Meet Bertha Madras - Part 2
One of America's foremost experts on how drugs affect the human brain sits down with Jason Curtis Anderson to discuss the Fentanyl crisis, drug legalization, and the future of American cities.
Jason: Do you think America can solve things like addiction and homelessness while also moving away from things like accountability?
Bertha: Part of the problem with accountability is that it operates at multiple levels. The government has not been accountable for enforcing drug laws. For individuals who have a substance use disorder, there is a very strong movement to destigmatize them in order to make them more comfortable to appear in front of treatment providers, in order to be more honest with their physicians.
That type of destigmatization is valuable if people are motivated. But what’s happening now is not a destigmatization of a person with this terrible disorder, but it’s to destigmatize use altogether. And to expect people who are using to give them whatever they want in order to feel comfortable, rather than giving them a safety net so they don’t die. But also trying to motivate them, and sometimes motivation can be heavy-handed but it may be necessary to get into treatment. What is being eroded is not so much destigmatizing the person with the disorder, it’s destigmatizing drug use per se. And that, from my perspective is madness. Number one is what are parents going to say to their children in order to protect them from initiating drugs if you don’t stigmatize drug use? I don’t ever want to stigmatize a person who has a disease or disorder, that is wrong. Because if that protects them from having treatment, that’s counter-productive. But if you say that this is normative across the board and we shouldn’t stigmatize drugs, then we are going down a path of normalizing it for anyone and everyone. And then the cleanup of this mess will eventually be impossible. We’re not going to stop the pipeline to addiction if we continue along this path. So how do we get people into treatment? Gently, with motivation. Some people claim that the only way to get people into treatment is by them feeling the need, internally. But there are incentives and disincentives to treatment that should be exercised and should be tested.
We have a whole cohort of academics here in Boston who absolutely rail against coerced treatment. From my perspective, I’ve looked at the data, and I’ve looked at what they’ve written. The whole modality of coerced treatment is very weak in our country in terms of how we exercise it. Some of these folks lump coerced treatment with putting a person in jail, getting them abstinent, forcing them into a detox center, or other draconian measures without ever looking carefully at how can we coax a person into treatment with contingency management, and with disincentives that would work. And we simply have not explored this. The Drug Policy Alliance has come out strong against this, but that I think is because of the philosophy of “let’s not interfere with drug use, period.” What we are losing in this country is this whole concept that drug use can lead to adverse consequences and therefore it’s better not to use. That whole philosophy that dominated is being eroded by very vocal activists who feel that drug use should be encouraged or supported or supplemented with housing and free supplies, safe supplies, and paraphernalia. Every decision we are making along these lines is leading to a worsening of the problem.
Jason: As drugs become synthetic they often become easier to make and cheaper to sell. Do you see any paths to correcting courses besides ramping up drug enforcement?
Bertha: In the patent literature of medicinal chemistry we have literally thousands of drugs that can be made, that haven’t ever been made. I was involved for a number of years in trying to make a medication to treat cocaine addiction. We designed over 600 compounds and made them. Cocaine analogs that we thought could help. But the cartels, they scour the literature, they look at patents. They look at medicinal chemistry manuscripts. There is no limit to this. So the feeling that I have is that no matter how many times we schedule something that surfaces from the endless stream of new psychoactive substances, the only way to address this is to promote a culture of prevention. Every one of these drugs is a human experiment without informed consent and absolutely no data on what will happen to your brain under the conditions in which you use these new compounds.
Jason: What are your thoughts about drug rehabilitation in America and its success rates? Is there something we should be doing differently and immediately?
Bertha: There are 14,000 treatment centers in the country. We have very effective medications for the opioids, we have some for alcohol, but nothing for anything else. We don’t have anything for marijuana, cocaine, methamphetamines, or for hallucinogens.
There are multiple ways for recovery, there are multiple needs for recovery. So the question is, of these 14,000 centers, which ones offer evidence-based treatment? And by evidence-based treatment I mean medications for opioids and psychiatric services. A very significant percentage of people who use drugs also have psychiatric needs. How many of these centers give them AIDS counseling? How many of them give medical exams? How many of them keep very detailed records of successes and failures? How many of them limit the amount of time a person spends in treatment or keep it open-ended? How many of them treat it as a chronic disease rather than 28 days and you’re out? Probably about ⅓ of our 14,000 adhere to these principles. And the federal government is literally supporting (as well as Medicaid, Medicare, and private insurers) a lot of treatment centers that should be out of business.
