the 1970s. They met at Ohio State University. I think it's the Ohio State University now. And they got married. They live in Columbus, Ohio. They've, they've stayed there ever since they, they went to college there. And I think one of the important lessons for me all growing up was that they conveyed to

us, my siblings and myself that say, they said, Hey, you know, Vikram, you've, you've, you've been given an opportunity that other people in the world don't get, uh, you know, we're immigrants. You've been, you've been given this awesome opportunity to get an education. It's important that you do some good with that. And so in the back of my mind, there was always this element of trying to do some public service or going towards a public service career. My training is based in internal medicine. And so we're physicians for adults, basically. I don't see kids. I don't know how to take care of kids, so for better or worse. But so I'm trained to see adults. And so in my

training, we call that residency training, I did a residency that was focused in taking care of patients who didn't have health insurance or didn't have access to healthcare in the traditional sense. And I also spent five months of my residency taking care of patients in Malawi. And so, you know, those two experiences really drove home to me the need for a strong public service sector to be able to address some of the larger problems that we face and experience around the world, but also specifically in this country, the richest country on earth. And so it quickly became apparent to me that with all of those experiences and my background that this was an important way to go.

And ultimately, I came to CDC to do something called the Epidemic Intelligence Service back in 2016. And what's the epidemic intelligence service? Yeah, it's that it sounds really interesting, right? When I say something like intelligence service at the end. Yeah, wait, that's I'm like, hold on a second. That sounds like you just dropped like the coolest name for a government program I've ever heard. The epidemic intelligence service sounds like this sounds like the name of like a CBS procedural drama is what it sounds like about medical investigators. What the hell is it? Yeah, the Epidemic Intelligence Service is a

two-year program for physicians and individuals who also have their PhDs to come into CDC service to understand how public health works, but also how to investigate outbreaks that might happen anywhere in the world and to build expertise in overall public health within the federal government, as well as state and local governments. And so I spent two years investigating foodborne outbreaks as part of my training. And then ultimately, I stayed on afterwards. Got it. Well, let's get into that.

Foodborne outbreaks, you said? Like what in particular? So think about, what's a good example here? So E. coli. So someone, there might be an E. coli outbreak, So think about somebody eating a hamburger that may have been contaminated. And part of my job was trying to figure out, okay, what was the source of that outbreak? Where did it come from? And who's getting sick? And so I might get sent somewhere in the country where an outbreak might be going on to help try and solve or investigate that outbreak. Got it. So that's what the CDC does,

is that when there's an outbreak of almost any disease, whether it be, I mean, opioid addiction and foodborne outbreaks are very different in some ways. Yeah, yes, yes. But they're similar in some ways in how the CDC tackles them. Can you break that down for me? Yeah, I think one of the biggest surprises, at least to my friends and colleagues, are that CDC is a huge umbrella organization that focuses on a number of different problems. Outbreak investigation is traditionally a bread and butter for us, where we do outbreak investigations routinely and have been for decades. And then you think about any other public health problem that we face, whether it's hypertension, heart disease, or the opioid crisis. And there's probably a program here at CDC to try and address that in some shape or form. And that's not the traditional send somebody out to

investigate an outbreak, but it also could be something as simple as what's the data say and where are we getting the data? And I don't want to say that that's simple. That's a hard question. But in terms of conceptually, there has to be someone out there within the federal government who's trying to understand what the scope of these problems are. And that's one element of what we do here at CDC. trying to understand what the scope of these problems are. And that's one element of what we do here at CDC. Yeah, it's like something is killing Americans. And it's, oh, oh, wow, seems to be killing a lot of them.

What is it? Why? Where is it coming from? How do we, what interventions can we take to reduce it? Is that the basic questions you're asking every time? Yeah, I think, Adam, you're capturing it pretty well in a nutshell. Thank you very much. We've got to understand what is it that are making Americans sick or ill or killing Americans. And we also have to think upstream are what are the issues that might be causing some of these issues in the first place or some of these diseases in the first place? And what can we do to prevent that? So if we take opioid overdose as an example,

what are the things that lead to someone actually overdosing on opioids? And so if we walk one step earlier and say, okay, can we put out some guidelines on how we should be prescribing those opioids? And CDC did that in 2016. And they've been really, really useful. I remember before 2016, not having guidance. And after 2016, I mean, it's just a sea change in terms of recommendations and what we should do. So as in like educating doctors, like here's a leaflet literally from the CDC saying, hey, keep this in mind next time you're writing that Rx. literally from the CDC saying, hey, keep this in mind next time you're writing that RX. Yeah, in a nutshell, that's exactly what it is. But it's more than that in terms of it's a synthesis or a combination of all of the literature that's out there and all the studies that have

been done and says, hey, this is what the data says that we should be doing. Here's what we don't know. Here's what we know. And here's how you can decrease the risk to your patients. Yeah. You won the, the Sammy award that you specifically won is the emerging leaders award, which is for, for a younger person. I won't ask how old you are,

but I could, I could tell you're not the, you know, you're not one of those old gray beards at the CDC. What are your goals for your, I'm curious as someone who, you know, has entered public service as a career, what are your, what are your aspirations moving forward? My aspirations are really centered around what can I do to have the greatest impact and do the greatest good for the largest number of people. And that's not simply working on a large program that affects a huge number of people.

