CommonHealth Live! with Dr. Rahul Gupta

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This transcript is from a CSIS event hosted on December 18, 2024. Watch the full video here.

J. Stephen Morrison: Today we are delighted to host Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy.

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This is the CommonHealth, from the CSIS Bipartisan Alliance for Global Health Security, engaging senior leaders on questions of how to address our common health security challenges in this post-COVID moment.

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Good morning, good afternoon, good evening. I’m J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies, CSIS, a foreign policy and security think tank, independent and bipartisan, based in Washington, D.C. Today’s episode of the CommonHealth Live is part of a livestream broadcast series of the CSIS Bipartisan Alliance for Global Health Security cochaired by Julie Gerberding and former Senator Richard Burr.

Today we’re delighted to be able to join – to be joined and to host Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy. Nominated by President Biden, Dr. Gupta was sworn in as director of the office on November 18th of 2021. Our focus today is what is the story to tell of Dr. Gupta’s tenure over the past three years in the Biden administration in battling the opioid epidemic that has claimed hundreds of thousands of American lives over the past decade, over 70 percent in recent years attributed to fentanyl. The Biden administration has made this battle a high priority. We’ll hear more about that. We’ll hear about what has worked, what has not worked, and what the future looks like.

And a very important part of that story is the – is the remarkable, and recent, and very positive news that there has been a 17 percent drop in overdose deaths between June of 2023 and June of 2024. We’ll be talking with Dr. Gupta about what are the drivers, what do we know has worked, and what are the unknowns, the still unknowns, around what might be driving these changes and how to sustain that change. And we’ll be obviously focusing here, as we approach the end of the Biden administration and the beginning of the second Trump term, the question of transition. What does the handoff look like? What’s the unfinished business? What’s the advice on the key steps to sustain progress?

Welcome Dr. Gupta.

Rahul Gupta: Thank you for having me, Steve.

Dr. Morrison: Dr. Gupta is a doctor and a public health expert, born in India, raised in the suburbs of Washington. Father, diplomat, based here. Earned his doctor of medicine from the University Colleges of Medical Sciences at Delhi University; a master’s of public health, the University of Alabama at Birmingham. He brought a remarkable body of public health and medical real-world experience to the White House Office of National Drug Control Policy. For five years, 2009 to 2014, he ran the Kanawha-Charleston Health Department in West Virginia. He graduated to direct the West Virginia Bureau for Public Health, 2015 to 2018, with a special focus on reducing overdose deaths from the opioid epidemic.

This was a period in which the deaths of the opioid epidemic was soaring and becoming a part of our national consciousness. And West Virginia was at the epicenter of this. He served successfully under both Democratic and Republican governors in West Virginia. We had the pleasure of hosting him last summer to reflect on the impact of the first year of over-the-counter access – expanded access to the overdose reversal medication naloxone, one of the most recent vitally important steps, which we’ll hear more from Dr. Gupta, in the prevention of deaths – overdose deaths.

I want to single out for special thanks my colleague Sophia Hirshfield, who very carefully choreographed and organized today’s event, supported by Michaela Simoneau, Maclane Speer, Caitlin Noe, and Rebecca Oladiji. I want to also offer special thanks to Kemp Chester, senior advisor to Dr. Gupta, who is integral to planning and thinking through this conversation. And I want to thank our remarkable CSIS production team, Eric Ruditsky and Qi Yu in particular, along with Dhanesh Mahtani.

We’re joined today – this production, this conversation is also being fed through the C-SPAN channel. We want to acknowledge that audience, and grateful that they can join us today.

A few quick, brief framing remarks, and then we’re going to turn to Dr. Gupta to help set the stage on where we are and what the future looks like.

It’s difficult to exaggerate the magnitude, damage, and threat posed by America’s opioid epidemic. It’s a scourge that touches every corner of American society. It’s at the root of the declining U.S. life expectancy, which something Americans are beginning to acknowledge and think about.

More seriously, it’s evolved from prescription opioids to heroin to fentanyl, the advent of the synthetic biology era. It’s steep escalation and that lives lost has been – has really been shocking. Between 1999 and today over half a million deaths.

As I think we’ll hear from Dr. Gupta those numbers rose to over – well over a hundred thousand in recent years. But we’ve also had this recent reduction, which we’ll talk about.

