Limb salvage situation. We were not sure whether the foot would be salvageable. Host you go to the hospital. You start relating the pain involved in the prescribed effort from the doctors. Pain isiscussions of important. When you talk about opioids, there is a response, today oh, you will just be fear mongering about opioids. I had traumatic pain. Friendss were my best in the world. Life was not livable without them for weeks. Five surgeries over the first month. The aggressive prescribing they started in the hospital was not assigned to anyone for long term and followup. Discharge from the final visit, i get home with escalating doses of powerful drugs. No one is watching me. I keep following the advice. Stay ahead of the pain every four hours. Host what kind of doses . Guest oxycodone, immediate release. 46 hours. Oxycontin, every 12 hours as extendedrelease. Every 12 hours did not get me far. Every 4 hours like clockwork, i popped pills. Host when do you have to start weaning yourself off of these . Guest im not thinking of anything other than recovery and avoidance of pain and trying to be present for my family. It comes as a surprise, two months or so after the accident, i go back with the trauma surgeon, he looks and says oh, this is way too much. You need to get off the meds now. He doesnt have any advice for me. He has not been managing prescriptions. He sends me to the surgeon who had been, a Plastic Surgeon and he says, not a big deal. Divider daily dose into 4, drop one each week and you will be off them in a month. Spoiler alert. Fantastically bad advice. I tried to taper really high dose opioids over 4 weeks, dropping a quarter each week which immediately sent me to withdraw. Host what happened in week one to week 4 . Guest week one, i said i was miserable. I would describe it to my family and say, it is like the worst case of the flu times 1000, you sweat, nauseated, get goosebumps. Withdrawal is the opposite of the drug effects. If you get euphoria with the drug, you get dysphoria. That you get pain related relief, you get intensified pain. Everything hurts. Terrible. Violently ill. Those purely physical symptoms were nothing compared to what came next. After i dropped the next dose at the end of week one, that is when dysphoria kicked in. Depression, zaidi, i started crying all the time, anxiety. By week 4, i was thinking i will have to kill myself. If the withdrawal symptoms didnt come out right, i cannot live like this. Host was there a moment when he realized this was a problem . Guest right away, when you are that sick, you are thinking this is not right. She called thea, prescribing doctor in the first week and he was like well, take care of your bowels. He was not concerned. After i started the depression and spiraling down in the following weeks, that is when we called him back and he got worried because he is clearly out of his depth. Go back on the meds. I cant do this. You need to find an expert. If i go back on the meds, i will have to do it again at some point. I feel like im dying. I will never do that again. We start calling anyone who we could think of who might be an expert. Three different hospitals, a dozen clinicians. No one will help. Oh, is when we realized, they put me on this medication that is dangerous and hurting me and theyre not going to help. That was the terrifying moment. Host the book is, in pain. Travis joining us for the discussion. If you want to ask questions about his experience and the overall topic of opioid addiction and opioid issues, 8000, eastern and central time zones. Mountain and pacific time zones, 202 7488001. If youre part of the medical community, 202 7488002. You are a bioethicist by training. Describe what that is and how it relates when you examine addiction and opioids. Guest a bioethicist is someone who thinks about the ethics and policy issues raised by medicine and public health. I dont recommend this as a strategy. Becoming impatient is a good way becoming a patient is a good way for a bioethicist to study something. You see all these gaps, deep chasms in the Health Care System. You see failures and you are trained to identify them. The journey i described in the book, not just a journey of withdrawal and coming to recover from that, is also about realizing, i have a unique voice because im specifically trained to identify these problems. I spent 4 years since then working on this. Host what is the top line about what you discovered . Guest two clauses. We think about how broken Pain Medicine is. Overprescribing is the language you hear in the media, for the last decade, that is too simplistic of what has been going on. Alongside overprescribing, which is reckless or irresponsible, you have under prescribing which is miss identifying someone as drugseeking or suspicious. Doctors, especially as we have gotten fearful of opioids, withholding medication from patients who need it and that has been causing problems alongside the crisis of addiction and overdose deaths. That simplistic message of overprescribing has got to go. We need to think about ethically responsible prescribing, weighing the costs and benefits and not letting the fear get the better of us. Ist you write that pain puzzling to deal with. We demand that doctors help us deal with it and our best tool to communicate it is deeply flawed. We simply cannot make it work. We cannot turn a private, subjective experience into an objective phenomenon. Can you expand on that . Guest if you are my doctor and i go to you and you say, what hurts . My foot. How bad . What can i say to you to give you data that is actionable . On the one hand, nothing that is truly accurate. Because, my pain is purely subjective. It burns. It feels like fire and acid. The longer you work in pain, you get good at identifying what words correspond to different sorts of pain. That is one of the skills of an experienced doctor. We need to know Something Like, how bad is your pain . How important is it for me to do something about it . We developed a simple tool which is the pain scale. Anyone who has been in the hospital in the last 20 years has heard, how bad is her pain . 