Ep. 3 Drug Trends Across Tennessee

In July 2019, the Centers for Disease Control released the most recent opioid overdose mortality rates, which showed a decrease for the first time in a decade at the national level. Unfortunately, that trend did not hold true for Tennessee, where overdose rates rose a modest 4.8 percent. In this episode, Special Agent Tommy Farmer from the Tennessee Bureau of Investigation Dangerous Drug Task Force and Dr. Robert Pack, Professor of Community and Behavior Health at East Tennessee State University, discuss the most recent statistics, where the state is showing improvements as well as new trends like the increase of heroin and fentanyl and the resurgence of meth.

Produced by Nick Morgan 

Transcript

00;00;01;23 - 00;00;27;07
Host
Welcome to Tennessee Court Talk. I'm your host, Barbara Peck. This episode is a collaboration with the Tennessee Judicial Opioid Initiative and is intended for all audiences. Today, we are discussing drug trends across Tennessee, and we have two special guests with us. Tommy Farmer is a special agent in charge with the Tennessee Bureau of Investigation and is the state director of the Tennessee Dangerous Drugs Task Force.

00;00;27;09 - 00;00;53;15
Host
He is over 30 years of experience in law enforcement, 20 of which were in the field of drug enforcement. Our second guest is Robert Pack. He is a professor of community and behavioral health and associate dean for academic affairs in the College of Public Health at East Tennessee State University. He is also the executive director of the Etsu center for Prescription Drug Abuse Prevention and Treatment, and the co-director of the Opioids Research Consortium of Central Appalachia.

00;00;53;17 - 00;00;55;05
Host
Welcome to you both.

00;00;55;07 - 00;00;56;03
Robert Pack
It's great to be here.

00;00;56;06 - 00;00;57;00
Tommy Farmer
Thank you very much.

00;00;57;02 - 00;01;26;17
Host
So in early July, the CDC released new overdose related fatalities statistics for 2018. And for the first time in 25 years, the numbers were down nationally with 5.1% less deaths in 2018 than in 2017. Unfortunately, that pattern did not hold true for Tennessee, where overdose deaths again set a record at 1837, which is a 3% increase from 2017.

00;01;26;19 - 00;01;30;01
Host
Tommy, what was your first reaction when you saw those new statistics?

00;01;30;08 - 00;01;50;06
Tommy Farmer
A couple of different things. I wasn't really surprised to see the numbers go up just a little bit more. I was surprised to see the numbers around the country as compared to other states them go down. I was anticipating, a slight climb. We were hoping that we would plateau off, and if there was any increase, it would be a slight increase.

00;01;50;06 - 00;02;07;23
Tommy Farmer
And so we did see a slight increase. There's no question that it's we our belief is related to the transition to illicit drugs. No doubt that, it has to do with fentanyl and heroin and the availability of those drugs. No doubt about that.

00;02;07;25 - 00;02;11;12
Host
Rob, what was your first thoughts when you saw the new statistics like Tommy?

00;02;11;14 - 00;02;31;29
Robert Pack
You know, I was I was pleased to see the change nationally. We've known for over a year now that the overdose epidemic has been increasing exponentially since the mid 90s. And so we actually have have known that if we don't do something dramatically different nationally, that we're going to see several hundred thousand people dying over the next five years.

00;02;31;29 - 00;03;01;13
Robert Pack
And so I was real pleased to see that, the national change and particularly impressed by states with very high overdose death rates like Ohio and West Virginia, make significant improvements. And so that's, that's those are good things. And in Tennessee, like Tommy, I, I didn't expect, just necessarily see a dramatic decrease. We have incremental gains and improvements and a number of things we need to do a number of other things in order to improve more.

00;03;01;16 - 00;03;07;02
Host
So let's let's look a little deeper at Tennessee. So where are we seeing improvements in progress?

00;03;07;04 - 00;03;31;23
Robert Pack
Well, I think one of them was is in, in improvements relative to access to buprenorphine. And, and good quality medication assisted treatment. And that, puts a good quality mat in front of that. But, you know, I think it's imperative that we, that we recognize that there are good providers for Suboxone and buprenorphine products that are out there.

00;03;31;25 - 00;03;45;04
Robert Pack
We need to begin to do even more to improve quality overall, because there are a number of less good, and, and in some cases, even poor quality Suboxone providers. And we have to do better with those guys.

00;03;45;08 - 00;04;06;29
Tommy Farmer
Well, I think we're definitely seeing progress in, in the reporting, collectively comprehensive reporting. And I think unfortunately and unintended consequences to improving our ability to collect information, analyze information from multiple sources. I think it has a tendency that it could be represented in some of those, some of those numbers that increase. We're doing a better job.

00;04;06;29 - 00;04;34;28
Tommy Farmer
Unfortunately, the it also shows us that before we said for a long time that the numbers are grossly underreported. There's a lot more out there than what we're actually seeing. I do believe that this number is indicating that we're doing a better job getting more accurate information and analyzing the data out there. Other areas I would echo exactly what, Doc Peck said we are doing better at educating others to include the courts.