We spoke earlier that it's also very important to me to be able to see patients who don't have the same access that other patients might have. They don't have the same health insurance that I have with my job within the federal government. And so I think for me, it's continuing to do work that is aligned with that overall personal mission. And I can't predict at all how that's going to shake out. I will say, I didn't see COVID-19 coming. I mean, I'm sure there are people out there who said, hey, and I know there are people out there who said, hey, coronaviruses are an issue. There's going to be a pandemic at some point. But I did not know that 2020 was going to be the year that we would say, here we are. So I just take every day as it comes and try to really adhere to that mission as we go along.

Well, look, what I what I love about talking to people from agencies like yours is that they're filled with people like you who got into it. You know, hey, you could you could have made a lot of money as a plastic surgeon in Beverly Hills or whatever. There's there's there's lucrative options out there for for a doctor such as yourself or someone as competent as you. But, OK, I actually give a shit about public service. I'm going to go into public service at the CDC and actually try to make Americans healthier. And that's actually what you spend your whole day doing. And I and the same is true of how how many thousands of your colleagues. Right. And that's that's a critical work that almost none of us know is being done.

It's really cool to hear about. And that's that's a critical work that almost none of us know is being done. It's really cool to hear about. At the same time, you know, I feel like we have another epidemic, a psychic epidemic of, you know, we we're sort of losing faith in some of these agencies, you know, like like our confidence in the CDC and, you know, other agencies is eroding a bit. I know I'm not going to ask you to speak to, you know, the broader issue of coronavirus and et cetera. But I mean, do you have that concern about the public's interaction with these with these agencies such as the CDC? Yeah, and I'm just one one aside real quick. And then I'll dive into your question is that I actually have a twin sister who is a cardiologist. She's a heart doctor. We talk all the time about where we are in our careers. And of course she makes multiples of the income that I do.

And, and we, and we often talk about our different trajectories and, you know, I respect her for what she does. And she says to me, you know, I really respect you for what you do and the decisions you have made along. Who do your parents respect more? That's the question. Well, I think I think it's challenging. This kind of gets it gets at your current question is how do you explain what public health is and what we do? And, you know, to my parents who had no concept of public health before I even went into this. That has been a real challenge. I think we've been able to do that over the years. But when public health works, you don't hear about it. And we stay in the background.

You just don't get sick. You don't get sick. If the vaccination campaigns are working, there isn't a measles outbreak, for example. And so these are issues that are not at the forefront of the public's mind when we think about what public health does. And I think the bigger challenge for all of us is to say to everyone out there, the work that we do is critical to protecting the lives of all Americans. Yeah, I agree that that's really important. I agree that that's that that's really important. I just worry that the message doesn't get through to the public. Right. Or that especially when, you know, agencies are in the news, they're only in the news for like one little topic.

You don't see the rest of the work that the agency is doing. Right. Sure. Coronavirus is is a clusterfuck in many ways. Right. But like at the same time, we've got, you know, really dedicated public servants working on issues such as such as the opioid crisis. I don't know. I kind of feel like we have to get better at telling those stories. Do you feel that way? Definitely. We do have to get better at telling those stories. And to the earlier question about eroding trust in public institutions, I think it's critical that we have a strong public sector workforce of individuals who are willing to do this work because at the end of the day,

without those strong institutions, the country won't work and it doesn't work. And I think we've seen that over the last several years of the work that we do when we do it and it works, the effects are critical to our success as a nation. Yeah, it's, I don't know. The problem is how do we not descend into cynicism, right? Like I'm such a fan of the work that you do at the CDC, right? And then we see, okay, the CDC puts out a guideline and then retracts the guideline, puts it out again, retracts the guideline, right?

And it's very easy to see that happen to go, ah, the CDC, ah, they all suck over there. They're always retracting their guidelines right after they put them out. Ah, it's so confusing. Instead, we need people to say, no, no, no, we need to improve this process at the same time that we safeguard what's working.

