Ben Levenson: Harm Reduction

Ben Levenson is the Chairman of The Levenson Foundation and founder of Origins Behavioral HealthCare. Ben chats with Valerie and Carly about harm reduction, or ways to “derisk” drug use for the millions of people who use drugs in the United States, and the gap between “the bench and the trench,” or between scientific findings and addiction treatment. Ben talks about international approaches to drug use and leaves Valerie and Carly with some excellent food for thought about the need to end stigma towards all people who use drugs, not just people in recovery from drug use disorders. 

Read more about Ben’s work with the Levenson Foundation here: https://levensonfoundation.org/

Read about the Rome Consensus here: https://romeconsensus.com/ 

Read about the National Harm Reduction Coalition here: https://harmreduction.org/ 

Follow Ben on Twitter: @BenLevenson

Transcript

Valerie Earnshaw: 0:09

I'm Valerie Earnshaw,

Carly Hill: 0:13

I'm Carly hill,

Valerie Earnshaw: 0:14

and this is Sex, Drugs, and Science.

Carly Hill: 0:17

Today's conversation is with Ben Levenson. Ben founded Origins Behavioral Care in 2009, a nd Origins offers comprehensive addiction, recovery services for patients and their families. In 2017, Ben founded the Levenson Foundation, which aims to reduce human suffering and promote w ellbeing.

Valerie Earnshaw: 0:35

We're grateful to Ben for joining us to continue thinking about how sex and drugs science is used, and also not used in the real world. And also to continue thinking about what it is that we just need more science about or what we need to continue researching. Ben is a tremendous advocate for harm reduction. And so we really focused our conversation there. Harm reduction, includes strategies and ideas aimed at reducing negative consequences associated with drug use. So in some of our other episodes, we've talked about Naloxone, which is a medication that reverses overdoses from opioids, medications for opioid use disorders, things like methadone and buprenorphine, syringe exchange, and overdose prevention sites. So all of these are examples of harm reduction that we've been talking about. So we hope that you enjoy this conversation with Ben Levenson. Ben Levenson, welcome to the podcast.

Carly Hill: 1:31

Thanks for joining us!

Ben Levenson: 1:32

I appreciate getting to spend time with you guys. I've been super excited to, uh, to chat with you and, you know, thinking about the audience that you guys have to build. It's this is a really special opportunity. So thanks for having me.

Carly Hill: 1:43

Of course, It's our pleasure.

Valerie Earnshaw: 1:44

Yeah. You couldn't be more excited than us. We've spent a couple of days like digging into your background, listening to other podcasts and things that you've done. And so we're 15 out of 10 excited to talk to you like.

Ben Levenson: 1:56

My condolences if you've been background checking me.

Valerie Earnshaw: 2:00

No, no, it's been fun. So could you start off, Ben, by telling us just a little bit about yourself?

Ben Levenson: 2:06

Sure, sure. I'm going to share a little bit from a personal frame and also professionally. Substance use disorder and, and kind of chaotic drug use kind of permeated my family generationally on the, on the maternal side, my mom lost her brother to an overdose in the nineties and, uh, she's 30 years in recovery now and I lost my brother the week the towers came down and I looked in the city and, and so it was a real double whammy. And, you know, you would think that, oh, after that you would just total, like I'm not-- but my drug use actually increased. And so I had my own, you know, my own journey with kind of problematic drug use. And I think most of us who end up here, like in the substance use disorder or kind of dual diagnosis space typically have some personal connection or investment, you know, I went to treatment and I was really a victim of this like acute episodic intervention on what we all know is a kind of a chronic process. Right. And just wasn't sufficient. And so, yeah, I mean, I, I decided to, to build, to iterate and innovate on treatment and, and that's what brought me into the field. It Was kind of like,"Hey, look, we can do this better". That was 20 years ago. And here we are. Thanks for asking about my background.

Valerie Earnshaw: 3:31

Yeah. So you started Origins Behavioral Healthcare. I mean, this is a little bit related to the first group of things I went in to talk to you about, which is, what do traditional models of care look like? And then what, what do places maybe like Origins do a little bit differently? So one of the things that you just said was that, you know, treating substance use disorder, treating problematic substance use, like in an acute short-term way, as opposed to a chronic illness, that seems to be one part of it. Are there other pieces or?

Ben Levenson: 4:04

There's reasonable data that, that suggests, you know, maybe 80 million Americans will use an illicit substance one or more times in 2021, if we rely on SAMHSA's data-- and we tend to act like we do-- they say there are 20 call it 24 million of those drug users, have substance use disorder and kind of writ large with the treatment apparatus, both public and private combined, only interfaces like formally with, with 3 million people annually. You know, the question used to be,"well, how do we get the other 21 million to, to, you know, to seek care?" Like, how do we motivate that? Then what's the breakdown on, on why they're not, you know, they're not seeking help. Is it resource related? Is it, you know, what are the barriers? But the world has changed. It's not just the 24 million who are, you know, kind of eligible for support. It's actually now the entire cohort because we have a profoundly contaminated, irreversibly contaminated drug supply. And every one of them are using from the same trough. It used to be the 66 million that, what do they need support for? I mean, they're, they're lower, no problem drug drug users. But they do. They, they need help understanding that the supply is contaminated. And it's fundamentally, you know, care that's centered in harm reduction sciences that, you know, helps them de-risk that drug use.