00;04;35;00 - 00;05;07;26
Tommy Farmer
We're getting more access to treatment law enforcement is better educated. Law enforcement is, having the access or being able to direct someone and those families to resources, to treatment resources, to options out there. That is a huge, huge asset for law enforcement, because I can tell you, they've been out there for a long time. Faced with those questions, and even to the point where the families literally begging law enforcement to arrest the person that that was going to be the only option that they would have that would save that person's life.

00;05;07;27 - 00;05;15;07
Tommy Farmer
We didn't get to this position overnight in Tennessee or in the United States. We didn't get here overnight, and we're not going to get out of this thing overnight.

00;05;15;08 - 00;05;25;00
Host
So you mentioned a little bit about the shift from prescription drugs to illicit drugs. So where are we on the fight with prescription drugs?

00;05;25;02 - 00;05;48;01
Robert Pack
Well, I I'll address it first, I guess. But, Tommy, you're going to have some really good data on this as well. But our peak, opioids and peak prescribed opioids, was really in the 2013 range. And we've been coming down with respect to prescribed and dispensed, opioids from the regular sort of traditional method of getting, you know, prescriptions.

00;05;48;01 - 00;06;15;17
Robert Pack
And as that began to decrease, the demand was still there. And that began to drive, heroin access and then the market for heroin and increase and then, basically fentanyl, adulterated heroin, and now fentanyl adulterated and other drugs like stimulants are more prominent on the market. And so there's there's been, basically prescription drug decline and an illicit drug incline.

00;06;15;17 - 00;06;25;15
Robert Pack
And so unfortunately, that's also being driven out of our larger cities where there's more, more, potential, demand for the for the dealers.

00;06;25;17 - 00;06;27;19
Host
Where are we making progress?

00;06;27;19 - 00;06;53;11
Tommy Farmer
Definitely making progress, with with the diversion, the decline of prescriptions and diversion. Those numbers are really good. And I think some of the tools that we've implemented in our state, from the chronic pain guidelines to the control substance monitoring database to education, and I think it's hugely important we're giving and providing those providers the opportunity, the ability to look at their patient and to better treat their patient.

00;06;53;14 - 00;07;17;02
Tommy Farmer
And at the end of the day, some and I think in the beginning of this looked at, is almost as an, an insult that we're challenging them. No, we're not challenging their ability to treat their patient what we're doing is providing them more tools to the toolbox to be able to treat their patients better. And I think another huge part of this is, you know, with, with, I don't I don't think we took a knee jerk approach.

00;07;17;03 - 00;07;47;00
Tommy Farmer
I think we've done this better than a lot have done because we we didn't go all the way at one time. You know, you can shut this thing out. We could pass legislation tomorrow if we needed to and say we're going to cut, prescription diversion or the amount of pharmaceuticals that can be prescribed by 50% tomorrow would just because we cut that off by 50% tomorrow does not necessarily mean that we reduce the demand or we reduced the need by 50% overnight.

00;07;47;03 - 00;08;18;15
Tommy Farmer
So when you do that, it I always use the analogy of a balloon. You can squeeze a balloon. The balloon has two options. It will either pop bust or it's going to push out one of the other areas. And so we knew and expecting going in I think doc would agree with me. We knew going into this that as we pushed forward and made progress and implemented tools to to address the problem, we were going to see a transition or an increase in illicit drug use.

00;08;18;18 - 00;08;42;04
Tommy Farmer
What we all tried to do in a balanced approach is before we start pushing fast or pick up the pace, we wanted to do it at a pace that was reasonable, that we didn't push too fast, too hard, and that we were implementing back support with treatment options, with enforcement and all of these things comprehensively moving forward so that we did not, derail this train.

00;08;42;04 - 00;08;58;23
Tommy Farmer
It's you can we've got this ship in the right direction. Sometimes takes a long time to get it in the right direction. We get it in the right direction. We have to keep it going in the right direction. Because if this thing starts to go off course, as we all know, it's very difficult to get it right.

00;08;58;23 - 00;09;00;06
Tommy Farmer
It again,

00;09;00;09 - 00;09;24;28
Robert Pack
So I want to add one point. We reached peak opioids around the time, you know, 2013, but we're still in the top five in the country for, for opioids and at one point, we were number 1 or 2 for toggling back and forth with Alabama for a number of years. And, and, you know, I think it's going to take a while before we get that down to, you know, the 50th percentile or less.

00;09;25;00 - 00;09;37;20
Robert Pack
But, need to point out that we're still in a, in an era of, significant prescribing for prescription opioids that is different than most other states.

00;09;37;22 - 00;09;48;09
Host
So let's talk about the rise of illicit drugs now. So what is fentanyl and how is it being cut with heroin and stimulants. And where is it coming from.