010. That has helped. I got good at using the scale for me. Below a five, i would not medicate because the medicine has costs. If i say to you, my pain is seven. You may rightly think, i am tougher than you, it would be three for me. There is nothing we can communicate that tells you, oh, here is the meter, the accurate reading is five. That is the deep puzzle of pain. Because that is true, because pain is subjective and because one of the key medications for treating it is liable to abuse, that causes euphoria and addiction, pain is deeply deeply suspicious. That is the central problem of Pain Medicine. Host is there a better way than the scale . Guest i learned interesting things in the literature. One of the stories i tell in the epilogue is i talk to these military doctors. They have built on several years of research about how that simplistic scale is too simple. If im asking you only to rate intensity of pain you are thinking, it is really bad. How bad is it . Your focusing on . Youre probably making it worse. What is important is, can you function . Can you go out with friends . Can you be a decent partner . Can you hold down a job . Can you sleep . What is your mood like . There are all these functional aspects of how pain interferes with your life. Those are just as important is, what is the intensity . There is a new pain scale being developed in multiple ways. Pain, is thest, in book. Nikki is in pennsylvania. Go ahead. Caller good morning. Kind of interesting. Religion was the opiate of the people years ago. What was said by that legislator, make sense as to what might be happening with cognitive dissonance of the people, especially men and women coming back from overseas. Since silver was taken of the coin in 1965, they have become a mercenary for corporate entities to use at their disposal in Foreign Countries to protect corporate interest. We have a mercenary force at afterbasically, because the silver was taken of the going host the question directly related to opioids . Actually,e opioids, if religion was the opiate of the people way back when, and then the opiates of course, you know, i have a problem, you know, when people have a problem with pain, people have a cognitive dissonance, so this kind of mess, the cognitive money has, and, it, become the opiate of the people. Host got you. We will leave it there. Guest . Religion inioids of terms of Pain Management . Guest we have become opioid centric over the last 20 years. I dont know that it is appropriate to call a religion. America, we have been sold the idea that we deserve to be pain free. Acetaminophen. N, the extension of that is here is a more powerful pill that will take care of all that ails you. The effects of opioids dont pain,ork on physical they also work on emotional pain and traumatic pain. Opioids can cure a lot of problems, emotional and physical pain, so if we think that is happening in the u. S. A lot, that may be part of the explanation for why we have such a big problem. Host washington state, peggy. Caller it is not really a question, just more a statement. 2001, had aback in severe back injury. He was going to the v. A. Given morphine. He was on it for several months. Someone broke into his house on a friday, stole his morphine and he had to wait until monday morning to get more from the v. A. Guess he hadg, just had enough. Killed himself. So. Just a statement. Thank you. Guest so sorry to hear that. Another testament to just how devastating withdrawal can be. If you are cut off from your despair is depth of pretty bottomless. In my experience, and the experience of other folks, it is a good reminder of why we have to have compassion for people who are already on opioids because if they are cut off, that is the kind of despair, suffering they may have and waiting. Who the Hospital System is responsible for determining how withdrawal is handled . Guest the milliondollar question. Right now, no one is given that responsibility. That is one of the problems i identify. The first thing i published on this topic was a journal article in 2017 and that was the upshot. I had this experience that people were willing to prescribe, i am the doctor, i allow you to access the substance, but then they think, hands off, that is the extent of their job. That cannot stand. If these substances have risk harm downstream, someone has to manage the patient over the long term. It prescribers tend to think is not necessarily them in complex systems. Maybe with the family doc, in a small town, maybe the only course that make sense, of course they are the ones responsible, they have to learn about dependence wish all withdrawal, tapering plans. What about a big system . No one designing a Health Care System will say it is worth the orthopedic surgeons time to do followups on pain medication. Someone has to fulfill the role. It is an institutional question. Maybe we train pas. Maybe we train nurse practitioners. Host power those people trained how are those people trained on how to prescribed opioids . Guest the training has been lacking. One of the things in the last 10 years as we have started getting data on how doctors are educated on this topic. Terrifying. Average medical school gives seven hours of Pain Medicine to for justins to physicians in training. Several folks have put