Valerie Earnshaw: 5:35

I'm really glad I asked because that's not necessarily what I was thinking. When I asked that question, I was thinking, how do we better serve the 20 million? That is really interesting to think like, no, actually we need to be thinking about the full 80 million and in Delaware, which is where Carly and I are, we think about this contaminated supply issue a lot because we've... we're the state with the second highest rates of opioid overdose deaths. And those rates really started to climb in 2017 when fentanyl gets in the system. And so it really does seem like it's, yeah, it's a contaminated supply issue. So is that, is that what you're speaking to in terms of the contaminated supply or are there other other pieces to that that I might be missing?

Ben Levenson: 6:23

So there are other adulterants that we're seeing in the drug supply. So it's not just fentanyl or fentanyl analogs there's Xylazine is, is showing up, which is kind of a, a veterinary drug. So yeah, I mean, I think when you asked about kinda treatment, you know, the systems that we still have and the systems that I designed domestically, um, you know, were rooted in this ethos, right? That says all drug use is pathological, you can be down at the bar drinking all afternoon, and you're just a swell gal, but if you use cocaine once it's pathological, right? The treatment systems that we built over the last kind of 40 or 50 years are a reflection of how we think about people who use drugs, drugs, themselves, and how they're used. And so, I think that the models that are innovative, are going to be responsive to the kind of the entire cohort who have really varied needs. And a lot of those needs kind of violate our fundamental beliefs about drug use.

Valerie Earnshaw: 7:27

Let's dig into that. So what are some of these fundamental beliefs about drug use. A part of it, from what you're saying? Sounds like, you know, any drug use is pathological. Right?

Ben Levenson: 7:38

Yeah. I mean, some of these beliefs are things like, certainly that, but also this idea that if a person uses drugs, there's really only, kind of, two states they're allowed to exist in. Either you're abstinent and everything is grand, or you're using, you're in chaotic use and it's jails, institutions, and death. Right. And that's just not true. That's not at all supported by the research. The bell curve lives through, you know,"in the gray" and actually very few drug users live on either of those polls.

Valerie Earnshaw: 8:10

Right. And so"A" that's like a really lovely description of it. That's really great to think about. And there's two things popping into my mind, you know, when I'm listening to you. So one is, I don't think that's how it works for any chronic illness, any chronic illness we would ever study has like a continuum of outcomes. You know, so I'm thinking about this right now because I live with a chronic illness. There are times when I'm like really very sick, clearly having a flare up. There are times when I'm like really clearly well, but right now I'm like definitely like teetering. So that would be terrible if I had to wait until everything was really out of control with my chronic illness until I had to like go interact with my doctor, you know, like I'm probably the 80 million zone, you know, or the 60 million zone right now who, you know, or the equivalent for like these substance use stats. And I'm able to be working with a doctor and like figuring that out. And how do we keep me out of like the kind of like extreme end of the spectrum. That's one thing that I'm thinking about. It just, it maps on to every other chronic disease, you know, contexts that we think about. And then the other is just that the way, you know, scientifically that we like measure our outcomes and like, it, it all does guide us towards thinking about those buckets. Like, you know, are you in like this very disordered use category or not? Right. And so if we don't use, I mean, we call them"continuous outcomes", you know, when we're like analyzing our data, like if we don't look at that full, like 1 to 10 scale, if we're only thinking about 10 versus one to nine, then yeah. You're going to miss all of that nuance. So that's a really interesting observation for me.

Ben Levenson: 9:55

It's really interesting kind of the departure, right? From, from even just, just fundamental medical logic and, and right? And scientific method that this kind of runaway medical specialty has been allowed to do. And I mean, and I, and I get why, like you go back in time, I mean, you know, medicine didn't have efficacious therapies for alcohol use disorder or a drugs related substance use disorder, but these"woowoo" people believe they had, you know, an answer. And so I think medicine was like, yeah, just throw them over the wall."You go, go do your voodoo. And when they need real medical care, bring them back to me". And so it was orphaned, you know, addiction treatment and medicine became orphaned. And in, in that kind of orphaned state, they never got, they just didn't get some of the scientific norms, you know, some of the logic and decision trees that we use in medicine. And candidly, I mean, some of the patient kind of rights were and are trampled pretty heavily today. And, and, and so, yeah, it's, it's, you know, you can look back in the history of medicine, look at Lobotomy, are there, there are examples, right? Where ideological kind of centered care in, got on a runaway train and on a level that's what we've done with treatment. And, and, and that has to change

Valerie Earnshaw: 11:18

Making connections to the bottom is really interesting. The other thing that is, I'm making connections with in my mind is, so with the history of, you know, for example, like black women in America, or women living with mental illness in America, like there was a long period and it probably, you know, continues today in incarcerated settings where women were just, you know, given hysterectomies. Like the decision to take away like the right to have a child it's like taken away from them because they were, it was decided that they weren't able to make that decision.