00;09;48;12 - 00;10;13;29
Tommy Farmer
The majority of the fentanyl. Two it's coming from a lot of different ways that commercial coming into the country, predominantly by commercial carriers originating, either out of China or out of Mexico and obviously other areas, it can be routed anywhere around the world into the United States, where it's uniquely different. Is that, again, the physical characteristics of fentanyl make it very dangerous.

00;10;14;01 - 00;10;46;04
Tommy Farmer
And really present, not only law enforcement first responders, but providers and everyone else. It presents some very big challenges, and requires a lot of protective equipment. But also from an enforcement standpoint, we're we're no longer we have something that is very, very powerful at very small amounts and the potency of this. And so that enables, smaller or packages of smaller amounts, but had the potency that you would be looking for.

00;10;46;10 - 00;11;12;27
Tommy Farmer
It's easier for me to detect coming across or to intercept a package of ten, 100, 500kg of something. The it increases our ability to detect those and to enforce those, as opposed to the equivalence in terms of potency or, fentanyl may only be, a couple of sugar packs or a couple of ounces of something that could easily be secreted and hidden and transported a lot differently.

00;11;13;02 - 00;11;19;20
Host
So is, heroin already cut with fentanyl when it arrives in Tennessee or is being mixed in Tennessee?

00;11;19;20 - 00;11;55;19
Tommy Farmer
That's the all different ways. Every one of those, it's easier. Typically, we will see the fentanyl getting smuggled into, into the United States, into Tennessee, and then once it's in Tennessee, it's used as an adult to different drugs. We'll see them in pill presses. We've had about 15, pill milling operations. We've had it, operations where they are cutting it into heroin or cutting it into methamphetamine or cutting it into cocaine, adding it to just about anything, because, again, it doesn't take much of that.

00;11;55;21 - 00;12;18;05
Tommy Farmer
And the the end result, the person's looking for a high not necessarily the and I hate to use this the wrong way. The quality of high. They're just looking for high. If they're getting high off it's meeting their needs that their expectations for high. Then it it's working for them depending on the source, if it's Mexican, we will see a lot of that already cut into the heroin.

00;12;18;07 - 00;12;27;22
Tommy Farmer
That's being smuggled across the border. Different ways. Pill forms. We see it both ways coming in already cut into the products or it's mixed into the products once it gets here.

00;12;27;25 - 00;12;35;11
Host
So does the buyer necessarily know that the fentanyl is cut in? Are you asking for that particularly or just asking for heroin both ways.

00;12;35;14 - 00;13;14;04
Tommy Farmer
You know, again, it's an unintended consequence. I had a, I was approached when, we had major operations, we had a series of overdoses, in a couple of different cities. And so when we were talking about, the problems associated with fentanyl, and we're saying you can't control there's no quality control here. It's not a matter of if it's a matter of when you're going to overdose yourself, because the optimum high, when you're getting high off of this very small a small amount but very potent amount, is it also about the same time that you're you're going into an overdose.

00;13;14;06 - 00;13;36;15
Tommy Farmer
And so where it triggers an overdose versus where it triggers the optimal high is is so close to each other. And it's, it's reckless behavior. It's a matter of if you're going to overtime, why would someone sell a drug knowing or that there's a higher potential to that their customer would overdose and die, and that's losing a customer.

00;13;36;17 - 00;13;59;01
Tommy Farmer
And the simplest answer I can see it doesn't, irrational people do not make rational decisions. What they are seeking and what they're looking for. And they literally if they are wanting the strongest drug that they can get and they view others that did overdose, as they couldn't handle it, they were weak. They couldn't handle the drug.

00;13;59;03 - 00;14;27;24
Tommy Farmer
I can do a better job. And so when we've had those episodes where we've made public service announcements saying we've got Percocet, fake Percocet, counterfeit percocets that have, high amounts of fentanyl, and we've had 19 overdoses. Don't do the percocets the calls to that phone increased the demand for that drug, that overdose. 19 people that we reported on increased it.

00;14;27;24 - 00;14;46;16
Tommy Farmer
It really shocks you to think, are you serious? You you did you hear what we just said? 19 people died as a result of this drug. Don't do this. I don't care who you are. You're Superman. You're still going to overdose if you do this amount of drug. It's so reckless.

00;14;46;18 - 00;15;11;09
Robert Pack
So I think that points to this sort of perverse, kind of rationale, of, you know, if there is a, in sort of the perverse economy of this particular drug, if there is, a rash of overdoses in some ways, that source of the, the drug can then see an increase in demand. And it's really, alarming.

00;15;11;15 - 00;15;34;17
Robert Pack
We have a study right now ongoing among patients in our, opioid treatment clinic. It's basically, you know, what are your experiences with fentanyl? It turns out that some people really like fentanyl. They like, you know, because it gives them a incredibly, powerful high. But they also, all of them have known a lot of people who've overdosed and died.

00;15;34;19 - 00;15;55;13
Robert Pack
And so, you know, that begs the question, if you don't have naloxone around and sometimes in the locks, and it's not even effective for for fentanyl because it's so powerful. You know, you need to have multiple, administrations of naloxone in order to counteract it. It begs the question, what tools does someone have to protect themselves against an overdose?