that up other data point, which is canadian doctors get more than 80 hours of Pain Medicine trading. We must assume they are getting training. What they are largely getting is, procedure for 60 tabs of percocet. That is not real education. That is a strategy for handing out scripts. There has to be a serious revolution. The way i think about it is, understanding these pills are complex. We think every physician, by virtue of md, gets to prescribe antibiotics for infections. We have treated opioids the same way. If you have a basic education in medicine opioids are hard. Pain, ae book, in bioethicist personal struggle with opioids. Dan in massachusetts. Good morning. Caller thank you for having me on. Think a lot of the problem is, our medical system is capitalist. Right there you have a big problem. Formotivation pharmaceutical companies, and you could say for hospitals and everybody else in the industry, is money. Say they this oath to will have patients, in their best interests, but recently, the doctor prescribed for me something i did not want. I asked for something i had in the past to take care of this fungus problem i had, i thought back. Fought back. He told me i would not get it. I ended up taking it, had a severe allergic reaction, which i am still so upset, i am in the process of writing a letter to the two doctors that put me in this position. Again, our medical system is a capitalist system, ok . Look at the history of opioids. Handinhandes with the invasion of afghanistan. What is in afghanistan . Opium plants. We went there and took control of the opium. As the earlier caller stated, where our military has turned into a mercenary for corporations, i think it is very clear. Until in america when we start looking at the root cause of all of our problems, rather than constantly trying to run around and put out the fire, we will continue to have these problems. Host leave it there. Guest the capitalism point is important. Where does money get involved with opioids and Pain Medicine . One of the things in the book is i trace a handful of the most obvious ones. One, pharmaceutical companies. Most common narrative, it is too simplistic but it has a kernel of truth. One of the main reasons we are in this mess is the pharmaceutical companies trained an army of marketers, pounded the pavement, told all the doctors that opioids are riskfree and good for all pain. A little too simplistic but a kernel of truth. A lot of misleading marketing. Farm is being sued. Pharma is being sued. Then you have treatment options. What are the most costeffective from a patient and hospital perspective . Morphine are ae penny a dose. Other medications are far more expensive. Acetaminophen, which is complicated, the evidence is mixed, it worked well for me, i wanted more and it was not given to me because it is orders of magnitude more expensive than morphine. When youre dealing with chronic pain at home, a lot of patients ought to hear from their physicians, and have not for 20 years, the best thing for a bunch of Different Things as physical therapy, yoga, mindfulness, acetaminophen and ibuprofen. Especially physical therapy, yoga. Insurance is not paying for yoga. Physical therapy is not covered often. Five dollar copay for opioids or for me, 100 per month for physical therapy. Money is shot through the problem and a bunch of ways. We are only scratching the surface. Doctors who prescribe higher get more funding from pharma. Look at the data sources in the book. It is an important point, as long as money is so shot through the problem, it will be hard to work out. Host paul from new york. Caller quick question. What is the percentage of people prescribed opiates actually get addicted . I listen to stuff on television and i dont actually hear an answer to that. Also, im looking at the cost of intravenous acetaminophen. 40 for 1000 milligrams dosage. I am wondering how that compares to what you were talking about . 1950s,hree, in the they used to send people to a farm in kentucky for about a year to get off opiates. There wouldnt be any around. This was sort of a way of getting them off it. Invariably, in many cases, a huge recidivism rate. I am wondering if you could describe that. I would be interested to hear, what percentage of people prescribed opiates actually become addicted . I was prescribed a bunch of them for a long time. Never got addicted. I did not use them chronically. Im interested in what the data is . Guest important question. Hard to get a singular answer because definitions of addicted vary wildly. We used to use addiction and dependence for Different Things. Now we use opioid use disorder. To 8 ofess than 1 people prescribed opioids develop a new addiction that was not already underlying. This is viewed as a claim that that is a low number, so, as you said, that is most people story. We should be clear. Most people do not get a new bottle, take pills and have this take over their life. The other way to understand it is, look at it from a Population Health perspective. Millions of people being exposed to opioids. If you have 6 chance of developing new addiction, and we prescribe aggressively when they are not needed, 6 of people who never needed to be exposed to this are going to develop this devastating, potentially lethal complication that is addiction. There is more data here. It would take me too long. There are sources in the book about new longterm opioid use, that is not necessarily addiction. That can be harmful in its own right. Do you want me to go on . About the iv a seven minutes and cost. Offend a set admin correct. Phen, 40 is you think it doesnt sound like much. I was asking for daily doses in the hospital. For me, it felt like it was as