It's just a complicated thing to ask of people. And it's, I don't know, it's so easy for folks to fall into cynicism. And that's my, I don't know, that's so easy for folks to fall into cynicism. And that's my, I don't know, that's a concern I have. I don't have a question. That's just what I'm concerned about. Yeah, I think we are in an environment where information is so accessible at everyone's fingertips. The challenge for all of us within the Federal Service and other agencies is how do we provide information that is accessible and adheres to scientific rigor and cuts through

everything else so that people get it, understand it, and act on that information to do what's important for us. I mean, in my selfishly saying, public health. But really to act in a way that protects everyone and themselves and ensures that they live a life that is healthy and productive and meaningful to them. Well, I want to talk a little bit more. I want to go back to something that you said earlier. You were talking about the CDC, the NIH, the FDA, and then you said local public health, right?

Local hospitals, local clinics, things like that. And that is, my understanding, a really critical part of our public health infrastructure. It doesn't even have an alphabet name. It's it's all the different local agencies. My understanding is that those have been cut a lot in recent years and that that's an infrastructure that is not as healthy as we want it to be. And I want to know if you could speak to that at all. And I want to know if you could speak to that at all. Yeah, I will say I don't have exact numbers here, but I think we all recognize that public health funding has taken a cut over the last 10 years and 10 to 15 years since the Great Recession. lessons from the current pandemic, as well as other crises that we face, the opioid crisis, the HIV epidemic, et cetera, that we recognize increasing that public health workforce is important to our success in fighting these problems. You can't fight these problems with

a diminished workforce, and you just simply can't do that. And so as we move forward, we learn our lessons here with the COVID-19 pandemic and others. We have a real opportunity to position ourselves for success in the future. I hope that we do that. I'm going to be here along the way to fight for that. And I'm really hoping that we do that. Yeah, me too. Well, let's close by bringing it back to the opioid crisis for a little bit. You know, it strikes me again that we've been talking about it as a public health issue,

but it's also a very personal issue to so many Americans, like you said, because hundreds of thousands of people have died. Many more are addicted. I'm sure there's folks listening who've been impacted by it personally. I've personally known folks who have passed away from overdose, and I'm sure folks listening have as well. And I'm sure many folks listening live in communities that are really impacted by it, and they see it in their own communities. What do you say to someone who, you know, say has a family member struggling with it, with with opioid addiction and is and is, you know, struggling to figure out how to deal with that? elsewhere recognize that addiction is not a personal failure. And that is a message that I have for everyone. And that addiction is a challenging medical problem. It's a chronic

medical problem. And one that we need to treat as such and provide the resources to anyone suffering from addiction to be able to get that treatment. For opioid addiction, specifically opioid use disorder, we have treatments that work. We just don't have enough people to get those treatments to the individuals that need them. Really? Yeah. Yeah. And so how do we, how do we do that? How do we, how do we get that treatment to the individuals that need them, where they need them, so that they can treat the problem that they're facing. And what are those treatments? You mentioned naloxone, which is just, I think, prevents death.

But you're talking about like, hey, we know how to help people kick the addiction? We know how to help people manage their addiction and potentially recover. You know, I think there are a lot of definitions of what recovery means. Ultimately, it's a personal definition of recovery. But we do have medications that work. And these medications, though they're not perfect, though they don't work for everyone, they do work and they help. And so the important thing is that we get those medications to people when they are in a position where they need them. So tell me a little bit more about what that gap looks like. Because again,

we're talking about logistics, right? You said we know what to do. We lack the people, we lack the resources. What's like your ideal response, right? For say, for a town that has a bad opioid problem that, you know, has a lot of folks who are struggling with addiction and it's, you know, causing deaths and it's causing despair. What what is the kind of in your utopia that what is the perfect response that we wish that we could have? And and what are the barriers that are stopping us from getting there? Yeah, you know, in a perfect world, we would all be able to stop opioids from getting into the community in the first place. And there are both sources of prescription opioids

as well as illicit opioids, which is fentanyl and heroin, and we'd be able to stop that. But that's really hard. And so if we're thinking about a scenario where people already have issues with substance use disorders and addiction to opioids, a perfect world would have an opportunity for each of those individuals to be seen by a healthcare provider to provide them with specific individualized treatment. And those individuals also have access to a counselor who could provide them with counseling and behavioral health treatment so that they could get both the medication and the behavioral health treatment to have what I hope would be a

successful recovery, recognizing that it doesn't always work, but that people will be in a position to be able to get the resources they need to recover. So you're talking like we've got a we've got a clinic folks can go to. Maybe we've got street medicine. We've got like, you know, medical workers doing outreach and helping folks. workers doing outreach and helping folks. And we've got counseling as well in enough numbers to serve every single person who's suffering from that. And I definitely can say we don't have that now. Based on my experience working with folks in LA, people are like, where can I get help? And there's no clinics nearby and there's no one coming to do that outreach. There's no clinics nearby and there's no one coming to do that outreach. Yeah, it's a real challenge, Adam. And our success in addressing the opioid crisis is really dependent upon how we get treatment to people that really need it.