00;15;55;16 - 00;16;16;00
Robert Pack
And so at this point, we're thinking through, you know, things like harm reduction approaches, education for the, the, community that is dealing with this relative to only use them with people, only, you know, perhaps even testing the product or, or knowing more about what the product is before they engage with it.

00;16;16;06 - 00;16;20;16
Host
So are we seeing cocaine mixed with carfentanil in Tennessee?

00;16;20;18 - 00;16;21;01
Tommy Farmer
We are.

00;16;21;06 - 00;16;24;24
Host
And why is it happening in some parts of the country but not others?

00;16;25;00 - 00;16;48;27
Tommy Farmer
Think that's just the I mean, the established drug trafficking organizations that are out there. It's just going to be what's available to them. Or and again, you can look at the particular drugs and how what drugs are being abused. For example, we see fentanyl cut into a lot of things. So one of the questions is why is, heroin, more popular in one area such as the Memphis area?

00;16;48;27 - 00;17;12;18
Tommy Farmer
It really hasn't it hasn't fluctuated very much. There's been a steady availability, and supply of heroin in Memphis, not so much in the eastern part of the state where now heroin is back filling. But the same goes with, oxy 30s are very popular in some regions of the state. Percocets are very popular in the Nashville area.

00;17;12;19 - 00;17;35;07
Tommy Farmer
Oxes are very popular in Oak Ridge area. So where we've seen those pill press operations, the type of pill that was being pressed was the popular drug that's in that area, Oak Ridge. If we see a blue oxy 30 coming in to the crime lab, that's a counterfeit. The likelihood it probably came from around that area. So that also gives us the ability to source back.

00;17;35;09 - 00;17;40;23
Tommy Farmer
So that's what it's about. It's what's popular or what's available to them. At the time.

00;17;40;27 - 00;18;05;15
Robert Pack
So there was an interesting study from, from there's the I think the Ohio Harm Reduction Coalition did this, did this, report, but they looked at, cocaine that came into the state and, and, and basically they partnered with their equivalent of TBI. And, they looked at the cocaine that was coming into the state at the sort of the base level.

00;18;05;15 - 00;18;27;14
Robert Pack
So the the stuff that was smuggled in. And then at each level down the interdiction, at each interdiction point, down the chain all the way to the street dealer. And this is cocaine. They look to see how much fentanyl was in each of the, each of the different levels. And they found a linear, increasing amount of fentanyl all the way down to the street.

00;18;27;14 - 00;19;01;19
Robert Pack
And so the question was, is this intentional, or is it accidental? And the conclusion that they came to was it was accidental because of the very small, nature of fentanyl, and the, and the processing equipment that is used to grind, the and mix, the different drugs together. Basically, their speculation is that it's contamination of the, of the, machines or, you know, coffee grind or whatever that is being used to, to mix up the drug.

00;19;01;19 - 00;19;21;24
Robert Pack
So to your question, you know, Tom would have a better understanding of what we're seeing in terms of interdiction in the state. But just at each level down the chain, all the way down to the street dealer. That study indicated that there was an increasing amount of fentanyl. And we're talking about, like, very small amounts of fentanyl having a significant impact.

00;19;21;27 - 00;19;49;17
Tommy Farmer
If I could. It absolutely is. So it each it's it's all about the money. It's dollars and cents about it. So when it's coming in the primary source or the major source is going to be in a bulk amount. So each time it steps down on those layers, typically what's going to happen is there's additional cost that's associated with either the transportation of it, distribution of it, the movement of it, the use of it by the individuals.

00;19;49;17 - 00;20;17;28
Tommy Farmer
So they're going to step on it or cut it. And so it worries exactly right. By the time it gets to the street level and you get to a dealer that's, that's dealing in, gram or ounce amounts, then that drug has already been stepped on a number of times. If that dealer starts receiving some complaints or in fear that he may receive complaints and somebody doesn't want to buy from them, that's where they will.

00;20;17;28 - 00;20;47;03
Tommy Farmer
They will explore and utilize options to cut it with something else. I've got this great this car fentanyl or or if you're in a fentanyl or something that I can cut it with. He's exactly right. The mechanisms in which we are, we are finding, crude is an understatement. There literally a blender, out of Walmart or, that they were Walgreens or wherever they would purchase a small blending object, the types of other adulterants that they're going to put in there is just off the charts.

00;20;47;03 - 00;21;10;08
Tommy Farmer
So we're literally seeing drugs that come in that are represented as cocaine or representatives as a pill, that contain absolutely nothing of the drug it's supposed to be. And we will we're doing a much better job now, even in our crime labs, of going in there and documenting exactly all of the other drugs that are actually that we find in there.

00;21;10;11 - 00;21;40;04
Tommy Farmer
And so it is a crazy concoction from anything that they can get their hands on, from aspirin to, ibuprofen to Nisa tall vitamin B12 to it's across the board. But again, it doesn't matter. Like Doc's talking about it doesn't matter is long as it got them high and the the narrow, the the potency of fentanyl, it's so powerful and microscopic amounts that it doesn't take very much at all.