I’ve been to many of them when I was working in government. The first question I would always ask is how many people are referred to you, how long does it take to get a slot? They don’t know. Many of them don’t even keep records. How many staff members stay for the entire term of their treatment? No records. How many of them relapse? No records. It’s so detached from the type of standards that the medical community has, that it is one of our travesties. The American Society of Addiction Medicine people are trained in both medicine and addictions. They have to adhere to standards of recording and record keeping and treating as a chronic disease that we just do not have in most of our treatment centers. I would urge anyone that wants to get a treatment slot to first look at the criteria for what is good treatment and see if this place fills it. And if they don’t, it’s not necessarily the best place for you. The other thing is there are many pathways to recovery that don’t involve all of this intense care. Some people benefit enormously from things like AA or NA, some people benefit from spiritualism because it is their inner nature. Some people age out spontaneously as they get older. Some people just need a person who believes in them, who loves them, who sees hope in them to get them motivated, and if they don’t have that, nothing can change. My mind is filled with stories of great successes and great failures, and some of these great successes and great failures are based on the human factor.
Jason: Recovery advocate Tom Wolf had a recent piece in the news talking about new versions of Fentanyl on the west coast that are unphased by Narcan and one that causes skin erosion. What are your thoughts about these new and evolving drugs?
Bertha: The skin erosion is due to xylazine which is an anesthetic that is laced into the fentanyl. We have to always keep our eye on all of these emerging trends, no matter where they are in the country because the next day that may be in your home or with your teenager. The details are less important than the fact that constant vigilance is essential because we don’t know when they’ll cross the Mississippi.
Jason: A recent story from SF showed that overdoses are up and 66% of them are happening inside a singular supportive housing facility. Do you think housing first and fentanyl are incompatible with each other?
Bertha: I think the concept of housing first is another one of these political feel-good moves which makes no sense unless you partner it with treatment. It’s very seductive to say “Well, a person is living in a tent, they have access to drugs, all they need is a house and they will thrive.” It makes no sense if they have a substance use problem. To put them in a house where there is no attempt at normalizing their lives, normalizing treatment, normalizing a recovery strategy for them. From my perspective, it’s another one of these harm reduction moves that I think has not been thought through in terms of cost-benefit. Most people who die from an overdose, die alone. It doesn’t matter if they are in a tent, on the street, on the beach, or in a house. If they have a problem, they can die from it, and the house is not going to make a difference to their death unless you treat the problem.
Jason: When people read this article and insist that safe supply is the only solution, what would you say to them?
Bertha: Well, there are two paradigms to look at, one is what happened in our country, and the second is to look at what happened in Canada. In our country, we had a safe supply for about 12 years starting around 1999- 2012, and that safe supply was prescription opioids that were pristine. Tightly regulated purities, supply chain, fillers, the dose was perfection, you knew precisely what you were getting. And we had the worst prescription drug overdose crisis in our history. Why? Because if you yield to safe supply there are zero guarantees that there is going to be safe use. They are two completely different things. So we had people who diverted these pristine opioids to thousands and thousands of people who overdosed. It was abused rampantly. We increased the safe supply by 300-400%. And as a consequence, what did we do? We recruited more people into opioid use problems, we recruited more people into addiction, and we recruited more people into death.
Anyone who considers that all you have to do is give a safe dose and that’s going to solve the problem, it’s completely and totally unfounded in terms of our own history. And what’s happening in Canada? Most people who are getting their so-called safe supply of hydrocodone are fentanyl users. They are tolerant of fentanyl. Hydromorphone is not going to give them the same buzz as fentanyl. According to the records I’ve read recently, the people who are getting their safe supply users in Vancouver BC are selling them. They are selling them to users who are not tolerant of opioids yet because this safe supply does not get them the same sensation they are seeking, and they are then using the money to buy fentanyl. So instead of solving the problem of trying to prevent overdose, they are exasperating them. According to the reports that I have read, which may be true or not.
Jason: If you were in charge of messaging for NYC’s health department, what would you want their public messaging about drugs to say?
Bertha: If I was the Mayor of NY or in charge of public health, I would recruit President Biden, his entire cabinet, and the drug czar to make an absolutely frank statement that drug use is not a safe activity. It is unhealthy, and it is dangerous, not for everyone, some people use and are fine but there are a number of people who use and get into deep trouble and we don’t want to sacrifice them. I’d start doing public health messages that are prevention-focused from the top down, in the state of the union, with the drug czar, Rahul Gupta. He is a good man, but he is just focused on treatment and harm reduction because he will be judged by how many people die instead of how many people are prevented from using. The first thing I would do is start with changing the culture. The second thing I would do is define harm reduction. Is it to facilitate use or is it to try to tide a person over from dying in order to get them into treatment? Is treatment the goal or not? And if it’s not the goal, why are we doing this? Why are we leaving people where we find them? The third thing I would do is use the police force to crack down on all of the illegal dealing in the city. I don’t care how many people you arrest, I think there should be a culture of fear of dealing illegally. Because if you don’t create that culture of fear, anything goes. If you have a child who is two years old and you put no restraints on their behavior, you will have chaos within a few weeks and at tremendous danger to themselves. What is missing from NYC’s response is resolve, and what is being listened to is people who are literally proponents of drug use and drug legalization. And they have had their center-stage moment. It is time for them to exit, stage left, and let people take over who really care deeply about the future of people, and know that the state of addiction is a very malevolent state for the individual. For their families, for their children, for their friends, for their grandparents. It is not a healthy state and there should be a resolve to do everything possible to get them out of this state into a hopeful state, and into a renewed state.