Carly Hill: 11:51

you're too hysterical.

Valerie Earnshaw: 11:53

Your too hysterical! That history sounds similar to me just in terms of like, how do we treat people over time? How much do we, like value their lives? How much do we invest in figuring out ways to keep them well? And it seems like an evolution that's continuing.

Ben Levenson: 12:16

I mean, you know, addiction is it's, it's anomalous addiction treatment is it's just anomalous in medicine. And, you know, it's one of the only kind of processes what-- and let's say, I mean, it's, we,-- we conducted this campaign as addiction professionals that said"you will call it a disease". Right.

Valerie Earnshaw: 12:32

Yes.

Ben Levenson: 12:32

And if you don't we'll attack you. Right. And so we're down this, this, this train. Okay. So fine. Okay. Let's just say we'll, we'll stipulate, it's a chronic, progressive deadly disease. Okay. So then why on the other hand, do we require like patients to really put their chief symptom drug use-- Right-- into perfect, immediate and sustained remission in order to initiate care? It's completely shocking. Right. And so I say that because when you were talking, you reminded me that, we fight for incremental improvements to patient health and safety every day in medicine. And if we can get a half a point improvement, right? Like that's amazing. But with people who use drugs, you have must either be perfect and perfect today, or-- right-- We'll discharge you from care and blame you, you know, for our inadequate capabilities, it's shocking. Like fundamentally, when you think about this and the rest of the world does this differently, but here we don't value incremental improvements. You know, a case example is like a patient who comes in and is injecting heroin 30 days a month and says,"I'm overdosing once a month. And I have a one-year-old and my wife and I have an-- our first anniversary is coming up and I'm scared and I'm scared I'm going to die, but I drink and I use cannabis every day, every other day. And I shot 14 people for this crappy country when I was in Afghanistan for you. And yeah, I overeat my benzos. Okay. But I'm not stopping taking benzos for my PTS today. My wife and I, we, we, we get, you know, we get a stimulant two to three times a year, some, some Molly or, or whatever, and we get the best hotel room we can afford, with great sex. And the connection that we build those nights are really vital to my relationship. I'm not stopping doing that. Will you help me?" Right. And the answer right now is"no"

Carly Hill: 14:49

No.

Ben Levenson: 14:50

"We can take your money. So you can come in and participate in our fantasy about your best life. Right. And so you could come in and masquerade that you're not going to drink. We're going to force you off the benzos. You can't take Bupe because we don't think it's real recovery. And look, when you get out and you return to active use, by the way-- you're a total treatment failure" and"go, go get finished and let us know when your ass is on fire again." Right. It's, it's, it's insane. And it's not, that's not what we do in medicine.

Valerie Earnshaw: 15:21

Can we talk for just a minute about-- well, first off, what an excellent example, like what an excellent case study to show what that could look like. Can we talk just for a moment about this dominant, like prohibition or abstinence narrative and where we think that comes from, does that, do we think that that comes from AA and, and how AA is so enmeshed in our treatment, like protocols and such in the, in the US do you think that's where it comes from? Or do you think it comes from somewhere else?

Ben Levenson: 15:49

So there's no question about the inmeshment between 12 Step kind of belief systems and treatment. And certainly I think that 12 Steps do focus on abstinence, and they do value abstinence as a primary outcome that they're seeking. Look, the prohibition, It's not about the safety of people, right? Prohibition isn't about like drug safety or keeping you safe. In fact, we Scheduled drugs that, I mean, that, that really aren't that dangerous. So it's not about drug dangerousness. It's a lot about controlling people, particularly communities that people think are threatening or whatever. And so, for example, prohibition predates Nixon and the Nixon administration. But we know from his senior advisor who helped kind of architect this, this modern drug war they've even said, right."We knew we couldn't make it illegal to be African-American or to be a hippie and a war protester. But what we can do is heavily criminalize cannabis, right? For the hippies and heroin, for the African-Americans and demonize that drug every night on the evening news, and use that to penetrate right there, their groups and their leadership and their homes". And he says, at the end,"did we know we were lying about the drugs? Of course we did". Right. It's not about...

Valerie Earnshaw: 17:23

Right. So one of the things that this makes me think about is, you know, stigma's totally pervasive in this, right? Like it's super pervasive. And there are folks who theorize around why stigma exists. Like, because if it's here, it must serve some sort of function for humans. Right. And so the two that ring relevant to me right now is that, racism is about keeping people down. It's about oppression, right? It's about maintaining the power of white folks in society, over others. And then, uh, substance use stigma or drug stigma associate with drug use is all about social control. It's about, they call it keeping people in, like keep like defining what the social norms are and then trying to keep people inside of them. And so these examples are like this perfect intersection of like, of very deliberately, like how do we keep people down? And then how do we like manipulate, like kind of like make this line in the sand around, like who counts as a good person in our society and who doesn't? You know, it's really interesting. We think a lot about structural stigma and like policies that have stigma baked into them. And it's just, it's such a, like, perfect example of a moment in time when people like created a policy to oppress and to monitor, like what makes people a good person versus a bad person?

