Dr. Gail D’Onofrio: Grappling with the Opioid Epidemic

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dr. Gail D’Onofrio, Professor of Emergency Medicine and Public Health at Yale University. But first we’d like to check in on current health news, and I saw that you published a new, very important paper on cardiovascular health yesterday. And I’d be curious to hear your thoughts about that.

Harlan Krumholz: Yeah, thanks, Howie. It was one of the largest and most comprehensive looks at risk factors for young women and similarly aged men who experienced a heart attack. And it was based on a large study that we’ve been conducting over the past decade or so that was NIH-funded that included a whole lot of people, more than a hundred sites across the United States. And we were able to accumulate information on more than 3,000 women and men.

And we purposely enrolled more women and then followed them over a year after their heart attacks to try to understand some of the key determinants and risks and so forth. And it’s nice to talk about today because Gail D’Onofrio, who will be joining us, is one of the co-authors and has been a great colleague on this. And of course, lots of people contributed over time. My colleague, Yuan Lu, who is assistant professor within cardiology, led this effort. And it was really interesting. We were able to combine this study with some other national datasets to illuminate some of the risk factors that were in men and women and what were some of the differences.

And there were some things that were surprising and some things that were sort of expected. First of all, a lot of the usual risk factors came to the surface; hypertension, diabetes, high cholesterol, for example, particularly in men, were things that came out. That was no surprise. Family history was really important. These are young people, but these were people under 55, 18 to 55 who had heart attacks, and turns out, family history, we always think about as being important, but it was almost doubly important. It was very important in this group.

And then some things came up that were a little bit disturbing and should give us pause like low household income as being a very important indicator of risk. And ordinarily people are thinking about, like I said, blood pressure and diabetes and smoking. Oh, smoking also, by the way, very important here. These things are the usual, traditional risk factors. And what we’ve been doing when we talk about social determinants is trying to introduce this idea that there are other factors that have to do with the way our society’s organized, that can be associated with disease risks, like a heart attack. And in this case, low household income for these early, premature heart attacks turned out to be quite important.

And then just to add one more thing on this that was an interesting finding was that the risk factors had differences between men and women and their importance. And so, for example, in women, two things that came up that were much more important in women than in men were depression and also diabetes. So these were important in men, but not nearly as important as they were in women. And they may begin to unlock an understanding about underlying mechanisms. And why do the sexes differ with regard to this? And what role are they playing and how might we understand it?

And I’ll just say one final thing, which is these risk factors that we identified, the seven key risk factors. Like I said, some of them traditional, things like high blood pressure and smoking, and some untraditional, like low income, they accounted for 85% of the risk of a first MI [myocardial infarction] in young women and men. And I say this because we’re at a point where we’re racing towards new insights and new what we call biomarkers, new blood tests or images that can help us understand more about risk. But the truth is, these very basic measures accounted for almost all of the risk. That is, the elevations in these or the presence of these risk factors explained about 85% of the excess risk that these individuals who experienced the early heart attack had.

And so it just gets us back to basics around saying, yeah, we should continue to try to learn about the next thing, but we got to double down on helping people manage the risk factors that we’ve known about for a long time and then also pay attention to social determinants if we want to make progress in this area.

Howard Forman: Yeah, it’s really remarkable. When I think about so many of our guests on the podcast have talked about modifiable factors that can either prevent or mitigate bad outcomes from disease. Even just last week with Professor [Melinda] Irwin, it blows my mind how much we invest in biotechnology and life sciences and innovations on that end, but how much value there seems to be if we could only hit people at those social determinants. So I always am so impressed with your research and the work that you’ve done and this helps us.

Harlan Krumholz: Oh, come on, Howie—but keep going.

Howard Forman: No, this helps us a lot in the way we think about disease. I appreciate it, personally.

Harlan Krumholz: Thanks so much, I appreciate it. Great. So yeah, let’s get to Gail.

Howard Forman: I’ve been fortunate to be working clinically and administratively with Dr. D’Onofrio for 26 years. So this is a great treat for me. Dr. Gail D’Onofrio is the Albert E. Kent Professor of Emergency Medicine and a professor in the Department of Chronic Disease Epidemiology at the Yale School of Public Health. She’s the former chief and founding chair of the Emergency Medicine Department at Yale New Haven Hospital in the Yale School of Medicine.