We started looking. Here at CSIS in 2017 and ’18 we went to eastern Kentucky, we went to central Wisconsin, we went to New Hampshire to look at this with my colleague Lily Dattilo, and I must say then it was shocking to see the impact on communities.

But it was also a moment of awakening, and this is in the period when you were actively leading in West Virginia. First responders were beginning to bring naloxone. Communities were beginning to mobilize. Congress was forming a caucus, a very bipartisan form of cooperation. So it wasn’t all despair. It was an awakening that we began to see.

My second point is we have to acknowledge the formidable complexity of this problem and the need for a multi-pronged and sustained approach, and we’ll hear from Dr. Gupta on that. Stigma and shame are powerful and compelling. It’s both law enforcement and public health sectors.

Naloxone – new technology raises questions around how do you get industry involved, new markets, financing. It relies on access to treatment therapies. We’ll hear more about the X-waiver and what that meant in expanding access to buprenorphine and methadone.

And the epidemic as it came to be dominated by fentanyl it became an international security and law enforcement priority in our relations with China and Mexico and India and others. It rose remarkably high levels in our foreign policy priorities, and we know we’ll hear more about China, how fraught that relationship has been. Yet, we’ve had significant progress there.

My last point is there’s good news and there’s reason for hope, and I hope we’ll hear more from Dr. Gupta on that, on the impact of over-the-counter naloxone, of the X-waiver. We’ve seen progress in our diplomacy with China. We witnessed some of that when we saw you in China and Beijing in June. We continue to see a foundational bipartisan cooperation which remains fundamental to our ability to achieve the things that you’ve been able to do.

And, as I said, we’ve seen this surprising 17 percent drop and we need to think about that. There’s substantial progress but it’s fragile. I think we agree it’s fragile and we need to be very careful to understand.

So let me now turn to you, Dr. Gupta. Thank you for your patience. Thanks for making time to be with us today. Thank you for your service to our country over the last three years. This must have been absolutely fascinating and exhausting, I’m sure, and congratulations on the progress seen.

So share with us where are we, how are you thinking about what’s been achieved, and what’s the way forward?

Dr. Gupta: Well, thank you, Steve, for having us here and thank you to CSIS, all the staff, as well as my office, including Kemp Chester. You know, we work with some wonderful people every single day. There is such a – it’s such a telling because Americans across the country are suffering in one way or another from the challenge of addiction, mental health, and others.

But let me start by saying, you know, as a country doc – that’s how I started my career. I worked in a town of 1,800 people. I was everything to the people that I served, whether it’s emergency room 24/7 availability.

But some of the biggest challenges for me there, which created a formidable challenge but also a formative experience, was that when I saw people I wanted to help them with their addiction to opioid pills, as they were. I wasn’t able to in a rural town. I just was not because you had to get all these licenses and extra barriers were there.

And I saw some of the same people that I struggled with to get help for in a rural area die in my arms in the emergency room. At that point I realized that this is bigger than any one of us, and it’s one that all of society has to come together to address. And therefore my guiding light has been about saving lives, but also understanding the complexity, as you very well noted, of this challenge. This is not only an issue of public health or only an issue of national security or economic prosperity. It’s all of those things. It has challenges in both global policy as well as domestic policy when we are losing an American every five minutes around the clock.

So when President Biden came into office, we were seeing 31 percent inclines. That’s 31 percent rise year after year in overdose deaths. And I said at the time that we’re going to have to put policies in place that make sense, that work for the American people right away, as quickly as possible. This large ship has to be studied, slowed, stopped, and turned around, and then get in the right direction.

We’ve seen that over the last three to four years. So we’ve seen a flattening of the curve, and now we’re seeing a change. We know that there’s a lot more work to be done, but the fact today is that there are, you know, 19-plus thousand fewer lives lost. There are going to be more seats filled at the dinner table. And every life is precious and worth saving.

We also know that some of the specific policies that have been able to make that impact, it’s important to talk about, and some of those enabling factors at the same time. So, for instance, it’s been very important to make people aware, for example, of the challenges of whether it’s the pills folks order online without going to a provider, that can often be contaminated with fentanyl, lethal doses, or it’s the carrying of overdose reversal medication like naloxone or Narcan that is so critical to saving lives.