00;21;40;08 - 00;21;57;04
Tommy Farmer
And so that cross-contamination of the devices, it's sticking in there. It doesn't it doesn't. We're not talking about five, six, eight grains of something. That could be the difference in that, in that substance or that transfers to that person.

00;21;57;10 - 00;22;15;05
Robert Pack
And think about what a coffee grinder looks like after you grind coffee, right? I mean, there's still got a bunch of coffee in it. And, even if you dump it out. And so there have been some harm reduction efforts aimed at dealers, trying to get them to clean their equipment. For this reason.

00;22;15;08 - 00;22;36;02
Host
So Tommy, I don't feel like we can talk about drug trends and not talk about meth, too. So I thought I thought that the meth crisis was something that we dealt with 12, 15 years ago when we had meth labs springing up in rural areas, but around and, and we had a lot of strategies we implemented and a lot of new laws come in.

00;22;36;02 - 00;22;47;23
Host
And I thought we had sort of handled that fairly well. But meth is making a comeback. So where is it coming from and how is it different than the previous meth.

00;22;47;25 - 00;23;14;07
Tommy Farmer
With a vengeance. We're probably on track to, to receive more, more submissions of methamphetamine into our crime lab than, than any time before even at the heyday and the height of our meth epidemic. And in 2010, where the state of Tennessee had the dubious distinction of being number one in the nation, the meth capital of the of the United States with 2086 meth labs, or about 7.8 labs per day.

00;23;14;09 - 00;23;33;27
Tommy Farmer
We did think and we threw a lot of resources at this thing, and we really went after it. But at the end of the day, just what we're talking about with the cycle and circle of addiction, this one's two prong it again, you squeeze the balloon. If we don't address the addiction issue, addictions, addiction. So we did reduce.

00;23;33;27 - 00;24;02;29
Tommy Farmer
We made it much more difficult for them to acquire the precursors. We did a stop and our, our meth lab seizures have decreased about 86% in our state, which is good. The bad thing is, is we still have an insatiable appetite for stimulants in our state. And the, the, the Mexican drug cartels, have a ready supply and the willingness to to, to feed and to fuel that desire for methamphetamine.

00;24;03;06 - 00;24;23;27
Tommy Farmer
The other second prong to this one, though, I think we're is a little bit different. A little bit unique is that if we look at the history of opioid abuse or epidemics and the United States of America historically, this is about number three for us. And it will look what followed each of those opioid, epidemics. It's stimulants.

00;24;24;00 - 00;24;47;00
Tommy Farmer
So again, this is that way for this is that transition we are in to the phase of illicit. And we are also transitioning into the phase where stimulants are becoming more and more dominant. It's this is not, this is not really nothing new from a historical standpoint. It's just bigger than it's ever been before. And we have a better way of communicating it.

00;24;47;02 - 00;24;49;07
Tommy Farmer
Out there. Meth is here.

00;24;49;09 - 00;25;11;21
Robert Pack
That's absolutely right. And, and and thanks for making that point about the waves. I mean, that's, that's exactly what's going on. We're seeing in our clinic, over Mountain Recovery, for example, our methadone patients that are coming in, if they're screening positive for illicit drugs, it's methamphetamine. And, you know, that's a problematic, scenario.

00;25;11;23 - 00;25;38;28
Robert Pack
There's an interesting paper that's published last year, by Ted Cicero and his colleagues from university, Washington University in Saint Louis. The indicated 82% increase in methamphetamine positives over the past six years at such clinics as ours and then they unpacked. Why? You know, they did a qualitative assessment thereafter and said, you know, why are you guys, engaging with methamphetamine now?

00;25;39;00 - 00;26;29;22
Robert Pack
And the answer was availability. And they really like to get high. The driver after the, the wave of of opioids, could be as simple as, as, going back to this earlier topic of prevention. Right. How are we going to, help protect our society from the problem of substance use disorder if, if we're only dealing with the treatment side, we've got to get upstream and and and fix whatever is going on relative to, driving people toward seeking their, you know, trying to fix their pain and their mental and emotional physical pain with, with some something besides, you know, coping and other kinds of effective strategies.

00;26;29;24 - 00;26;41;23
Host
Normally across Tennessee, we've seen a lot more opioid activity in East Tennessee and, and sort of less as you move across the state to the west. So how is the most recent statistics showing geography wise?

00;26;41;26 - 00;27;03;08
Tommy Farmer
Again, going back to some of the reporting, talking about the larger cities versus some of the smaller cities. I think this also goes into one of the questions from earlier about reporting, a lot of the rural communities, those overdoses were going unreported. Now, those are more so when we compare that to the major cities. You get a couple of things going there with those.