Ben Levenson: 18:50

There's no question about it. And I think the data, you know, it makes it it's in controvertible. I mean, the disparate kind of application of drug policy and drug law, and the way that that effects communities of color is, I mean, it's profound. I mean, you can just look at the incarceration rates for non-violent drug use. And, you know, we see that, you know, it's almost like it's like one to nine, in terms of ratios, between, you know, white people and those incarcerated who are people of color, but we use substances at the same rates and at the same levels. If people want to say,"well, they use more drugs". No, they don't, they don't use more drugs. Right. You arrest them and white people get to go to treatment. That's what you do. It is, it's deeply broken and, you know, I mean, I think that there's a call to like tear it to the ground. I don't think that's how change actually occurs. It sounds great. Right? The system needs a complete reinvention. You know, I think the truth about change, is that it's the same thing about valuing incremental improvements in our patients. I think we are going to need to seek incremental improvements to drug policy reform, but we're at this very special moment. There's no question about that. And change is happening.

Valerie Earnshaw: 20:01

You know, I go around, I give these talks about stigma to folks and they're always like,"how do you change stigma? How can we, how can we do this?" Then I'm like, great question. So, yeah, I'm always, I have this spiel about how there's like"many tools in the stigma toolbox". And I always like to say that, but you know, the thing I'm always thinking about is like, as a woman standing up here, like, we still have sexism, we still have racism. Social change is slow. Even right now, I would argue, we are in a period of rapid social change around like LGBTQ stigma and equality and human rights. And even that is too slow, you know? So yeah.

Ben Levenson: 20:41

Yeah. I mean, I think for drug users-- I mean, fundamentally right-- when we want to stigmatize something, we criminalize it. I don't believe that any drug user will be free of the threat of stigma until active drug users are not stigmatized either. Right. And we have this crazy view, like where, when we talk about stigma and anti-stigma endeavors in terms of drug users, it's always about people in recovery. It's always about,"oh, wait, well, but she's sober. She's a good person now", as if abstinence gives rise to being a good person, you know. I do think that the criminalization of drug use, which is not in and of itself a crime, and it's also something we've been doing since time immemorial; altering our consciousness. You know, I don't think that we're going to get to where we want to go without addressing, you know, the criminalization of not just drugs, but of drug users too.

Valerie Earnshaw: 21:39

I really appreciate you bringing that up because I study, and Carly is involved in these studies, It's like, we focus on people who are in treatment, who are on medications for opioid use disorders. That's our population. So when I'm thinking, when I'm studying stigma, like that's the group of folks that I am focused on, but for me, this is like really great food for thought that, that I'm not going to solve stigma for that population until I help to solve stigma for all people who use drugs. Like, and that's wrapped up in that criminalization. Like, I can't just be like, oh, if you are at the end of the spectrum substance use disorder, in treatment, I need to be helped, like working on that. I need, you know, you really need to think about the whole thing to be actually helpful,

Ben Levenson: 22:22

But that's part of the fantasy that we live in as Americans. Right? Talk about baked in stigma. I mean, it's, it's almost baked in violence, really. It's, it's, it's like systematic violence to, you know, to do what we do to active drug users, which is we starve them out. We won't engage with you. We systematically or systemically believe that people who use drugs should face maximum risk, unmitigated harm and, and deep and lasting consequences, because we mistakenly believe that those things precipitate recovery. When you take away my kids, and my car and insurance, and my ability to make money, you give me a felony, you lock me up. And my kid, I missed years of my kids' life. The research has never suggested anything different. What we know is that that precipitates, chaotic drug use. Which is fine with the system. Cause they'll just incarcerate you again. And so, yeah, I mean, it's this trillion and a half dollar, it's one of the most violent policies that we've had in I think the moderate, modern era. I don't know domestically, if there are policies that are more brutal to our fellow Americans than that.

Valerie Earnshaw: 23:34

Yeah. It's traumatizing with a big T.

Carly Hill: 23:36

Yeah.

Valerie Earnshaw: 23:37

Then I know you do a lot of work with folks internationally and some of them do this better, and some of them do it worse. I do a lot of work in Southeast Asia. So like in Indonesia, Malaysia, uh, you know, familiar with what happens in the Philippines with folks who use drugs. It's not great. Could you fill us in a little bit on your perspectives of what other countries do better, or maybe what other countries do worse in comparison to the US with these international collaborations that you have?