And really, for the past three decades, she has developed and tested numerous interventions for substance use disorders, alcoholism, opioid use, et cetera, and really making an indelible impact in the field. She’s also separately done groundbreaking research on women’s cardiovascular health and done some of that work with you, Harlan. She sits on numerous committees. She is multiply awarded for her work. She has received lifetime achievement awards for her contributions to the field of emergency medicine, to the fields of addiction medicine and so on. And I could not be more thankful and appreciative of having you here today, Dr. D’Onofrio. Gail.

Harlan Krumholz: Howie, she’s the founding chair of the Department of Emergency Medicine and has brought it to remarkable heights. I mean, to come in with no prior department in a place that is very basic science oriented into a department that’s very clinical and clinically research-oriented and to raise it into one of, arguably the top, emergency medicine department in the country with regard to grants and so forth.

Howard Forman: That’s right.

Harlan Krumholz: Just among the achievements, I want to just cite that one because—

Howard Forman: No, absolutely. And let me say, I got to watch this. We will not air our dirty laundry in public here, because Gail and I were there, I’ve been here 26 years, and I’ve watched that Emergency Medicine Department evolve. I was here when we started the residency program and watched the first class graduate. I could spend the entire podcast just talking about her accomplishments in just this administrative regard, but I’m going to put it aside because I think that the public—

Harlan Krumholz: Well, let’s let her talk. Let’s let her talk.

Howard Forman: Yeah, exactly. I think the public would love to hear about what are the challenges and what are the solutions to an opioid epidemic that kills over a hundred thousand people a year in the United States alone? And for which we seem to be making too little progress. So the floor is yours.

Gail D’Onofrio: Right. Thank you for that wonderful introduction. I hope I can live up to it. So obviously, we have lots of efforts that are being done. Not only here but throughout the country, there are a lot of people working on this, and we seem like we’re losing the battle. So as you said, we are escalating with the number of deaths. There’s probably over 70,000 that are related to opiates per year, which is a massive amount of deaths. It’s almost 200 a day. And so those are people, real people, that we have to understand they’re people’s kids, they’re their mothers, their fathers, brothers, sisters. They are real faces of individuals often who are young, who are dying, before they get to really make a statement with their life. So it is a huge deal.

So what are we doing? Well, we’re not doing it fast enough. So we have evidence, the evidence is clear that opiate agonist treatment does work, and it reduces overdose deaths, it reduces infectious disease spread, it gets people back into the workforce and makes them part of society again. The problem is, that we’re having such a hard time getting people into treatment. And why is that? We have lots of things we’ve done, American College of Emergency Physicians, we’ve written a consensus recommendation statement, we have the legal action committee and council from New York who said, “If you don’t do it, you’re defying our EMTALA rules,” which means that we’d have to take care of everybody who comes in. We’re actually defying the Rehabilitation Act and Disabilities Act and everything else, and we should be sued if we’re not doing it. We have all kinds of things. ACEP has put out a quality network that says you should be doing this, but we’re not.

So we really need, right now I think, some teeth behind it. If you’re not giving evidence-based care that there should be some negative thing that happens to you if you don’t, and you’d be called out for it. So I used to do a lot of carrots, and this is why we want to do it; we have to make it easy. So actually some really exciting news is that Epic [electronic medical records] is taking our algorithms, and this month in the new update, they will have all of our algorithms and pathways for initiating buprenorphine. So it’ll be pretty easy for people to do it. We’ve done that. We’ve done all the teaching we can, and now we just have to get people to say, you have to do it.

So ACEP has created these quality networks that Dr. Venkatesh and Dr. Hawk here are very involved in, and they can choose some hospitals, many rural hospitals; about 500 have chosen to use some type of identifying patients with opiate use disorder. But there’s really, that’s a small group. And even when we look over that group, only a few percentage are actually giving out the buprenorphine. So we have to do more in doing that.

We know what happens with inaction. There have been some great articles that have been out from Massachusetts, Larochelle told us that in looking at 17,000 patients that present to an emergency department for non-fatal overdose, that we very rarely give out, albeit agonist, and that almost 5% of them will be dead within 12 months. So that really is just, Harlan, that’s kind of up there with MIs, right?

Harlan Krumholz: So say that again. What percent are going to be dead?

Gail D’Onofrio: It’s 4.8%.

Harlan Krumholz: So about one in 20 people who go out will be dead within—

Gail D’Onofrio: In one year.

Harlan Krumholz: Within a year. That’s crazy, yeah.

Gail D’Onofrio: So I would challenge people to find other things that this would happen to with such a huge amount of patience that we see.