It's also important – I knew that just like, you know, I’ve seen on the ground as a local and state health official, that we often – you know, when traffickers move at the rate of business, we move at the rate of government. So it’s important for us to catch up. It’s also important to realize that, you know, I know as a doc, but any EMT knows, that when you are bleeding, the first thing you have to do is stop the bleeding, because we cannot treat dead people in this epidemic.

So getting drugs like lifesaving medications like naloxone was so critical, making them available far and wide, making them affordable. Now they’re available at the lowest price ever. For most people across the country, they’re available at no cost and they’re available over the counter.

It was important – it was also important to remove the stigma from using naloxone, very much like, you know, a CPR device or an AED on the wall. That’s how we want to see it. And I’m so glad that, through these efforts, that we’ve been able to have airlines like United, Major League Baseball, and so many other small and large businesses adapt that commitment to save lives first. So that’s the first piece that was important.

The second was to expand treatment. We knew that a fraction, just literally a fraction of people of the 8 million Americans from opioid addiction, but overall, about 47 million with addiction, were getting treatment. And there are so many reasons for not getting it – societal reasons, personal reasons, stigma reasons. But it was important to expand it rather than just talk about it.

So the president worked to get – remove this called ex-favor, the extra license, that often providers need. We’ve been able to get 15-fold increase in the number of prescribers, increased access to drugs like methadone and buprenorphine, which is one of the – two of the three FDA-approved medications, and make it far and wide available to marginalized populations, to rural communities, to people in communities of color, and across the board.

We’ve also increased the availability in jails and prisons, because we did the analysis, let’s find out where most of the people are dying. And one of those areas is actually upon reentry from being in custody. So we’re working to expand that as well. The fact is today way too many people are incarcerated because of addiction, a disease of the brain. They’re not often treated in the system. Over 90 percent are released. And guess what happens? Either they are dying of overdose or being reincarcerated with crime and other aspects, and we’re all paying the price and these families are paying the price. So we wanted to make sure that treatment, whether it’s telehealth or other aspects, is widely available.

And the third component, I would say, is making sure that it has become more difficult, more expensive, as well as more tedious for the bad guys to manufacture and traffic drugs like fentanyl. This is important because we have to make treatment more accessible than getting illicit drugs. And if someone has to walk past five drug dealers to get to their treatment center, well, they’re never going to make it. And that was the predominant aspect of this.

So we have worked with countries like the People’s Republic of China, with Mexico, with Colombia, with India, and others, both on the synthetics as well as the organic side, and develop cooperative means to address a scourge that is global in scope and has the potential of affecting, you know, not only just any American but across the globe anyone. And it’s one that affects not only from a public health side, but affects the livelihoods as well as the communities across the globe.

Dr. Morrison: Thank you. Thank you very much.

I’d like to follow up a bit on each of these elements. When you talked about naloxone – we had a great conversation back in the summer on this – one point you made towards the end of that conversation still stuck – is stuck in my mind, which was, yes, we’ve made remarkable progress, there’s X million available in the marketplace in America now today versus earlier, but we still don’t have – we’re still – there’s still a huge gap in the manufacturing capabilities for naloxone at affordable prices for Americans. And that requires a long-term and very strategic outlook on how to get industry motivated – incented, really – to create that capability. They’re going to need a market before we go to real scale. We still have a gap there. There’s still probably some demand that’s not met or we should be generating demand. Say a bit more about that.

Dr. Gupta: Steve, I think that it’s really important to understand the fact that oftentimes someone will go and be – getting a nonfatal overdose 10, 12, 15 times before they finally overdose and due. We believe the first time somebody overdoses is a cry for help, and oftentimes our health system/society is not listening to those voices. So it becomes important that we make a lifesaving medication like naloxone far and wide available and affordable and accessible.

I’ll give you – I’ll tell you a story. When I visited the native lands in Washington state, they were still having to purchase it for about $80 a kit, whereas across the country it was available for 50 (dollars) if not $24 a kit which is now the case. We worked with the state to make it available at the lower price, and there’s places where people can pick up free naloxone. And one little girl picked up this kit, and she was going up the hill, and she found her grandma at the same time overdosing, and provided the naloxone right there and then because she had been taught how to use it, and saved her life. Now, what do you put a price on that for?