good as morphine for my traumatic pain. What they had to do, they did not say this, they had to think, as a hospital, if we gave every patient who asked this unlimited doses, to keep it low enough that it would not destroy the liver, what would that cost . There are several papers that say hundreds of millions of dollars over a year if hospitals did this. On the one hand, it does seem them, ii was telling will take morphine if you give me more tylenol. They said, no. That seems absurd. I was angry. It is not obvious. We have to contain costs in the Health Care System. Someone is crunching the numbers saying, is the data there to support the expenditure . Dependenceological on opioids is not the same thing is addiction. Addiction involves something else. What precisely . It turns out this is hard to answer. Why is that . Guest this goes back to my response about how many people report addiction. People hear my story and say, boy, that is too bad you got addicted after a short amount of time. That is not a great description. Addicted, i i was would talk about it, i think we should destigmatize addiction. It is important we do not confuse physiological dependence on addiction. There is what happens to every persons brain if they are on opioids long enough. The brain tries to readjust. That is called the formation of tolerance and dependence. Because the brain has tried to readjust and doesnt want to go crazy every time you get a shot of morphine, if you take that morphine away, they going to really terrible withdrawal. The longer they have been on, the higher doses they have been on, the worse the withdrawal is. That is not a sign of addiction. It happens to every single person. How may people get addicted . If withdrawal was evidence of addiction, the answer would be 100 . That is not helpful. Something else is present with addiction. Maybe they lose a family, their job, they cannot keep their life together, even if they are holding down a job. They chase this reward to the exclusion of all else they should find meaningful by their own life. Even in the face of negative consequence, they impulsively chase this thing and crave it all the time. That is the behavioral aspect. We should think about someone as addicted if they have this aspect. Does away with this dependence and addiction and puts it all under Substance Use disorder. They can be moderate or severe. We have to teach this. When you see someone in withdrawal, you do not necessarily see someone addicted. It has different policy locations. Every single one of us needs dependence treatment if we are on opioids long enough. A smaller number, which is more costly, need Addiction Treatment. Host eric from pennsylvania, next for our best, travis. Go ahead. Caller travis, this is interesting. I was ahead of the curve. I became a convicted felon because of this stuff in 2001. Theve gotten introduced, in 1980s as a migraine patient, and it went from there. Assumptions and presumptions about who gets caught up in this, what is your Research Bear out regarding the changing phrasing and attitude, now that there is welltodo suburban white kids getting caught up in it, it is an epidemic, it is a medical problem, but not too many years ago, you are seeing, if you were involved in the stuff, you are seeing it as a common drug, criminal with potential for violence and all manner of criminality just because of the class of drug it was. Guest yeah. Super important question. I am grateful to talk about it. I say at the end of the book, you cannot responsibly have this conversation without saying explicitly a bunch of the things you just said. Serious drug problem in this country for decades before anyone was calling it a crisis. 1990s,ned starting mid 19992010, overdose rate from prescription opioids quadrupled, same time that prescribing quadrupled. Where we shifted the kind of patient that was seen with addiction, Substance Use disorder, but it is really on us that, who was getting hit by that change . We had this older opioid epidemic, largely heroin in inner cities, disproportionally affecting minority communities and when it switched to white,ption, it affected rural and suburban patients. We are now in a third wave. Everyone is a victim. There is no discrimination among demographics anymore, partially because there is a huge amount of prescriptions, there is heroin everywhere and it is laced with fentanyl, which is super potent. It is everywhere now. The story is important. If we act like, this is only worth tackling now because a bunch of white people and people who have more power, politicians are now personally have family members and friends who have died from overdose, if react like that is the only reason to address the crisis, then shame on us. Were are just admitting our response is shot through with racism classism. That means, looking forward, one, we have to own it looking backward and looking forward, when we devise policy solutions, we cannot be thinking only about the kind of patient we like for the kind of victim we like. If you think, oh, this is worth it because the white suburban High School Football player gets addicted and dies, we cannot devise only prescription restrictions. We have to do something more comprehensive. Host they viewer on twitter saying imperative that government contribute to Pain Research. Is anything happening . Guest there is Research Money going into Pain ResearchAddiction Research new interventions, something called the heroin vaccine, using the bodys immune system to respond. There is Research Money going in. The person is online, the person is correct. It is imperative. Im not 100 sure this is the best use of resources. We have a ton of things we can do now on the pain side