00;27;03;11 - 00;27;24;27
Tommy Farmer
Number one, that is the source of supply for the for the majority of the illicit drugs. That's that's an easier place. And the price going straight to the, to the major city, the price of the drug is cheaper, too. Just the nature of the drug addiction and the drug abuse and the way that it works, they're going to find a way to get closer to the source.

00;27;24;27 - 00;27;46;03
Tommy Farmer
And going to the source means that's where they're going to do the drug. As soon as they get it, they're overdosing, they're doing the drugs, they're getting the drugs, and they're overdosing at that location. And that's also where we have majority of our resources in terms of forensic pathologist in our facilities to to analyze those and to determine that it was actually an overdose.

00;27;46;06 - 00;28;09;03
Tommy Farmer
But those major cities, I don't think I think they get labeled. They probably get a few more. And that's where it's going to be reported. Even if that person traveled in from Kentucky or in another state, if they overdosed, in Nashville or in Chattanooga. Then the stat for the overdose is actually going to be, attributed to Chattanooga or that city.

00;28;09;05 - 00;28;47;03
Robert Pack
So, to to your question, are the that you made about, to the point that you made rather about, we should see more in East Tennessee and so or moving west. It is true. I mean, we saw more, earlier on in, in, northeast Tennessee. And then as we began to increase access to treatment options there, and Suboxone providers and others began to proliferate, our overdose rates in the, in the northeast are beginning to level off.

00;28;47;05 - 00;28;59;22
Robert Pack
That is not true. Moving west. So living just outside of the 8 or 10 counties, northeast Tennessee, and then moving west, you begin to see, growing numbers of overdoses per year, but you also have, less access to treatment there.

00;28;59;28 - 00;29;07;05
Host
So who's that? We talked a little bit about reporting, Tommy. What changes have we made in reporting and still today who's being missed?

00;29;07;07 - 00;29;29;19
Tommy Farmer
We've made a number of changes in terms of the agencies and identifying those agencies that are receiving the information or that that are in a position to capture, and report. So some of the they just to, to name a few, one being the hospitals and the emergency rooms and then the mechanism in which they do report and who they report the information to.

00;29;29;21 - 00;30;06;16
Tommy Farmer
So there's been some legislation, there's been some changes there that now they are required to report those overdoses. And then the time frame in which those overdoses are also reported to. There's also some limitations to that because you have forensic pathologists or the forensic centers. We have five forensic centers across the state of Tennessee, and they serve as particular counties or groups of counties, in those areas, the way they record an overdose, versus the way it may be recorded or reported from a forensic pathologist.

00;30;06;18 - 00;30;34;06
Tommy Farmer
So those also we have not overcome necessarily the, the, the hurdles in terms of systems. So we have different systems. The forensic center in Knoxville may operate off of a different, platform or a different reporting system than Memphis and Nashville, which are on the same system. And then versus Chattanooga. So we're not quite there yet in terms of linking and interfacing all of the systems together.

00;30;34;08 - 00;31;05;07
Tommy Farmer
And that's just on the overdose. So there's a lot of moving parts. Law enforcement, for example, is another complete, system. EMS is another complete system. And that one will actually go live, October, where all EMS operators and there's well over 100 different EMS units across the state. But they had their different reporting systems that they reported to different proprietary or not.

00;31;05;10 - 00;31;22;10
Tommy Farmer
So we've got a bunch of moving parts out there. And those moving parts, when you have so many, you really run the risk of, we're capturing and they're doing their jobs, but we're just not getting it to a central location where we can look, evaluate, and report all of the information.

00;31;22;10 - 00;31;39;28
Robert Pack
And this is a good this is a good point, though. The data systems don't all speak to each other. And and there are efforts at a, at our state level and in other states, to, to begin to merge those systems and to begin to, to make them speak to one another and for, for the public's benefit.

00;31;40;00 - 00;31;49;01
Robert Pack
And so I applaud, Tommy and others on the State Epidemiology Outcomes Working Group and others that are beginning to move to make some of those things more available.

00;31;49;08 - 00;31;54;19
Host
Doctor Pack put this epidemic in perspective to other public health crises that, oh my goodness.

00;31;54;22 - 00;32;26;04
Robert Pack
Well, so a colleague of mine, Randy Wyckoff, our dean of, public health, ETSU said that in his career, HIV and Aids was the defining, epidemic for his for his cohort of professionals that came through. And, and, others may say, well, it was cigarets, right. And tobacco and tobacco control was kind of the defining, risk mitigation, strategy for that.

00;32;26;07 - 00;32;51;21
Robert Pack
This is certainly for my career. The most alarming, crisis that I have seen in this country for, for reasons of its insidiousness, and, and also the long, duration of opioid use disorder and the fact that, you know, this isn't something you can prevent with a vaccine. It's not something you can cure with, with one simple treatment.

00;32;51;24 - 00;33;21;01
Robert Pack
It's something that is a chronic, relapsing, disease, brain disease, basically. And, and, my colleague, Judge Duane Sloan, says that we have an opioid and mental health fueled addiction and suicide crisis, and that begins to unpack some of the complexity of what's going on. But, you know, a lot of this is driven by undertreated, and untreated, mental health in the first place.