The fact is today we don’t – we could save a lot more – many more lives if we have more naloxone. So it becomes important for us to continue to push not only the availability, but also the accessibility, which requires the production. We believe that there’s millions of doses, more doses, that can be utilized across this country, which will yield in more lifesavings. And of course, you have to connect people, when you use naloxone, to treatment and to resources. But the first step – as I said, you cannot treat someone if they’ve already passed away. The first step is to make sure that they’re alive in the first place, and we’re listening to their crying voices.

Dr. Morrison: What do we do to expand the market – the production, and the market, and the affordable price? What more needs to happen in that area?

Dr. Gupta: So I think one of the basic things – this comes back from my sort of business background – is producers have to know – have some certainty in their ability to be able to produce. One of the things we are doing is, for example, the governor of California announced recently the purchase of $3 million of naloxone. So I think it’s going to be very important, while not encumbering the local purchases, but to figure out how to guarantee larger purchases, like we do for vaccines, like we do for other drugs and medications.

We have to figure out that we can have a predictive supply chain model, where producers understand that if they are making that product it will be purchased, and it will be utilized, and lives saved. We can’t have products that are sitting on the shelf – first of all, they expire – while people are dying on the street. So we have to build in some predictability from the federal and state governments and local government standpoint so that the manufacturers are aware that this is how much is needed. And that’s the kind of work we’ve been doing.

Dr. Morrison: Yeah. I want to relate one personal story that has to do with people’s consciousness around the need for naloxone, and perhaps to put it into your medical cabinet, or put it into your bag or your car. I live on Capitol Hill. I don’t live very far from National Stadium. I don’t live very far from the public housing there. And within the last two years there were two tragic episodes in which there had been a delivery of opioids laced with fentanyl, in which there were large numbers of folks who went into overdose. Several died. Fortunately, several survived. And it was shocking to the community. These were respected, long-term users, chronic users, but very respect – many very respected members of their community.

Now when I thought about this I thought, I ride my bike through this neighborhood periodically. I walk through this neighborhood periodically. Am I carrying Narcan? Am I carrying naloxone – some form of naloxone? No. And I’ve asked my friends at different points in time, do you – do you actually own and carry in your car or in your medical cabinet, or the like? And it’s a very mixed – it’s still early days, I think. I can begin to see the that it’s beginning to get mainstreamed in terms of transportation, and schools, and public settings, and putting them pre-positioned with AED cabinets. All those things are brilliant and very important. But at a personal level, people getting into the habit of thinking, this is something I need to have at the ready and be comfortable to have and know how to use, are we making progress in that way?

Dr. Gupta: Stephen, absolutely we are. I’ll give you a couple examples. When we launched the White House Challenge to Save Lives From Overdoses, we now have more than 260 affiliations of institutions across 50 states, from the United States Postal Service to, you know, airlines, transit, school systems, and others. Just since L.A. School District, for example, have begun to use, they’ve used this several times in the school system. So imagine, there can be no larger or greater tragedy than children dying because naloxone was not available. And that’s what we’re trying to make sure that happens, is that naloxone becomes more available. We ask each of the Cabinet secretaries to consider that – placing in federal government buildings as well, because it’s really important on this issue to be able to walk the talk.

Dr. Morrison: Yes.

Dr. Gupta: And we want to make sure that we are doing the same. I carry naloxone with me. But the fact today is that it is no different than having a lifesaving tool, because oftentimes death comes in a way people are not even expecting. They could be ordering what they think is Adderall over online, or oxycontin, or Xanax, and it turns out that between five and seven out of those 10 pills that are ordered online have potential lethal dose of naloxone – I’m sorry – of fentanyl. And that’s the part here where naloxone is so critical.

Dr. Morrison: Thank you. On the expanded treatment, a couple of questions. One is, it’s very important, the attitudes of medical providers. You’re expanding their opportunity for primary physicians to be able to prescribe the therapies that are needed. But it requires a bit of a shift in attitude among the medical providers. And as we’ve seen in other instances, like the HPV vaccine, which the use of that in the – early in the last decade had dropped, and President Obama put a commission together for a year. And they came back and said, the key to this is getting onboard our medical providers, our primary physicians. And, lo and behold, there was a concentrated effort, and it turned things around pretty dramatically and pretty fast.