And that's a separate issue from the prevention problem, which is how do we make sure that people don't get addicted to opioids in the first place? You know, that's a separate issue. to opioids in the first place. You know, that's a separate issue. But in terms of making sure that people have access, we've got to increase the number of people who are able to provide treatment to these individuals, to individuals who are affected by opioid use disorder. And we've got to decrease some of the regulatory barriers to making sure that individuals can get treatment.

So it's something that I hope will happen in the future and is critical to our success in addressing the opioid crisis. I mean, are you optimistic about the, the future of the opioid crisis? I mean, you're, you're, you're working on a day to day. Um, does it, you know, sometimes I feel like when you're working on social problems, you can have one or two attitudes. You can have, hey, we're making progress with this big social problem and we're, you know, we're going to get the genie back in the bottle and hey, here we go. Or you say, you know, I'm just trying to help the people I can, right? Which is when you, where do you, where do you find yourself falling there?

Where do you find yourself falling there? I am an eternal optimist, I will say, so maybe I'm a bit biased. But I will say that I am optimistic here for a couple reasons. One is that we have the political will to tackle the opioid crisis. I mean, I think everyone has seen that over the last five years. We have a commitment from organizations across the country to tackle the opioid crisis. We have a recognition, a widespread recognition that there is a problem. We have dedicated funding across the country to multiple agencies to address the crisis. So we have really pulled together people in a way to really be successful in addressing the crisis.

Do we have more to do? Definitely. But have we come a long way in the last 15 years? We sure have. And what do you think has caused that recognition? I mean, the, you know, the, the bluntest version of it I've ever heard is America started, you know, taking drug addiction seriously as a public health issue once affluent white people started suffering from it right in their communities. I feel like that might be some of the story, but I imagine you might have a fuller view. I'm just curious. I think what I would say is the opioid crisis is not new. It's been going on for over 100 years. It goes way back to before the 1900s. And so one of the issues that probably caused a lot of the current focus on the opioid crisis is the escalation in the number of deaths over the last 20 years. I mean, you've seen a huge increase in the number of overdoses and the number of deaths.

And this is not a problem that you can ignore. It's not something that's going to go away simply by ignoring it. And so safeguards and interventions and policies needed to be put in place to make sure that this problem is contained and that we can successfully address it. Yeah. I mean, this showed up in just straight up demographic data. Like when you look at life expectancies of, you know, entire demographic groups like white white men have been affected by. Oh, that's my understanding. Yeah. By the opioid crisis. So life life expectancy did go down. And, you know, the opioid crisis is not a sole contributor to that. But without the opioid crisis, we'd be in a better position than we are now.

Yeah. For folks who let's end on this note, because I'm inspired by your commitment to public service and the fact that you've, you know, devoted your devoted your career to it. For folks who are listening and saying, God, that sounds great. I want to I want to do that. What do you what do you say to them or how do you encourage them to try to take that step? I think there are ways to get involved in your community at every level. I mean, every community has a need to have higher volunteer participation to be able to address the problems that we face locally. I mean, for me, that's volunteering in a clinic and seeing patients. For other people, that might be figuring out, is there an organization that I can work with that distributes naloxone? Or is there a syringe service program, which is a program that is really engaged around harm reduction,

protecting individuals who may be using drugs? Is there a syringe service program that I can volunteer at to provide services to individuals that really need it? I mean, there is, the great thing about America is that there are a number of organizations who are doing incredible work who always have a need for increased numbers of people to help them. So, Adam, as you referenced earlier, I mean, this is all work that we can do and become involved in to really fight for the greater good here in terms of dealing with the opioid crisis. That's amazing. But you said something, and now I have to ask you a follow-up question. I'm so sorry. That would have been a wonderful note to end on, but I have curiosity here that I must follow through on. You said harm reduction and I want to get it because that is a topic I've

covered in the past and I just wanted to get your thoughts on it because, yeah, I think it does follow that once you see addiction as a health problem, you need to start treating it a little bit differently. And so I wanted to, yeah, can you speak about harm reduction as a strategy as opposed to maybe what we were doing a couple decades ago? Yeah, harm reduction to me has been about meeting people where they are. And when you look at addiction, not everybody is in the same place in terms of whether they want treatment or are in a position to accept treatment. And there are lots of things that we can do to decrease the consequences of drug use. And naloxone is a prime example of that. So how do we make sure that we can get naloxone into the hands of people that are using drugs or

to the community members that may have an interaction with somebody who's using drugs to better protect those individuals? That is a prime example of how we decrease the risk of someone having an overdose death. And so it's a critical intervention in helping us stem the tide in the opioid crisis. Yeah, it's a real sea change in the way that we've looked at it. Because, you know, I grew up in the war on drugs era, which demonized, of course, drug dealers, but also drug takers as a moral failing and as something that you want to stamp out.