Ben Levenson: 24:05

You know, I was raised in this abstinence centered ethos. Most of us have been, right? And I got to this place where I was tired of like this monolithic case-mix that I was treating with, like not even very much diagnostic variation in the case mix. So we decided to take it, take some money off the top line of the hospitals. And it was like, look, let's go find a population that's not like what we're treating. And let's not walk in as Americans with money who know it all, let's walk in with money and a deep curiosity and a willingness to be taught and to learn. And that began this journey for me, this ideological journey, you know, now is centered in harm reduction, which includes abstinence, by the way. I mean, Abstinence is... it's an extreme form of harm reduction, but yeah, I mean, I ended up in environments where, like you mentioned in, in, in Malaysia, but for me, it was in the middle east. These were, you know, strict, uh, Sunni, Islamic cultural containers where homosexuality and drug use are really, really dangerous for people who, who do that. Helping build systems that are responsive to the cultural conditions, or at least mindful of the cultural conditions and responsive to the patients was some of the, of my favorite work. But that precipitated this journey into the Balkans. And then, and then west westward, where I started to learn about how the rest of the world cares for drug using populations. And it broke my brain and my heart too actually. Um, I'm coming back and I'm like telling my mom, like these are high level peers at the, all the brand name, treatment programs that we all know. And I'm like,"Hey, do you know that the rest of the world engages with people who are actively using drugs? You know, they don't condition care on an agreement to live this moral version of life that we think we're going to force down your throat?" What they do really well is there are systems, particularly in Western Europe, that I admire a lot because they're centered on person empowerment. The same really laws that we have here and rights that we have here that we just, we just trample them. But I'm talking about things like, like agency, and rights of self-determination, and even rights to kind of informed consent, which they honor. I'll tell you a story. There's a fantastic program that together we have partnered with them and others on this thing called the Rome Consensus. And it's a humanitarian drug policy framework. You know, that's international, it's this core kind of framework of drug policy that can be acculturated, you know, locally to reflect the populations that it's affecting. And, and we're really proud of that work. Uh, I think that it, it, it speaks about how we see the world right now, and I encourage folks to go take a look at it. But in that process, I was working on a, uh, volunteering on a, on a mobile kind of syringe service van in rome. And there was this guy who kept coming, you know, I see him every day on the, on the van right. Coming to, and he pulls up in his Mercedes and he gets out, takes the suit jacket off. Right. And he comes over to the van and he chucks some old syringes. He prepares an injection, does one and grabs a plate of spaghetti that we're making in the truck, does some backslapping, you know, with, with other people who were there from totally different walks. And, and I, and I, I said to this guy, I'm like,"what are you going to do today?" And he said,"well, I'm going to do what I do every day." He goes,"I'm going to go back to work. And then, uh, I'm coaching my daughter's soccer practice tonight. My son has something in the theater. My wife, is going to see that. We'll have dinner and prayer. And then I will wash, rinse and repeat." He said, and I go,"you like your life, don't you?" And he goes,"I love my life. This is exactly the life I want to live. It doesn't mean I don't need support. It doesn't mean that I, you know, I can't be safer or be healthier. I want those things just like everybody else, but no, I love my life the way it is right now." And being able to meet him in that space and validate that and connect-up with that is so fundamental and so important in terms of how we begin to care for domestic populations who use drugs also. Look, everybody uses drugs. The question is, what drugs do you use? Are they ones that white people say you should and pharmacists, you shouldn't, or are they approved or unapproved, right. Which is not again, rooted in any, anything meaningful, other than bias and crappy policy.

Valerie Earnshaw: 28:55

All right. Observation, number one, Ben is a gifted storyteller, and I wanted to drill down into why that's so important for just a moment. And from my perspective is that one of our ways that we can reduce stigma is through storytelling. And so I know that implicitly, you know, that that's what you're doing when you're doing this is that you're humanizing folks. You're helping people do perspective taking and empathy, but like just what an amazing thing to do in your day to day to like, come on these podcasts, or, you know, before you got on with us, you're talking to a Senator-- Which I'd love to come back to-- but, you know, just to like bring these stories and share them and then be such a gifted storyteller at it. That's great. But putting that, you know, just putting that observation aside, I just had to say it out loud. The thing I'm really noticing here and in a fundamental difference, and I know that you said this, between like the US and these other places that are really getting right is the fundamental right to self-determine. To decide what a good, what a good life for me is. And also to say that that can include drug use, can include substance use. One of the things I'm wondering about connecting to earlier in our conversation; do you think that like the narrative around saying that substance use disorders are like a brain disease is getting in our way? Like if we call it a brain disease, do we think that that makes it harder to believe that people can self-determine that they can be trusted to decide what's best for them?