and the addiction side using resources we already developed. For Pain Medicine, we could educate physicians. That would go along long way and does not require new research technology. We can scale up Addiction Treatment facilities, using methadone, the Gold Standard for Addiction Treatment, introduce Harm Reduction services where they do not exist. We know how to do those things and we could start them now. Research, absolutely. That is a longterm plan. There is stuff we can do now efficiently. Host what was the experience for your wife and daughter . Guest traumatic. Ought, she wants to, this is something she could do, to family members going through this. It was traumatic for me in a particular way that i have this personal view. It was traumatic for her in a completely different way that she had to watch this happen to me. She knew i could recover, that i could be whole again. She couldnt convince me of that. She watched me believe i was dying. She was trying to raise our 1. 5yearold. She could not leave her job. She is a research scientist. She had to hold down a job. I am grateful my daughter was only 1. 5, because she does not remember it. I said to her, every day, god, i hope you dont remember this. It is secondary trauma. Us, howd remind, all of lucky i was that i only wrestled with withdrawal for one month and two months of exposure. There are people whose lives are destroyed and the trauma must be orders of magnitude greater. Host when did you know you were off opioids . Week we stuck to the 4 weaning plan because we never got better advice. I didnt know that if i change anything, it would get better. No one would tell me that. I believed if i would go back on the meds, i would never get myself to do it again. Month100 free after one of the medication and the acute stage of withdrawal lasted a week. Up, mye acute phase let life started to recenter and i started to think, i will survive this. Withdrawal symptoms can flareup for months, postacute withdrawal symptoms. That is a scary thing. If you have been traumatized like this, months later you can get tremors again. Host do you still have pain from the accident and how do you manage that . Guest i do. It was a limb salvage situation. You dont fully heal. It depends on how bad it is. I will need another surgery eventually. Surgeonve an orthopedic clear out some of the painful components. I sometimes use ibuprofen. I try not to use it everyday. All drugs have side effects. First rule of pharmacology. Ibuprofen and a set a minute for they work really well for me. Things like physical therapy, shame on me if i dont put this into practice. Over the course of six months, as i was finishing the book, i ramped up my regimen and it is borderline magic for me. The kind of pain i have in my foot responded well to exercise. If i am too busy and i neglect myself, the pain goes up. Host williamsburg, virginia, randy. Caller good morning, america. My condolences to the families of the tragedies this past weekend. , good morning dr. , that is wonderful youre bringing up exercise as a recovery tool. In anlf was injured industrial farm accident in 1998. I was thrown from a roof and broke my neck. Ended up with seven screws, two plates of steel and part of mybutt and neck. When i was well enough to volunteer, i did so on the pediatric injury for an brain injury. 2000, that is when i saw how well, how, not only, there was little equipment for children to get back some of their physical abilities. I also found out how in school, we dont teach fitness so much. That is what really saved my life. I was an endurance athlete. I knew the difference between injury pain and training discomfort. That is what i relied on for the first two years out of the hospital, which i spent 10 weeks in. They said i would be there six months at least. Sir, i will get right at this and that is what i did. Stationary bike is what brought my lower extremities back. More andn, more and more and more work in the gym and i was able to separate the discomfort of improving my health from the discomfort of the injury itself. We are not teaching that in school. As a result of that, please let me finish, ive built a mobile fitness facility which i have been sharing on cspan for 20 years now. This murderwith all and mayhem on these blocks, psychologically and physically, fitness is a great respite for those directly affected or for those in the community. Host thanks. Right to is exactly talk about the importance of fitness. One of the interesting things i learned in my research was we have these tools we recognize because we use them. Another one is breathing. The first thing i thought when i read about this was, no, how can breathing be that important . Doctors said, your wife gave birth, right . Yeah. What did they teach her to do in the pain of childbirth . Pain management and focused techniques. One of the interesting things i found was evidence for things chi combined tai elements of good recovery techniques. You strengthen the body with exercise and do mindfulness meditation, focusing on your breathing and all of those, it can sound hokey if you are not on board but a lot of those are evidencebased. They are good tools for recovering from pain. Host doug in washington. Caller good morning. I was hit by a tree. Paralyzed from the chest down. Spinal cord injury. Lots a hardware. I tried everything for the first two years. It has been 12 years. I tried everything. Now my management is, i was lucky enough to get the ring of fire. It burns and hurts around my chest. Anyway. For the last 10 years, all i oxycodone milligram and lyrica. I only take eight pills a day. I choose to only take 10 milligrams. I could have gotten a higher does all this time but i