Harlan Krumholz: Yeah. One thing I wanted to ask you was, you’ve been in the midst of this, and you have been pushing forth the research and the policy, been in so many different venues, you’ve talked to so many patients. I mean, one of the things people need to know is, you’re still in the trenches, you’re seeing the patients. So you’re one of the quintessential clinical researchers who does the work, actually manages and cares for people, as well as produces knowledge to propel. It’s extraordinary really.

And so, if you were able to whisper in the presidency and say like, “I get it, we got to focus on the pandemic, but there’s another pandemic that has taken a toll. It was so big that it also decreased the life expectancy in the country.” So we know the COVID pandemic did that, but so did the opioid epidemic, pandemic, whatever we want to call it, was everywhere. We lost ground. We lost ground on life expectancy as a result of this thing. What is the path forward? Because every time I think that there’s somebody standing up and saying, “This is a national priority, we got to fix it,” and we take a step back, and in the course of the COVID pandemic, if anything, it got worse. I get it, there was a trigger and a stimulus to worsening, but what’s our path forward to making sustained progress in this?

Gail D’Onofrio: Well, several. When we have to have all the treatments available, which we do in EDs, we have to do away and X the X waiver [waiver authorizing outpatient use of buprenorphine for the treatment of opioid use disorder], which is some crazy, bureaucratic way that a physician has to do certain.... Right now, we don’t have to do the eight hours of training. We used to have to do that, but you still have to apply for it through SAMHSA [Substance Abuse and Mental Health Services Administration], go through the DEA, get it back. So that’s a barrier for a lot of people to do that. So we just need to get rid of that X waiver.

We need regulation to be a little bit relaxed in terms of being able to not only use buprenorphine but administer methadone and be able to use methadone in our ED and in primary care settings. It shouldn’t just be an opiate treatment program. There’s a lot of stigma around people standing in line every day and getting their meds. And some of that was changed a little bit and did great through COVID, that was one of the positive things, that they let people have more take-homes. But we need to relax some of the regulations around that.

If we then say that there are these real quality measures and teeth to those quality measures, just like there would be, as you know, we can’t allow people to pick and choose. This is a quality measure. Are you giving out buprenorphine? Are you approaching all the patients with any of these issues with overdose or presenting with any complication? And you have to keep track of that, and you have to understand when you’re not doing it, why you didn’t do it.

Now, the other problem is, even if we did all those things, the population now is so vulnerable. When we started doing this in 2008, really, the majority of people had homes. The majority of people did have support systems. And right now, in all of our studies that we’re doing, 60% of people have unstable housing. So I’m trying to start them on a medication. We’re now even testing, even really very innovative things. We’re now giving out massive doses. So I’m going to give 32 milligrams of buprenorphine, which in primary care, they start at 2 or 4. I give huge amounts that will last for four days. We’re even starting to give some of the injectables. We’re testing some of the seven-day injectables. And we do have a 30-day injectable, and we’re starting that earlier than we ever did before, but we need to get the hospitals to allow us to do that because it’s expensive. And then we need somewhere for them to go. And because they’re homeless, it’s really hard to start medications and get on the right path. So we need very regulated places.

I know we have these things called sober houses, but they aren’t regulated, and you don’t know what’s going to happen when people go there. So we need housing. And I don’t know what else to tell you. We don’t need more inpatient units for opiate use disorder like you do maybe for some alcohol. We can do this as an outpatient, but they do need some place to go. Even when I’m trying to get them into what we used for medical respite, saying, “Can I use a five-day medical respite bed for someone I’m starting and initiating? It’s going to take them a few days to feel better.” They won’t let me do it. “Oh no, they’re substance users,” right?

Howard Forman: Our audience is very sophisticated, but I will say even among physicians, I don’t think everybody understands buprenorphine versus methadone or even versus Narcan, Naloxone. Briefly tell us how they work and why methadone and buprenorphine are so different and why it’s such an advance.

Gail D’Onofrio: So both of them are opiates, but methadone is an opiate agonist, a full agonist. The more I give, the more it gets in the bloodstream and the more action I have. So much so that someone may die with it if I give them too much. And it’s reason to use that because if someone’s taking a lot of drugs, a lot, there is no end to that. You can just keep on going up until you can get to an area where the person feels better. The problem with it, the way it is now, is that patients have to go to these opiate treatment programs. So they have to stand outside, they have to go through all this rigmarole, even if in New Haven where it’s great and they really have great access. If I send them there Monday through Friday, during the morning, they’ll start them on the medicine. It’s very difficult for them to get there. Especially if you have a job; you can’t leave your job and go there every day.