Say a bit about your dialog with medical providers, with the AMA, with others. And are we making progress? Is there much more work to be done there in order to make them more comfortable in playing this role of taking on something that they thought up to this point was a little difficult, a little stigmatized, a little dangerous for them, or risky for them? Now they can take this up, and it’s very important that they do.

Dr. Gupta: Yeah. So from – first of all, from a data standpoint, we know that we do a certain type of phone survey data and we find how many of you who are suffering with addiction go get treatment. We’ve seen a severalfold increase over the last three or four years, which is encouraging. From a policy standpoint, we’re removing a lot of barriers to make treatment accessible anytime, anywhere, 24/7. Because the fact today is, look, if someone gets up at 9:00 p.m. and they feel like, this is enough. I want to go get help, I want to change my life around. And they call a 988 line and they say, well, we have an appointment 30 days from today, that doesn’t work for that person.

In this business, and in this condition, you have to be able to help people when and where they want to. So there’s been increased number of providers. Yet there’s a long way to go. And I say that because, on one hand I’m very encouraged by the young generation of providers – whether it’s clinician, like doctors or nurse practitioners or physician assistants – who are stepping up, and who are looking at this saying: Look, when 47, 48 million Americans suffer from addiction, and I think they’re not part of my cadre of patients on my panel, then it’s me who’s missing it, because that means I’m not looking for them. And I should be. So the fact today is more and more, at least the young generation of providers, are looking at this as a way to address it.

Now, for those in my generation it’s going to be really important to continue to push the importance because, right now, not enough medical and nursing schools are teaching curricula. And we know from evidence that when you are teaching that in the formative years, that students are going to learn, have an interest, and go to get trained in it, and be able to become providers. So that’s one challenge we have. We have to make sure it’s part of the curriculum. And we’ve done a lot of work with schools and organized medicine to make sure that happens. And AMA, the American Medical Association, has been very much forward leaning on this and been able to move forward on this.

Second, I think it’s also important to develop reimbursement systems that support providers and patients in the treatment of their diseases. We know that when reimbursements increase or are added on for a certain condition, magically, those conditions are diagnosed more often and treated more often. So it’s also important. And the last thing I would also say is parity. It’s very important. Somehow in this country we figured out how to remove the head from the body. And we’re all suffering because of that. We work very closely with Department of Labor to make sure that we are enforcing parity laws that require us, all of us, to treat the diseases of mental health and addiction the same way you would treat diseases like diabetes and hypertension, because addiction is a chronic disease.

So these policy changes that have occurred have allowed us to make that progress. But there is still a long way to go to make sure that we’re removing the stigma. Stigma, look, it exists in families, in society, in our communities, but also is alive and well in the healthcare sectors too.

Dr. Morrison: Thank you. On the expanded treatment issue, there remains controversy and opposition to what might be called substitution therapy, harm reduction measures, both the therapies but fentanyl strips, various other measures. The language that is used is very important, but we have very prominent elected officials and others who continue to voice concern that by introducing these substitution therapies we’re just substituting one form of opioid for another.

There was a great piece last night on PBS “NewsHour” about this that was walking through this experience. Are we making progress there or are we continuing to really have a major battle around trying to find the right language, find the right pathway forward where this is seen as, yes, not a sustainment of addiction but a cure?

Dr. Gupta: You know, when I went to medical school, Steve, the science overall had not progressed the way it is now. I actually looked at the curriculum of my own son, who is in medical school, and I was amazed at the amount of neurological sciences that has advanced the last decade or two.

The fact is when I went to medical school there wasn’t a clear indication that addiction was a disease or a disease of the brain or a chronic brain disease. We did not understand any of those mechanisms. Today we do, and it’s incumbent upon us to learn and get educated and get up to date on that, first of all.

Second, if we do then it’s important to understand that, look, we – I, as a doctor, tell my patients with diabetes, hey, it’s important to exercise and eat right. But I do not deny them medications like insulin just because their exercise and diet has not gotten them the glucose levels where they need to be because the fact is there may be a need for that insulin or medication that increase the production of insulin in the body.

Addiction is no different. So what happens is when oftentimes there’s a chemical imbalance people go into addiction. They need medications that stabilizes their life, that does not cause “highs,” quote/unquote, that allows them to function in society and take control and hold over their own lives and get into recovery.