00;33;21;03 - 00;33;47;07
Robert Pack
And so until we get upstream of this, we're not going to have any significant impact with just treatment and just, naloxone, for example, is often said you can't arrest your way out of this problem. Well, you also can't Narcan your way out of this problem. And, you know, we need to get way upstream and start doing really good prevention, with younger kids, so that they grow up with the resilience to, to, not be affected by this problem long term.

00;33;47;10 - 00;34;06;25
Tommy Farmer
Go into what his point was. The volume of this is just so large and this is huge. You know, you can easily it's easy to compartmentalize addiction and whatever the flavor of the day. And I hate to use that type of an analogy, but the flavor of the day where it was methamphetamine, where it was this one, the difference though.

00;34;06;25 - 00;34;31;29
Tommy Farmer
Yes, the flavor is changed. This is pharmaceuticals. This is opioids. It's just the it's so far reaching and the volume of people that are impacted, affected of all types. And it doesn't discriminate one way or the other. And everybody can be. But it's also the wave where we would you're going to transition, you're going to have to go through this and we're going to go through this and there's going to be the intended consequences.

00;34;31;29 - 00;34;53;28
Tommy Farmer
And then the unintended consequences. But what you have to do is you have to keep keep your foot on the gas. And we have to keep moving forward, understanding that we're going to have some hiccups on the backside of this. The Buford orphan, for example, or going from diverted pharmaceuticals. We've slowed that pace. We're transitioning in. It's going to the illicit drug flow.

00;34;54;01 - 00;35;11;24
Tommy Farmer
We know the illicit we're gaining on that one. I think that's probably an area we we still need. We're going to have a lot of work. It's but it's going to be a problem a long time. We're doc is correct. We've got to go upstream as far as we can to prevent the addiction before we start getting in.

00;35;11;24 - 00;35;27;10
Tommy Farmer
And we've got to stop the cycle of addiction that's occurring within these, because it doesn't matter if we don't stop that cycle of addiction, then all we're going to do is repeat it and it's going to be a different flavor. It's going to be something else, and we'll repeat it.

00;35;27;12 - 00;36;11;27
Robert Pack
There's a the provider side. Right. Sometimes those restrictions are seen as being, constraints on, on, medication assisted treatment practices. And those can be significant disincentives to getting involved in and addiction medicine and, and really we need more access for high quality providers or by high quality providers. And, and some of the things that, that, you know, we need to examine in this is, co prescribing a benzodiazepines and minimizing that to the extent possible and making sure that the providers are, accepting all forms of insurance, making sure that that they have counsel, good counselors and well trained counselors on site and, and, and, you know, we organize

00;36;11;27 - 00;36;40;11
Robert Pack
the system in a way that, the incentives to engage people, engage physicians and other prescribers on on the provider side is is really good. And one more point that I would like to to make about this, is we also have to educate pharmacies about addiction medicine, because the interface of the patient with the pharmacist is often very, challenging for the patient and is is loaded with stigma.

00;36;40;11 - 00;36;58;03
Robert Pack
And there's all kinds of stigma associated with this, with the condition. Anyway. But there are number of pharmacies that just simply won't they won't dispense buprenorphine and, they won't they won't give it out to their patients. And so we have to begin addressing that as well. And so focus of some of our research on Etsu.

00;36;58;05 - 00;37;11;16
Host
Let's talk about that a little bit. So what we're talking about is medically assisted treatment. And some of the drugs that are used for that could be diverted and used in an inappropriate way. That kind of what we're seeing a little bit around the state.

00;37;11;18 - 00;37;12;07
Tommy Farmer
Yes.

00;37;12;10 - 00;37;34;19
Robert Pack
Okay. And and less so with methadone because methadone, the constraints on methadone are very, very high. To actually start a methadone clinic, you have to have all these diversion controls in place. But I think it's very common to see diverted buprenorphine on the street at this point. Some harm reduction folks would say, overdoses related to buprenorphine alone are unlikely.

00;37;34;25 - 00;37;53;10
Robert Pack
Then that's okay. But but honestly, very few people are single drug only overdoses is is more it's increasingly common to have buprenorphine and an overdose toxicology report. Because it's being used with other substances.

00;37;53;13 - 00;38;09;16
Host
Okay. So one thing that the overdose, our 1,837 overdoses in Tennessee last into 2018, one number that's not captured in that are suicides. Yeah. By people who have an addiction issue. Is is that a trend that we're seeing.

00;38;09;18 - 00;38;59;01
Robert Pack
This is an extremely important topic. Untreated mental health. And this part partially driving the opioid problem in the first place. But then when, when people are in the throes of addiction, as one of my dearest friends was when he took his own life, you know, it's one of the situations where, we need to almost lower the threshold of, of access to care so that they can begin getting good counseling and getting good, the proper type of treatment, at that time, it's it's just, so challenging, though, to parse out the reasons for an overdose, because often they could be suicide related.