The other, buprenorphine, is called a partial agonist. And what that means is that you can use it and there is a dose effect up until a certain plateau. In which case, it doesn’t matter how much I give you. So in that case, it’s very safe. If I give you up to 32 milligrams, I’ve pretty much saturated all these receptors in your brain, and I can protect you from dying. So if I give you 32 milligrams of bupren, I get you to your full maximum amount and not everyone needs 32, could be 24, whatever, could be 16 a day. And you go out and you use because you will because your brain is not totally corrected. We don’t know when those pathways, if ever, will be normal; you will not die, because I’ve protected you.

Different than methadone. Whereas you’re going to get a full agonist and you’re going to take more opiates on top of that full agonist and you will die. So there’s some real benefits to buprenorphine also because I can prescribe it, you can go home with it. I can do it by telemedicine now with COVID-19. It just doesn’t work with everybody because I only have a certain dose I can get to. And there’s a lot of talk going around about how with all the fentanyl around that there’s more problems with precipitated withdrawal or some negative effects. But quite truthfully, I’m testing this in 30 sites, we have 925 patients who are enrolled in a trial. And we have had less than 1% have precipitated withdrawal. So people keep saying this and it’s possible, but we can take care of it in the ED setting if it happens.

Harlan Krumholz: So Gail, there’s a subtext to how you’re talking about this. I think just important to maybe develop a little bit for people who are listening. Which is talking about the treatments, how do you understand what the problem is and how do you treat it? It means that it’s framed now within the context of essentially a disease, as something that people need to treat. And for years and years and years, this was about a personality flaw or people’s weakness or things like that.

And also along the way, the terminology has changed. And I wonder if you could just, for our listeners, explain this evolution and terminology to, for example, substance use disorder because I think a lot of people haven’t really caught up to this changing terminology. You guys of course now are using it. Can you explain to everyone exactly what’s happened with the terminology and the framing of your approach to people who are suffering from substance use disorders?

Gail D’Onofrio: Sure. It’s actually fairly simple that we’re talking about an individual and not a disease state, so that we try to be as less stigmatizing because this is probably the most stigmatizing disease. And so instead of calling a person by that disease, like an addict, for example. They aren’t an addict, just like not that diabetic over there. So you would say there’s a person with a substance use disorder, an opiate use disorder, and that can be mild, moderate, severe, but it is a disorder. And we have treatment based on those different things. And a lot of people will say, for example, substituting one opiate for another. Well, that’s totally untrue because what I’m prescribing is a medication, that medication is taking as directed over a certain period of time, and the definition or the diagnosis of a disorder, a substance use disorder, really for any substance, is really loss of control and doing things when you know you shouldn’t be doing them. So it’s consequences and loss of control.

And you are not doing that when you’re in treatments, you’re not selling your family’s objects. You’re under some doctor’s care. So it doesn’t meet that criteria of disorder if you’re in treatment. So that one, we want to make sure people don’t think that you can’t do it because you are substituting one for another and somehow that makes you less of a person. And we want to make sure people understand that you don’t have “dirty urines” and “clean,” pejorative terms like that. We don’t say to someone who has diabetes, “Oh, you’ve got such a dirty urine. There’s so much sugar in it.” We have urines that are positive for opiates, and we have urines that are negative by toxicology. And if they are positive for drugs that we’re not prescribing, then what we need to do is escalate that care. We’re not doing something right.

So whether it’s more medication or it’s more “you need to go to group therapy” or there are other wraparound services that you need, whatever intensive outpatient therapy you need, we have to offer more, not less. And we’re better at harm reduction now, because I think even the government, ONDCP [Office of National Drug Control Policy], is coming out now with harm reduction. Before it was always, you had to stop or be on medicine. So now they’re saying, okay, we can do this.

So in fact, we’re giving out lots of the antidote, which is the Naloxone, and we’re treating patients by dispensing it. We want everybody to just give it. As far as I’m concerned, we should have it on every street corner. Go get some, wherever it is. In a school, as you know, here in Connecticut, we had two middle school children die, which was insanity to me that they didn’t have any Naloxone available. You only have a few minutes before you die. And so everyone should have that at their fingertips. So we need to do more of that. We need to do more of prevention and work with adolescents now, because adolescents are using all types of drugs, unfortunately. And with the way the world is coming and more issues with everyone, the more that they will turn to using these substances. And usually people don’t use one substance; they use multiple substances.

Howard Forman: Is there one community intervention that if you could wave a magic wand to have happen, in our area of Connecticut, let’s say, that you would do right now?