choose not to. Because i was told you will get used to it anyway. The pain never goes away. I am always in pain. It takes the edge off. It manages it. Fouroblem is i have lost teeth, they just crumbled, and my question is, what is my longterm issue going to be from the oxycodone and the lyrica . That is the only thing that bothers me. I listened. I will go ahead and let you tell me. Guest i cannot give medical advice. I am not md. I would not do it on tv anyway. And that storys there is a population of patients stable on low doses of opiates and a big question for the community for academics and policymakers and people trying to figure out the american response to the crisis, a big question is, what do we do about that . Youre getting evidence saying Something Like opioids are not great for longterm chronic pain because of the way they were, we just dont have any good reason to think they work over longterm. Then we have patients who are stable. Do you try to get them off if they feel like it improves quality of life . There is a lot of disagreement. Im not willing to say anything but a lotnt right now of colleagues i deeply respect think if the evidence as, you are not being helped after 10 years, we should get you off this whether you want to or not, im not sure that is responsible. The dose is relatively safe, the patient is stable, it improves quality of life subjectively and the medical establishment is, who put them on without good reason . I think exposing them to potential suffering of withdrawal, the emotional suffering of anxiety of having to get off, i am not sure that is justified especially at the doses the caller is talking about. There is a question about longterm data. We do not have it. Lyrica is not an opioid. If you are on it for 30 years, we dont have any idea what the longterm effects are because we have never done those studies. It is not evidencebased. It is part of that lack of evidence all around, is part of why we are getting more cautious about prescribing. We have put patients on opioids with the intention of leaving them on it forever, apparently, without any evidence that was good or safe to do. It is a concern. The country is struggling with it. I do not know the outcome. Host how has the medical community changed attitudes toward prescribing today . Guest by large, it is different for different pockets. I work for jon hopkins which is not representative. My colleagues are by march, brilliant, insightful, and doing good responsible Pain Management. There are doctors everywhere, probably including hopkins, that i do not know, who are just scared now. That seems to be the overriding factor. 2008,ng in the late 2000, you start hearing things like, there is an epidemic. Doctors are killing people. Now the easiest thing to do is to say, got it. Not prescribing. That has led to inadequate treatment of pain. Have ahead of the time, i will not listen, i will treat them with suspicion. We become suspicious of oxycodone. If you already have patients, they could be abandoned and face withdrawal. Basically have to figure out how to handle things like, when we know we need opioids for trauma surgery, then what do we do . That is more nuanced. It is more than just, should you prescribe . We know we will prescribe. Now we need to know how we will actually manage it and get them off . The general answer is, we have been scared. A lot of physicians do not have a nuanced answer at all. They know how to write prescriptions. The only way to move forward is to do something more careful. Host jeff, springhill, florida. I am 64. Es, i first hurt my right knee when i was 25. A. C. L. Acl inwas 35, i tore my my left knee. Ive had six operations including my right knee replaced and im currently now going through having my left knee full replacement. Couple questions. First of all, the tolerance i have. They keep wanting to give me narco and things like that which are about the equivalent, i have never been addicted to opioids. Ive always had an easy time quitting once the pain is gone. Second question is, is there a difference in the pain level betweennd or addiction synthetics, semi synthetic and straight opioid . Because, they keep wanting to give me things that just wont work. They wont give it to me because of the situation. Host thanks. Guest it is not so much a distinction between synthetic and natural occurring opiates, which is what we call derivatives from opium. It is more about potency. Norco, which is a hydrocodone percocet,en that and common brands, you have different opioids. Hydrocodone versus oxycodone. Is about as potent oxycodoneligrams is about as potent as 1. 5 milligrams of hydrocodone potency. Others are stronger. Hydromorphone is even more potent. Fentanyl, which everyone has heard of because of the illicit version overseas mixed into licit, but there is a version. It is 100 times more potent than morphine. There is a difference in potency. Only increasest the pain relief but also increases euphoria, which taps the reward system. Host travis in 1979, a Small Network with an unusual name rolls out a big idea. Let viewers make up their own minds. Cspan opened the doors to washington policymaking for all to see, bringing you unfiltered content from congress and beyond. A lot has changed in 40 years, but today that big idea is more relevant than ever. On television and online, cspan is your unfiltered view of government, so you can make up your own mind. Brought to you as a Public Service by your cable or satellite provider. Up next, a hearing on the satellite and local Television Broadcast act. Association of broadcasters president gordon smith is a former republican u. S. Senator from oregon, testified at the house subcommittee hearing