Jason: Are you seeing fentanyl users surviving years 3 & 4 of regular daily use? Or are they dying before reaching year 3?
Bertha: We don’t know the exact number of people who are using vs the number of people who are dying. I would say that on average, 10% are dying within two years. There are some users who think they have the most pristine distributors, that they will never sell them bad fentanyl and they can continue this way and perpetuate the use indefinitely because they feel that they are protected by the dealer. I would submit that there are no guarantees, it is a case of Russian roulette. It is fascinating to see how the user’s mindset has changed.
When I was serving as director of ONDCP we had a fentanyl explosion of 1,000 deaths a year (which is 1% of what we have now), and I panicked. I was on the job for about a month when we started to see an uptick in deaths. What was fascinating at that time was people were interviewed who were using it, and they were seeing their friends die and the newspapers reported a number of them going into treatment. They were terrified of dying from fentanyl. The death rates went up until somebody took out the super-lab that made it in Toluca Mexico, and they went back down to near zero. I was fascinated by the fact that people then were not willing to risk their lives. And now we see a shift in that they are pushing the envelope without that fear. Hillary Connery, a psychiatrist at Mclain has interviewed some folks and she asks the ones who have survived an overdose: “Were you trying to kill yourself?” a very significant percentage, maybe 25% said that they weren’t really worried about that, they were indifferent to dying or they were suicidal. What we are seeing is a real shift in the mindset about the terrors associated with drugs. From my perspective, if somebody that I knew was using fentanyl, I would be in a state of complete and total panic that they could die. But that panic is not the norm anymore.
Jason: I may have misphrased my last question a little bit. What I meant was when someone is in an extreme state of daily addiction like we see on the streets of SF, is there only a certain amount of years for that person to find an off-ramp before dying?
Bertha: My feeling is that we don’t understand if fentanyl’s capacity to adapt the brain is different from oxycontin or heroin. What we know is that it’s so potent that the pathway to addiction is very rapid. The highs are so extreme, and the tolerance level becomes rapid as well. Users need more and more to achieve the same euphoria. I just think that based on the data, the pathway to recovery really depends on the load of other factors that an individual carries. So if they have a psychiatric disease, if they have a personality disorder, if they have used it from a very early age, if they have no social supports outside of their culture of drug use, all of these factors make it harder and harder for a person to recover. This is certainly true for alcohol, I think it’s certainly true for some other drugs as well. So the question is, should we give up on some people that have very little hope of recovery? From my perspective, I don’t believe we ever should. Tom Wolf was at the bottom, and yet it was a form of coercion that brought him back. We don’t know how many people are like that in that status, but we should treat everyone as if they have the potential to get better.
I remember doing tabletop rounds in Washington with a group of psychiatrists who were going through their list of homeless drug users. They would send people out in cars to check on them. They knew them all by name, they all had medical records, and many of them had psychiatric disorders. They would go out and find these people, lift them, carry them to the car, take them to the hospital, rehydrate them, get them back on their anti-psychotic meds, and try to motivate them into treatment, all because they never wanted to give up. This has been my philosophy since the day I was born, you never give up on anybody, and I still believe that.
Jason: I think my earlier assumption about fentanyl leading to death in a short time frame may have been influenced by Sam Quinones's recent findings on P2P meth. I believe he said something along the lines of users only have 6-12 months before reaching severe states of psychosis.
Bertha: Methamphetamine is a nasty drug. We’ve done pre-clinical research in the lab comparing adolescent with adult use. Methamphetamines are known villains in terms of toxicity. Which means that you can actually see the nerve cells deteriorate. Every nerve cell has a wire that connects it to another, just like old telephone wires. Once those wires are broken they cannot regenerate. That’s why people have spinal cord injuries and are paraplegic for life. The cables don’t grow back in the same way that a bone can heal. Methamphetamine (and probably these more powerful analogs) are notorious in terms of destroying cells. I also think that we are overlooking the effects of some of the other drugs at well. In adolescent pre-clinical studies (which are animal tests), marijuana causes a very robust inflammatory response in a key brain region, and we have shown that only happens in the adolescent brain, not in the adult. That key region is involved in depression, anxiety, stress, sleep problems, and a whole host of functions that are essential for Darwinian survival. I was stunned that we did this in 3 labs to verify it and they all came back with the same data.