Ben Levenson: 30:29

Great question. How that manifests in certain quarters in treatment today. What it looks like is, you know, we have a patient who comes in first of all, but there's a predicate that says that if you have substance use disorder, you can not make meaningful and effective choices about your health and your safety. Right. Right. That's not true. It's not legal, like a person with SUD, their rights to agency and informed consent are not reduced at all because they have substance use disorder. Lawfully. It's not-- there, there are some interventions, legal interventions that reduce agency, but not generally. Right. But we act like that's the case with everybody. So we're treating them from this frame, like they've been committed, like they have had their agency limited. And so how that, how does that show up in treatment systems? It's like patient comes in and says,"man, I, I'm not staying here longer than, you know, three weeks. I'm not staying here a month. I'll be here three weeks". And they're like,"buddy, you need to be here six weeks for that. We've got to tell you what your length of stay is. You know? And basically we're going to treatment plan in ways that are completely opposite of whatever you say you think is right for you, right? Your best thinking got you here. You're going to let the treatment team think for you." Right? Look, let's use buprenorphine as an example for, uh, Sarah Wakemans' work out of mass general, in the comparative study that I encourage everybody to go look at, they looked at 45,000 opioid use disordered Americans and they controlled for everything basically. They were doing an outcome, a comparison of treatment pathways, based on clinical outcomes. Okay. Including morbidity and mortality and other health centered outcomes. The treatment to be candid, doesn't even seek treatment, seeks one outcome it's abstinence. And that's it. They don't really treat to health, but in any event, her work showed that buprenorphine has a 72% reduction in likelihood of overdose at month three and like a 59% at month 12. Okay. And it, I mean, no other intervention that they looked at, not counseling, not a, uh, not residential treatment, none of those had any measurable efficacy during the fentanyl contaminated drug supply crisis, because that risk paints all of the data. The old ways we engage, you know, they're not responsive to the changed conditions. And so what could happen in treatment, which is very common, is a significant section of treatment, they don't believe that buprenorphine is sober, right?

Carly Hill: 33:17

yup.

Ben Levenson: 33:17

And here's how that shows up. So patient walks in with opioid use disorder. You know w hat, let me tell you what they're not doing. So thousands of patients in detox units all over the country this morning w ere met by a nurse or someone who came in and said,"listen, it's the end of your buprenorphine taper. And you knew that was today. You don't worry. It's going to be a difficult couple of days. We have some Ativan, some clonidine for you, and we're going to get you through this." Right. But what are they not saying what they're not saying, they're not coming in and going,"listen, you are about to proceed o n a far more lethal pathway recovery. The medicine that we're going to take you off of today, simply taking you off of this medicine, no matter what else you do results in a 600% greater likelihood of overdose in the proceeding 12 months. And we just need you to sign here t hat we've warned you. Right? And we've counseled you and you're still s hooting". That's not happening. They're not saying anything to them. Right? It's-- so i magine oncologically, if you're stage three, you go in to MD Anderson or wherever Mayo or wherever. Imagine if the prescriber had personal bias against the one chemo that s ave you a life. R ight. And doesn't tell you about that. Look, that's trampeling agency. It goes beyond malpractice. Look, right now, there are a ttorneys general who believe that that crap ventures into criminality. And I believe it does too. It's those kinds of scenarios that people need to think about and go, oh my gosh, like there's no standardization. This is crazy. It's crazy.

Valerie Earnshaw: 35:02

Well, it's definitely valuing somebody's idea of abstinence over keeping people alive. Right? Like, that's really interesting to me, like moral enforcement is more important than keeping people alive. So one of the things I've been wondering is thinking about your work, Ben is like, what's the problem? How can scientists help better? So like, you know, some of the times I oversimplify it and I think like, does science need to communicate what they have better? Or do we need to do more science? So what you just described there was: the science is there. Like we know that these medications are good, that they keep people alive, that they prevent overdoses, but people aren't using them. So that seems to be part of the problem. I also think that, you know, we can dig into like what the gaps are in science, but what are your thoughts on this disconnect?

Ben Levenson: 35:54

There's always been this gigantic gap between the bench and the trench when it comes to substance use disorder treatment. And one of the reasons for that is we talked a little bit earlier about kind of the runaway ideological train, that the orphanage of, of treatment. One of the ways that I want to kind of talk about this for science for scientists is: treatment married a therapy. We married a therapy, that's 12 step centered, that we have profound personal attachment to."saved my life. I got the, I have the elixir. You just have to do it the way I did it." And you know, we don't marry therapies in medicine. In fact, we stand before the river of science and as evidence flows by, we pick up and leverage that evidence and those tools and those therapies for our patients. And nobody is butt hurt about not using penicillin anymore for streptococcus. It's like, no, there's a better, there's a better-- amoxicillin is better, right? Nobody's like, oh, well, you know, you, you know,"you have stage three ovarian cancer. And when I got treated in the eighties, this is what I--", that's just not how it works. Right. So if this is weird attachment, at the expense of patient health of public health, certainly disposes it with science. And it's like, what else do I need to know? I mean, I'm a master, I've got my doctorate in recovery. Like I don't need to learn anything else. So there is this huge departure between treatment and, and the research. And it's terrifying. It's maybe one of the kinda dirtiest little secrets in American healthcare is that there is no standardization in treatment. The research is not valued. Scientists would do well to support, you know, ways that motivate the field to value research. And there's some ways including influencing some of the purchase models that can do that with value-based and risk-shared, uh, arrangements. Put their fiscal well- being, align that with patient health outcomes. You wanna see an ideological divorce overnight? This is the only thing they care more about than their ideology, it's their money. So value-based purchasing has the ability to revolutionize the way we care for people who use drugs. Because the next morning, when we do that, when we attach his or her margins to patient health outcomes, the next morning, they're walking into the office going,"what does the research say we need to do today to keep this gal out of the emergency department in month seven." Right? And it's like,"well the buprenorphine switch you got to do".--"Oh, great. Well, we're going to support buprenorphine then" right? There, there's some important opportunities for research right now in the space.