We have so many Americans, about 22 million Americans today or more, that are in recovery and the majority of them are working, gainfully employed. So we need to be thinking about the full circle of this epidemic which is let’s save lives with naloxone and drugs like that. Get people in treatment and get them into lifelong recovery and become productive in terms of economic opportunities, educational opportunities.

To do that we have to follow the science and the evidence where it takes us and where it takes us in the 21st century is that the medications do work. There’s plenty of evidence about that. There’s three FDA-approved medications today.

We should be working to make sure that we are doing everything to expand access to medications like we would for diabetes or heart conditions or hypertension and a whole array of other diseases.

So it’s important to stay up to date, understand, and I continue to work with those who may not be aware of that. The fact today is there are judges in our judicial system that aren’t aware. So when I was in West Virginia I’d actually as the health commissioner send letters to the judiciary in the state of West Virginia to say please consider treatment of folks when you are looking at your drug courts and others because it’s an important way.

The fact is today, as you mentioned a lot of the figures, we are – the number-one killer for working age population in this country – 25 to 44 – is drug addiction overdoses, and if we don’t do that – we already have the lowest birth rate on record in this country.

So imagine where we would be. So I tend to think not in terms of election cycles of two, four, and six years but in terms of what does prosperity look like for the country in terms of decades, and I think we need to head in a way where we have more productive population who is able to, again, contribute to society.

Dr. Morrison: Thank you. I want to make sure we cover the diplomacy with China and diplomacy with Mexico.

In the case of China, President Biden, President Xi met in Woodside in California in November of ’23 and agreed to launch the counternarcotics working group. So you had at the highest levels a commitment to this as a priority. You and your colleagues in the Biden administration carried that forward. There were a series of meetings in Beijing, in Washington. And I think it’s fair to say that, for those of us who are not experts in this but watching what’s going on, the press statements, talking to both the American and Chinese side, something changed and there was significant progress.

Now, there’s still debate. There’s still deep skepticism of the Chinese. It’s pervasive in our political system, in our foreign-policy circles. But this was a bit of a standout, right? It was very difficult to achieve a whole lot of cooperation in other health-related fields. But in this area there was an exception, and we saw some major gains.

Tell us, as you’re in conversations with skeptics on this, what do you point to as the concrete steps that the Chinese have taken that do attest to the fact that things have changed and improved?

Dr. Gupta: Well, Steve, I think the meeting in Woodside last November was an important one. It allowed the two leaders to agree to cooperate in some measures. And this was an important measure, perhaps the most important measure.

What has happened since is, you know, an understanding of what we need to get done, first of all, with the United States and China, and secondly, what is being done. So I’ll explain some of those things. But before that, I think it’s also important to understand that we often take our competitor in the People’s Republic of China as one glob, thinking, OK, maybe this is being done deliberately in terms of drugs.

It was important for me to understand the long history the Chinese people have had with opium and opioids, way before our contemporary issues that we’re dealing with. It goes back all the way to the 1800s and the opium wars and their leader, Lin Zexu. And when you understand that, you realize that what Chinese people have dealt with is historic. But the embarrassment of those wars and others are pretty significant and they last a long time.

So with that understanding, you know, we went to the Chinese and we were very clear that, listen, we need to make sure that you know that there are criminal actors, criminal actors within the People’s Republic of China, that need to be held accounted for. That includes platforms. And now we know that they have taken offline so many websites and online platforms. They have made arrests. They have scheduled over 50 controlled substances already since my visit in June to Beijing. Some of those are used to produce fentanyl and meth. They have controlled substances that we have not yet controlled in our Congress yet.

And all of this is to – you know, we – our beginning line was, look, to be a global leader, you must act like a global leader. And part of that’s making sure that you’re responsible and accountable for the bad actors within China.

Now, as you may know, when you’re having conversations with the highest levels of the Chinese officials, these are tough conversations, by no means that are easy. But they needed to be had. And we needed to understand where we stood. And since then, we are seeing on the ground, for those who are wanting to make fentanyl and traffic fentanyl, a real difficulty in obtaining the precursor chemicals to make fentanyl and to be able to traffic those. And there’s a number of sort of elements that point towards that.

But it’s a progress that is occurring. It’s a progress that is contributing to the decline in numbers. It’s a progress that must continue, because in the darkest of the days of the relationship between two countries, this cannot be one that can slow down, because American lives depend on it.