Gail D’Onofrio: Yes, housing. I don’t even have shelters anymore. Forget about housing. I don’t even have a shelter because of COVID. In the ED this past year, we changed everything in the last couple years with COVID. We let people overnight who are freezing to just sit in our waiting room. We actually hand them out blankets and we give them food. We would never do that before. We said, “Well, we can’t have this,” blah, blah, blah. We’re going to open up different shelters. We’re going to use the train station. Well now with COVID we didn’t have those options. So what is someone going to do that’s freezing and homeless? And granted, many of these individuals also have a mental health disorder, probably half of them. So we need better mental health services, which we do not have.

Harlan Krumholz: I want to just go to one other issue and then thank you, because you’ve been so great, and I know how busy you are. So what do you think about what we’re doing with the trainees? As the doctors are coming through medical school. I just remember, I got so little right attention to this and especially in proportion to the harm it causes. I had the opportunity to do rotation at Cambridge City at that time, and they did have actually some good programs over there, but it was out of the mainstream of the Harvard hospitals, really, where I was able to see this. Both for alcohol and drugs.

So what are you thinking about what the future of this, with regard to training, is? And how can we prepare healthcare professionals? And you of course have experience, as a physician, before that as a nurse, how do we all, across the spectrum of healthcare professionals, how do we prepare people to do a better job?

Gail D’Onofrio: Right. Well, we need to have training, real training in pharmacology in regards to all of these medications. And we didn’t even really talk about naltrexone, but we need for alcohol too. I mean, alcohol is egregious, that we don’t treat that correctly. So we do have medications, they’re not quite as good or efficacious as we do for opiate use disorder, but they’re decent, and we should be trying them. So we need to have that integrated into medical schools. We did have the X waiver integrated and then they took it out at Yale Medical School because they said, “Oh, you don’t really have to have that.” But the—

Harlan Krumholz: You want to explain what that was?

Gail D’Onofrio: So that was a training program of really talking about opiate use disorder and what these medications were and how you administer the medications. And just because we don’t have to do that to get an X waiver doesn’t mean we don’t need the training. So we do need that, and then we need role models, and I’m happy to say now at Yale New Haven Hospital, we have an addiction service line. Which we’re always asking.... I helped to get that started a few years ago, and we need even more resources because when you look at the people in the hospital who are getting those aortic valves replaced, who are giving the liver transplants, who are doing all these big things, if you don’t deal with their addictions, you’re going to send them right out again, and they’re going to have more problems.

Each hospital needs to have addiction specialists. And I’m happy to say that addiction medicine is now recognized by the American Board of Medical Specialties. I represented emergency medicine on that original group who we got that through. And now we have over 90 accredited, ACGME [Accreditation Council for Graduate Medical Education]-accredited fellowships in the country where we graduate maybe around 150 or so fellows a year. That’s not enough, but we’re getting there. And we should try to encourage the government, by the way, to pay for more of those slots because they’re over and above everybody’s slots that they want. But every major hospital that has training programs should have addiction medicine slots. And then you should call them, just like we call you as cardiologists, everybody doesn’t need to know everything, just call me up. And the good thing about addiction is, you really don’t even need to be with a patient.

You just tell me, and I can talk to the patient on the phone or I can do anything and then I can help treat them. I don’t have to be there that second. You can really do a lot of consultations in the system with just having a few people available, but we need them 24/7, 7 days a week. And we don’t have that ability because when you think of how many people there are in the hospital that need this, it’s amazing. So they need psychiatry to do the psychiatry addiction, and they need the addiction medicine. So we, as a group, really could do really life-saving interventions.

Howard Forman: You know, they use the term triple threats and quadruple threats to describe physicians that are great teachers, clinicians, researchers, and administrators. But when I listen to you, I also think that you excel with compassion, both for individual patients as well as the greater population of people who suffer. And I could not be more thankful to have you as my colleague for all these years and to continue to work with you. And thank you very much for joining us on Health & Veritas.

Harlan Krumholz: Yeah, thanks so much, Gail. You’re amazing.

Gail D’Onofrio: Oh, I don’t know, but we’re trying.

Harlan Krumholz: Thank you.

Gail D’Onofrio: All right. Thank you.

Harlan Krumholz: So, Howie, we’re now at the part where we talk about things that are on our mind, keeping us up at night or somehow stimulating us, about something, one thing or another. How about you, what’s up this week for you?