My colleague found a correlation between the inflammatory response and these animals who were then allowed to grow up and did cognitive testing, and they were terrible at it. Which seemed to reflect that there is a functional consequence that could persist for life. Even though methamphetamine can have this glaring effect on nerve cells, this damage that is irreversible, we are just beginning to find out that some of the drugs that we have assumed are less toxic are actually quite toxic depending on the platform where they are operating like the adolescent brain.
Jason: someone asked me if young people smoking high-potency marijuana regularly will slowly induce them into forms of psychosis like schizophrenia and bipolar disorder, or, does that person have latent schizophrenia in their DNA and this triggers it into activation?
Bertha: That’s an excellent question. We don’t know yet, but here are some of the data. If you give normal people without any symptoms (controlled subjects) intravenous THC, they will develop symptoms of psychosis under the influence. They won’t develop full-blown psychosis, but they’ll develop paranoia, some types of thought disorder, deep detachment from the world, and so on.
If you look at the dose response of marijuana, the more potent the drug, the greater the probability of developing psychosis. If you look at the timing, psychosis usually comes after the use of marijuana, psychosis does not proceed it. If you look at people with schizophrenia, they will become much worse if they use marijuana. Their symptoms will just become much more florid, and much more likely to be hospitalized and to have multiple hospitalizations.
So the question is, all of these things could be explained by people being attracted to the drug because they have an underlying problem, and is it causality or association? The field is moving more and more toward causality.
There are certain factors that are coming into play that do not compute with a person being attracted to it to alleviate some symptoms they had. One of the most interesting things long before marijuana became a political football, a profit football or a financial issue is that the India Hemp Commission published a report in the 1890s in which they looked at people at the Bengal Insane Asylum, they found that up to 40-45% of people there had been heavy marijuana users. They looked at other factors like alcohol and opioids and they were very low. And so they concluded that marijuana is likely to trigger psychosis, and all of this was long before the politics. The other big problem that I mentioned earlier is that people that have a first episode of marijuana-induced psychosis and go to the emergency department (even with very light uses) if they are followed up for a number of years and they continue to use, their conversion to full-blown schizophrenia rate is about 25-40%. The association-causality debate will go on forever. The people who like marijuana will say it’s all association, but there is a possibility that the genes that contribute to schizophrenia are also contributing to marijuana use. There is an overlapping of those genes. We can’t predict who will become psychotic, but it is actually quite a risk factor.
Jason: Is there anything you would like to share with the people of NYC? There’s a good chance many politicians will read this, as well as parents who are trying to navigate their teens experimenting with drugs.
Bertha: For parents, I would say the following: read the recently published data showing that if parents use marijuana, their children are more likely to use.
If you think you can say to a child: Do as a say but not as I do, it’s not gonna work. The influence of parents on their children’s drug use is massive, it’s been underrated, and it’s been undermined by a lot of people who think that parents really can’t control their teens. Parents have a massive influence on their children’s lives, especially with drug use. And there are a number of ways in which this can contribute to whether or not a child uses or doesn’t use. We are developing a very lengthy (available on the web) course at Harvard on how to protect your children from drug use.
Parents, you have a massive role to play in what happens with your children. Don’t tolerate it in your children’s schools. Don’t tolerate it at home, because it will influence what your child does, not only the access, but also the normalization.
For politicians, there is no question in my mind that you cannot treat your way out of this, harm reduce your way out of this, arrest your way out of this, or prevent your way out of this crisis that’s getting worse and worse in our country. The only thing that you have to do is develop the resolve to implement all of these strategies. You have to put a heavy emphasis on prevention, and denormalizing drug use, and forget the tax dollars. The tax dollars are going to be wasted away by the consequences of drug use. It’s just a false accounting of your revenue stream. Prevent it, intervene, implement screening, and brief interventions throughout the entire medical community. Develop evidence-based treatment. Not treatment that is so mediocre that it’s an embarrassment to this city.
Don’t facilitate drug use, and don’t accept it, because, in the end, it does not help the drug user for you to normalize and make it easy for them to have drugs. In the end, the best thing to do is to try to recruit them into treatment.
And be hard-nosed about those people who are selling the drugs, because they are profiting off of the lives of your citizens, your taxpayers, and your voters. We are at a crossroads, and there is no better strategy in warfare to destroy a country than to flood a country awash with drugs. Because everything breaks down from that point. Excellence, construction, thriving, education, the rule of law, everything erodes into nothingness. This is really one of the most destructive periods in American history and I am very worried about it.