So while we work on other aspects in relationship with China, it’s going to be critical that we sustain this progress moving forward, because, you know, it’s really important. We don’t know, if it’s fentanyl today, what it will be tomorrow? Because we have these drug traffickers and producers that are working hard – overtime – to make sure that they’re creating the most dangerous substance that they can and most addictive substance as they can to make money, to make profits at the end. So it’s very important for global leaders to work in the interest of the world people to stop these bad people from doing that. And China, we can work to make China a part of the solution for this crisis or they can remain a part of the problem.

Dr. Morrison: President-elect Trump has been very vocal recently in tying continued progress on fentanyl to threat of tariffs in his – in what he’s said about our future relations with China, but also with Mexico and in Canada. What does that mean, do you think? I mean, partly he’s signaling there’s more work to be done here – we’re not satisfied with the improved cooperation we may be seeing from China, Mexico, Canada, and others; we want to see more, and we’re going to twin it with the threat of tariffs. What does that mean, in your – in your view? I mean, this is – this is an important – this is an important thing. It’s very prominent in the rhetoric and statements – the most recent press conference and various other statements made. It’s out there. It’s very, very clear.

Dr. Gupta: Well, two things.

First, President Biden has led the way on making sure that there is progress being made, not just talk, when it comes to work with China, work with Canada, work with Mexico, and work with India, because we want to make sure that the bad guys don’t shift the chemical industry from China to India when the pressure is on the chemical companies in China. So first of all, progress is being made, has been made, and that is also clear.

But, second, I think it’s important to keep the pressure on. It’s important to keep the pressure on in a way that’s productive for both our countries and its people and across the globe. So I think there’s no harm in keeping the pressure. What we need to make sure is that the pressure is kept with a sense of understanding of what is already happening and taking – and being aware of the progress that’s already being made.

So we would like the drop to continue in overdose deaths. We would like the relationship to continue. Now, today – it used to be where the relationship with China on counternarcotics was only in law enforcement cooperation, but today we have scientist-to-scientist exchanges. We have regular calls with their scientists and our scientists. We have established a direct hotline between my office and the minister of public security in China, Minister Wang. And these are the elements of progress, so that when we see an emerging threat, when we see a new compound come up, we can pick up the phone and directly call and say, hey, we need you to look into this; it’s coming; this did not exist before.

So these mechanisms, we must make sure that they’re being protected while we continue to make progress and demand. I mean, the American people want nothing less to demand more progress and to continue to save lives in the incoming administration. That’s a mandate. But at the same time, we’ve got to make sure we understand. And I’m confident with the transition team’s conversation that they will – the incoming administration will develop a better understanding of those elements that have been working with these countries across the globe.

Dr. Morrison: On China, do you think that this progress opens the door towards cooperation in the biomedical and public health fields in terms of substance use disorders, prevention, treatment, recovery? There’s a lot, and these are issues of mutual concern to the United States and China. Do you think that the progress that’s been made through your office and the administration writ large in the dialogue with China, does that open the door for cooperation in those areas?

Dr. Gupta: So when I went to Beijing I was able to see their unit of government on the ground, how they operate, and how these specific units address – help address the challenges of individuals. That includes addiction and mental health. I think there’s a lot to be learned from each other moving forward. So I think it’s important that we, you know, use these relationships like the scientist-to-scientist exchanges, like their treatment centers and our treatment centers to understand what’s happening. These are opportunities to cooperate and collaborate.

Look, we have only, as I mentioned, three FDA-approved medications for treatment of addiction – for opioid addiction. There is so much more possibility. In fact, soon we’re going to be having a technology summit at the White House. This is designed to bring in the best technological advances that are happening, even those that have been approved and not yet approved, emerging technological advances.

So we have to look beyond only pharmaceutical therapeutics, non-pharmaceutical, technological solutions when it comes to addiction and mental health aspects. And that’s where I think advances in science do not have to be only held in one dimension. They can actually work across countries. And that’s where it becomes important that this cooperation opens the door, at least a window, into a role for cooperation on not only – on treatments and the ways to treat, but also emerging technologies that could be really record breaking and lifesaving for the American people.