Howard Forman: I think all of us have been shook by the revelations out of the Supreme Court. That Roe v. Wade seems to be on the cusp of being overturned completely. I mean, this is a piece of jurisprudence authored in 1973, we’re fast approaching the 50th anniversary. It is considered precedent. It is one of those things that every single Supreme Court justice has basically been asked and answered and said, “This is precedent.” And to see it overturned is a shock, I think to everybody. It doesn’t matter what you believe on the issue.

This is a topic, for me at least, that I’ve generally avoided discussing because it’s one that people can be very passionate about, and for some it is tied to their religious faith, and I try to avoid that. But in the current climate, in the face of seeing women’s autonomy over their own body under threat, I cannot sit idly by and be complicit in that. And what this means for everybody in a material way is that a large number of exclusively GOP-led or -leaning states will outlaw abortion to one degree or another and that women who do not have the resources to travel—and by that I mean poorer women—will be denied the full spectrum of reproductive care that has been previously available to them.

In Democratic-led states for the most part have been codifying their reproductive care and abortion rates, and abortion will for the moment be spared any changes. But that doesn’t mean it’ll be spared forever because state legislatures and governors can change again. It emphasizes to me how much elections in this nation of ours matter to everyone. And that ultimately when changes like this occur, the poorest among us end up suffering the most from the power and the voting of those with power and or money. And like I said, I have truly avoided this topic on social media. I’ve understood that there are people, I think it’s a small minority, who have a deeply strong religious conviction about it, but I just cannot sit quietly about this anymore.

Harlan Krumholz: Well, come on, Howie. First of all, it’s not a small group, there’s a large group. Second of all, this was a foregone conclusion. I mean, McConnell manufactured this when he got people on the Court and how he was able to do this. This is gamesmanship, and it was certain to happen. I’m really interested to see about our national response to this. We’ve known elections have consequences. We knew it from the day that Trump was elected and what happened and transpired. And we’ve known it forever in the history of the nation as well. But I mean, I’m just saying it’s been brought into bright relief and then the gamesmanship that occurs within the Senate to be able to get the Court in this position was I think going to happen.

To me, this concerns me, but I mean, it’s not a new concern. I was expecting something like this, but the issue is that the legitimacy of the Court is threatened now, because really it has been politicized to the point where people are on the Court with known positions and are going to take known actions. When you had Chief Justice Earl Warren who was brought on by Eisenhower and making choices around civil rights, you had a sense that justices’ ideas evolved over time, they were open to new arguments. They were thinking about how society was evolving in different directions, and justices weren’t necessarily predictable. I think now we’re getting people on the Court, on all sides, but we’ve got a difficult situation where there’s lack of trust now. And this is a big problem.

I’m also, can’t get over, you’re talking about that news. I’m from Ohio. J.D. Vance wins big after Trump endorses him. I don’t mind when people are arguing about differences in policy, but if you’re really going to come out and say that Biden didn’t win the election, you’re going to say stuff that is just blatantly false in a way to rile people up around the election and foster this sense of unfairness in our system. It just, again, causes me angst because can’t we come together and say, what do we agree on? And can’t we agree on some certain facts around things?

There was an extraordinary expression of power in the state I grew up in, incredible, because he was lagging around 9%, he was behind and former president Trump weighs in and lots of people are still following that and they don’t seem to be disturbed by the fact that there are aspects of what’s being said that are counter to the best interests of the truth.

Howard Forman: The power of one man in our country is truly frightening. I don’t think, certainly not in my lifetime, there has not been one power broker of this magnitude in our country and it is—

Harlan Krumholz: On a national scale, unbelievable. Unbelievable. So, anyway, I’m in with you around the concern. Who knows what the final opinion will look like. This thing gets leaked, we’ll see. But ultimately this country, there need to be votes. The problem is, the way the country’s currently configured, is if the Democrats are interested in making a difference, they’re going to have to win by five, six points because right now it’s stacked against them. And so that’s another thing for the country to deal with, which is in four of those justices, the ones that helped make the majority were put forth by presidents who did not get the majority of the vote. They did not win the majority of the votes cast. That’s George W. Bush and that’s Donald Trump. And they did not win the majority of the votes, and yet they’re really responsible for what’s now become the majority within the Supreme Court, you had Clarence Thomas that you got the five. And the country’s got to be thinking hard about the way that we’ve configured this democracy.

You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find this on Twitter.

Harlan Krumholz: I’m at H-M-K-Y-A-L-E that’s H-M-K Yale.

Howard Forman: And I’m @thehowie, that’s at T-H-E-H-O-W-I-E.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Sherrie Wang, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.