And instead it looks at it and says, no, this is a health problem. It's a medical problem that has been with humanity for a long time and has gotten more intense in recent years. And our first duty should be to try to reduce the harms and make sure – first we should make sure that people don't die. And then we should make sure that they are as well as possible. And helping treat the addiction is like part of that. But it's no longer saying,

hey, if you're hooked on something, fuck you, right? It's like, if you're hooked on something, we're still gonna try to help you not die an early death and not suffer, right? This is part of what keeps me optimistic in that we have, over the last 15 to 20 years, had an increasing recognition, widespread recognition, and acceptance of harm reduction as a philosophy in terms of treating

drug addiction. And I like to equate it to other chronic medical problems that we have in terms of, how do we prevent high blood pressure and diabetes? We ask people to go out and exercise and make sure they eat well. And that's not harm reduction in the traditional sense, but we're really still trying to make sure that we prevent the onset of someone getting a really adverse consequence. So, you know, for example, if someone's diabetes gets way out of control and they get their foot amputated, that's bad. And so if we can prevent someone from getting diabetes in the first place, that's great. But it's also important if they still have diabetes to make sure their foot doesn't get amputated.

Oh, yes, yes. Reduce the harm of the disease. Yeah, exactly. And so it's really important, even within that sense of people who are diagnosed with the disease, how do we prevent the consequences of that disease process in the first place? So think high blood pressure. How do we stop someone from getting a heart attack or their kidneys going bad? Or if they have diabetes, how do we prevent them from getting a stroke or heart attack or having their foot amputated? Those kinds of things. And we need to treat addiction like a chronic medical problem and make sure that individuals have access to the care that they really need. And this is treatment with medications, repeated visits to physicians who have close monitoring of individuals who are affected,

and success is out there. It can be done. The stigma is so deep, though, that people have in them about, you know, like even people who, you know, do struggle with addiction, put the stigma on themselves sometimes, you know, and say, oh, God, I don't deserve help because I'm hooked on this. And it's certainly something that people say about others. But have you seen a change in that attitude as well? Stigma is so, so hard. And this is another piece that keeps me optimistic in that I do feel like the stigma is changing. that keeps me optimistic and that I do feel like the stigma is changing. I think that we have a much better recognition that the opioid crisis is widespread,

affects a huge number of individuals. And this is not something that we can simply ignore and have it go away. It takes dedicated effort and interventions, interventions that we do have to be able to address the crisis. Well, I really appreciate you for putting in that effort. And I appreciate you so much for coming on the show today. Thank you so much for being here, Vikram. Adam, it really appreciate you for putting in that effort. And I appreciate you so

much for coming on the show today. Thank you so much for being here, Vikram. Adam, it's been a real pleasure. I really appreciate the time. And, you know, let me know if you ever like to have me on in the future. Oh, we'll check back in in five years and we'll find out how you single-handedly solve the opioid crisis. You'll tell us that whole story when you come back in a couple of years. Well, Adam, hey, thanks a lot. And I hope you all have a good rest story when you come back in a couple years well Adam hey thanks a lot and I hope you all have a good rest of however the rest of the pandemic lasts I hope you stay safe

and everything goes well you as well thank you so much Vikram well thank you once again to Vikram for coming on the show I hope you enjoyed that conversation as much as I did if you did please consider leaving us a comment or a rating wherever you subscribe. It really does help us out quite a lot. You can also drop me an email with what you might like to see on the show in the future at factually at adamconover.net. I want to thank our producers, Dana Wickens and Sam Roudman, our engineer, Ryan Connor, Andrew WK for our theme song. I want to thank

Falcon Northwest for building me the incredible gaming PC that I'm recording this episode on and that I use to stream video games on Twitch at twitch.tv

slash Adam Conover. You can also find me on social media at Adam Conover wherever you get your social media and my website is adamconover.net. Is that enough

different permutations of my name? I hope it is. Well, hey, thanks so much for tuning in. We'll find you next week on Factually, and please, until then, stay curious. That was a HateGum Podcast.