Dr. Morrison: Thank you. In our closing minutes here, I’d like to turn back to two things. One is the announcement of this remarkable reduction, 17 percent. And my question there is, does this change our national conversation? This is a big – this is a big piece of news. This is a very promising development. We don’t fully understand what’s driving that. We don’t fully understand how important or by what exactly to sustain that progress. But my gosh, it got attention all over this country, this news. It really got people to sit up and pay attention in a new way. And I wanted to get your reflections on what this means, in a very positive way, for being able to rally people around the next steps.

Related to that is, where are we having the greatest continued problem in this large, complicated country that we have – that’s multiple geographies, multiple populations, folks that find themselves marginalized for any number of reasons around ethnicity, race, economic status, geographic location? Speak to those two issues. One is the 17 percent reduction in opioid overdose deaths. How does that help us? How does that news help us? And then, secondly, put the spotlight on what really keeps you awake still tonight as to the enduring – the places that are still the most problematic in this large, complicated country of ours.

Dr. Gupta: So the Joint Economic Committee, I believe, in Congress, issued a report that said that we’re losing, just from the opioid crisis, the economy of about $1 trillion a year in 2020 dollars in the United States. In 2020 that happened to be almost the GDP – entire GDP of Russia. So we’re losing a lot of money. It’s not only the lives, but also part of our economy that’s been sucked away. The president understood that. And he’s invested about $166 billion into the American communities in terms of expanding treatment, providing lifesaving measures, helping recovery.

When I traveled during my time to meet with President Lopez Obrador in Mexico or Petro in Colombia, or so many world leaders, one of the things that would consistently say, that you all have a demand problem that you’re not addressing. I think we’ve answered that question in investing in unprecedented ways into the American people. It’s going to be very important to not, you know, lift our pedal off the gas when it comes to continued investments towards saving lives.

At the same time, addressing the other side of this, our international diplomacy, supporting our law enforcement community across this country to make sure that they’re seizing, they’re also interdicting, and really going after the bad guys – not the people with addiction, but the people who are up to no good do harm to American communities. So that’s where I think work must double and triple down so we can see continued progress. I think there’s a lot of scope to see more progress happen. What we cannot – what cannot be acceptable to American communities is the reversal of this progress. And we must continue to save more lives.

Now within that, the second part of your question, look, the progress is not uniform. We still have marginalized communities –communities of color, Native American populations – and some areas where the numbers are going up, in the reverse direction. So we have to make sure that we are thoughtful and planned in the way we address those specific challenges as well. Information needs to get through. Treatment has to be made available to everyone, you know, where they live when they want treatment.

It’s really important, as I mentioned my visit to out west, that we provide sometimes inexpensive treatment modalities and the information to provide that. So it’s going to be important to continue to keep in mind those that have the least, both to get the help but also to sustain that help. We need to make sure that they’re able to be reached and help is able to be provided to those as well.

Dr. Morrison: Thank you. Thank you very much.

OK. Your closing thought. What gives you the greatest hope, the greatest optimism now, as you look forward into 2025 and beyond?

Dr. Gupta: When we set the goal for a 13 percent reduction in the president’s 2022 strategy, by the end of 2025 there were few in Washington that believed it. Today, we have not only exceeded it but we’ve done it a year and a half ahead of time.

I think that’s what gives me hope is the American people all coming together because this is a bipartisan – this is not a red state or a blue state issue. This has been a part of President Biden’s unity agenda. It is America’s issue.

That gives me the greatest hope, that we coming together making this a nonpolitical issue can actually address this and beat the opioid crisis, invest in it appropriately, and work together as one team, and when we do that there’s no problem that we can’t solve and this is at the top of that list.

Dr. Morrison: Director Gupta, thank you so much for spending time with us here this morning. Thank you for your leadership over the last three-plus years in this role in directing the White House Office of National Drug Control Policy. This has been a period of remarkable dynamism in the U.S. approach both at home and internationally in our diplomacy.

Congratulations to you. We’re all in your debt for what you have achieved and we look forward to hearing more and as you put your reflections out over the – in the coming period.

We will be posting the video of this conversation on the CSIS homepage, CSIS.org, and shortly thereafter we will be posting a transcript where you can find it.

Thank you. Thank you so much.

Dr. Gupta: Thank you for having me, Steve. Thank you.

 (END.)