Valerie Earnshaw: 38:53

Well, It also just strikes me that, you know, people with lived experience have tremendous expertise for these folks who say, like I have a PhD in rehab. Like it strikes me that one of the problems is also when we have research happening that doesn't involve people with lived experience, like, that prevents the uptake as well. So inviting folks from these communities to work on these research projects might also, you know, be helpful. We think about that a lot in, you know, just in the HIV field and things like that.

Ben Levenson: 39:31

So in terms of areas of focus, I very much agree. I, I think again, we talked about kind of the norms of focusing on populations that no longer use drugs, but the most meaningful research and the research that I'm using at the federal level and at all levels is looking not at that, but rather at this much broader cohort of Americans who use drugs, right? And it's, it's about sitting down in the reality, right? The people use drugs. And I think that what we want to do, and I think what harm reduction is all, I mean is a lot about, is, you know, helping people live the safest, healthiest version of the life that they choose for themselves today based on the science, based on an unbiased presentation of the data. Right? And so data that, and research that, that starts to break away these old ideas, that if you use drugs on the weekend, you can't, you know, we're not going to research that because the guy's health is, you know, whatever catastrophic or something though, it's exactly what we need to be researching, because it will inform, you know, how we care for people. As we normalize, as drug use becomes more normalized in the United States. And as you know, the clinical architectures are kind of reformed in ways to interface with, and care for those people.

Valerie Earnshaw: 40:51

To me, it really speaks to, for scientists, like, how do you think about your outcomes? You know, the thing that you're predicting, which is usually like, this is good, or this is bad. And, you know, in this field, it's almost always like substance use. Substance use yes. Substance use no. So like, what's really interesting about this conversation is like, usually if I have an intervention, I want to show that intervention is, is working well, I would need to show that that intervention is leading to less people falling into the substance UCS category, right? Like more people who are abstinent. And this conversation though suggests that like, I may not need that outcome at all, or I need to like, think about like quality of life, less depression, better financial wellbeing. Like, I need to really extend what I'm thinking about, and then-- which I'm all for doing like, as a scientist right? But then, you know, my challeng is, when I go to get that funded, the National Institute of Drug Abuse me, they care about the yes versus no, usually, or at least the peer reviewers do. Carly and I are working on this intervention that's focused on disclosure, helping people disclose that they're in recovery. And our main outcomes that we're really fired up about are like, when, if people go through our little intervention, when they do disclose, do they get a better response, like, than people who don't, which we think matters a lot. Like when you tell somebody, do they give you a hug or do they like run away from you or yell at you or something like that?

Carly Hill: 42:24

They kick you out.

Valerie Earnshaw: 42:26

Yeah. We think that's a big deal, but we have to like to prove that it matters. We need to show that people who use our tool engage in less substance use eventually, which is like really weird,

Ben Levenson: 42:39

Right. It is weird. And it's ideology predicated on prohibition and in criminalization and this binary, you know, kind of perspective on drug users, when we don't do that with really anybody else, it's important for researchers to recognize that the drug-using population is really saying, look,"nothing about us, without us". Right. That, that, you know, it's them who get to kind of inform what good outcomes are. There was a study that dropped a couple of weeks ago that actually looked at drug users, mainly people in recovery, which is, which is not what I'm asking them to do. But anyway, and, and asked them like,"what are, what are good outcomes for you, right? Like, what do you think is a good outcome?" And, and it wasn't like,"that I stay sober forever." It's not what they said. You know, they're looking for quality of life. They're looking for improvements to, you know, to their domains of health and, you know, a nd, and family and relationships and things t hat are important to them. But we don't design care for those outcomes.

Valerie Earnshaw: 43:44

Yeah.

Ben Levenson: 43:44

We design care for abstinence and that's it. Right? And so that patient I mentioned earlier, who is injecting heroin every day and wants to stop. We can induce him on buprenorphine, get the needle out of his arm. He's no longer at risk for hepatitis C. He's no longer at risk for HIV. H e's no longer at risk for overdose, right. Medicine. And we can go to work on,"Hey, let's look at evidence-based interventions for moderation around the alcohol, the continued alcohol use. We'll prescribe your b enzo. We'll write it for you." Right."And let's get you try to get you to a therapeutic level with that". So medicine looks at this case and they're like,"Holy crap. That's amazing. How did you guys do, how did you get that outcome?" Right. Treatment looks at that exact same case and says,"he's a treatment failure." Right. And they'll terminate buprenorphine. They will knowingly send him back to a fentanyl contaminated heroin supply because he smoked a joint.