00;38;59;01 - 00;39;25;27
Robert Pack
That could be someone's desperate, and they kind of don't care about what's going to happen to them in the future. So I think that it's a challenging question because you can't know for for sure what, what the intention of a suicide is, if there's no note or something like that. But, I think that there is a significant amount of what's called suicide misclassification, in the overdose, in that larger overdose group.

00;39;25;28 - 00;39;30;26
Host
So how does meth today differ from meth of ten years ago?

00;39;30;28 - 00;40;03;29
Tommy Farmer
The methods in which one, how it's getting into the United States, the amounts, the volumes of it. It's a synthetic drug. So it can be mass produced. And where those chemicals are not controlled, it can be mass produced, which it is. And then unfortunately, that predominantly happens to be Mexico. So we've got a very, very, also very powerful drug that's very cheap, the, the cost that we're paying or that we're seeing it, on the streets is very cheap.

00;40;04;02 - 00;40;10;12
Tommy Farmer
So you got a cheap drug that is, very powerful, very good quality, unfortunately.

00;40;10;12 - 00;40;12;25
Host
And is it being caught with other drugs as well?

00;40;12;28 - 00;40;33;29
Tommy Farmer
We do. The crystal meth is a little bit different, but it's easy. There's in terms of a potency from a even if it's a what would be called or characterized as a dirty math versus a crystal meth. The crystals are obviously what they, are seeking. They think that that's going to be much more powerful, much more potent.

00;40;33;29 - 00;40;55;20
Tommy Farmer
It's a better form of methamphetamine. It's just another process. I can take the same high quality methamphetamine and take it to another process to crystallize it and make it happen. That so in one sense, looking at it, if it is crystallized, we have a less tendency to see, that it's going to be adulterated with something like fentanyl.

00;40;55;22 - 00;41;18;29
Tommy Farmer
It's not say that it can't be if it's more in a powdered form, dingy brown, white or whatever. It can be pink. You can add any color to it. Those are obviously the the ability to adulterate with fentanyl use, it is much higher. It's not uncommon, though, when we're talking about poly substance abusers. That is just the way.

00;41;19;02 - 00;41;43;14
Tommy Farmer
And again, that's not something that's actually rare. When I was in the throes of the the in the meth bites, years ago, you show me somebody that was using addicted to methamphetamine. I'd also show you somebody that's addicted to, benzodiazepines. They were doing Xanax. And again, it was to counteract the side effects of that drug.

00;41;43;16 - 00;42;06;17
Tommy Farmer
So we we would also even years ago, it wasn't as prevalent as it is today, but we would see the other common poly substance abuse would be methamphetamine or cocaine with an opiate. It they they like the effects of of one. And they want the effects to to to counteract some of the side effects of the other drugs.

00;42;06;17 - 00;42;29;29
Tommy Farmer
So it's not uncommon to see more and more of those many folks that we have spoken to doc may comment to that more, that, they, they may come in and they see that, meth is the only thing that I can that helps me. I can't transition to another type of drug off of opioids if I to if I don't have heroin, I'm going to get sick.

00;42;29;29 - 00;42;34;01
Tommy Farmer
The only thing that I can do that I will not get sick would be methamphetamine.

00;42;34;03 - 00;42;36;17
Host
So where do you think Tennessee will be a year from now?

00;42;36;24 - 00;42;57;27
Tommy Farmer
I was really hoping to see the, 2018 numbers kind of plateau. The good thing is, is the the rate of increase. I am encouraged by, the low rate of increase as opposed to, or compared to other years prior to. So I'm encouraged and I'm going to go back and say it again. I'm hoping that we've reached that plateau.

00;42;57;27 - 00;43;18;22
Tommy Farmer
We're going to turn the page, and we're going to go on the other side of this and start decreasing that. And we definitely see the decreases on prescribed opioids. The decline of those prescribed opioids, the amount of those opioids, also indicated coming into our crime lab, through from law enforcement, seizures and law enforcement incidents have declined.

00;43;18;25 - 00;43;51;07
Tommy Farmer
So all of the indicators there are very good and very consistent. And then looking into the future of this, you know, has come up a couple of times talking about mental health. We need to use all of these, gain new, newly gained partners, from all of the various disciplines, and take all of this information that we are learning through hard knocks and look into the future to what may be the next issue that's coming down in and address this mental health.

00;43;51;07 - 00;44;12;12
Tommy Farmer
We don't know anything about cannabis. If we don't know anything about marijuana. What we do know. Yes, it's a gateway drug. I know for a fact. And those who did try that not only were more likely to try other drugs, but the amounts of the other drugs that they tried for greater.

00;44;12;14 - 00;44;14;21
Host
Gentlemen, thank you for joining us today, but.

00;44;14;23 - 00;44;15;16
Robert Pack
Thank you very much for the.

00;44;15;16 - 00;44;17;13
Tommy Farmer
Opportunity. Thank you very much for having us.