Carly Hill: 44:44

Y ep.

Ben Levenson: 44:45

It's indefensible. Right. And it's happening every day in America. So we have to start thinking and valuing any positive change. That's the goal and change that is, that is patient driven. That's person driven, right. L et's be generous and say out of the 3 million that we talked about being treated earlier, let's be generous and say five, let's say half a million of them maintain perfect abstinence. And so what, what's the b enefit. So we get all of the health outcomes associated with half a million Americans not using drugs anymore. O kay. It's very small. What if we could seek and obtain a 15% improvement to health and safety across 80 or 90 million Americans? That's where the meat is. And I just want researchers to get that, like, stop obsessing about abstinence, r ight? It's about the big gains, right. That are there to be had which are improvements to, to health and safety of drug users. I d on't, I keep saying that, but it's, that's what it is. And getting off of this train that says,"oh, t hey've g ot t o be sober." No, they don't. They don't have to be sober. Look, drug use is not predictive of catastrophic health and abstinence is not predictive of whole health. T hat's just not how it works.

Valerie Earnshaw: 46:04

Yeah. I mean, just circling back to your other, you know, your point you made earlier, like"it's drug use in context". So it might be it's"drug use" when the civil supply is corrupted or it's"drug use" when there are certain criminalization policies in place, or like it's these social structural things that are happening that are harmful. Before we let you go, could-- w e talked about your trajectory in Origins, and I feel like it's, to me, it's pretty clear where in this narrative, you, you shift over to the Levenson foundation, but could you just share with us with the listeners, like, what is the Levenson Foundation? And we'll post links to that and the R ome Consensus like a n episode notes cause w e'd love for people to read that I found it to be like, fantastic. So would you just share a little bit about that before we let you go?

Ben Levenson: 46:50

I will. And I, and I want to share about a, another coalition that we're involved with the foundation is supporting the national campaign for harm reduction funding, which is comprised of some fantastic advocates and groups, including, you know, the Drug Users Union who have a voice in that coalition, which is great. It's the first time Congress has ever used the words"harm reduction" in this, you know,$1.9 trillion plan that passed,$30 million was included specifically for harm reduction. It was the first time that Owen DCP, even, which is the white house's office on drug policy. The first time they've even used the words harm reduction. And so there's a lot of energy going into how do we get it to the, to the end user, but that's really important. So I want to make sure we get to lead into that. Also, the Foundation is just really focused on, you know, some harm reduction philanthropy. And so we're, we're funding harm reduction agencies who may have fiscal challenges. And I mean, it's like they're giving out bleach kits, like, why are you giving out bleach kits? Because they don't, they don't have any money to buy syringes, right? Like they're doing everything they can. It's how harm reduction has been treated. That community is treated so terribly by us from a civil society and a governmental perspective, you know, working to just help normalize and validate and scale harm reduction for populations that use drugs. That's really the focus. And we were working abroad a lot, but when the contaminated drug supply became kind of apparent, we pivoted almost everything back home, that's the foundation. And then I'm focused on, on the for-profit side on systems of care that are extremely disruptive to treatment systems that are designed re containerizing treatment altogether inside of primary medicine, where we build an instance of care, that's able to longitudinally, engage with a drug using patient and the families and journey with them, right, as they go through their choices and their experiences with their drug use help seek and celebrate incremental improvements on pathways that they choose for themselves based on the evidence. But even more importantly to that, than that to destinations that they're choosing for themselves, including partially abstinent, fractionally, abstinent, maybe even substance specific safety, like the patient I mentioned earlier. This is a system that would say, alright. We'll help you. We'll help you write it yet. Come on. You know, we'll write your benzo, like let's, let's let's journey. Right. And so excited about that as that kind of develops all sensitive information back to you guys. Maybe we can do something on that.

Carly Hill: 49:34

Please do.

Ben Levenson: 49:36

It'll be fun.

Valerie Earnshaw: 49:37

Ben, thank you so much for coming on the show. Thanks for what you're doing. Thank you for giving me personally, like so much good food for thought today. Like this is, this is exactly why I like to do this podcast because I'm going to be thinking about this all week. This is great. And you know, this is our first time chatting and I'm really hoping that I can force friend you, force colleague you, stay in touch and try to support some of the great work that you're doing.

Ben Levenson: 50:02

I feel super fortunate to get to visit with, with both of you and your audience. That's growing as we speak. And I'm just real fond of the work that you're doing here. It's really important. So thanks for showing up and doing that, appreciate it a lot.

Valerie Earnshaw: 50:18

Thanks to the Stigma and Health Inequities Lab at the University of Delaware for their help at the podcast, including Sarah Lopez, Molly Marine, James Wallace, and Ashley Roberts,

Carly Hill: 50:27

Thanks to city girl for the music as always be sure to check us out on Instagram@sexdrugsscience, and stay up to date on new episodes by clicking subscribe.

Valerie Earnshaw: 50:37

Thanks to all of you for listening.[inaudible].