Transcripts For CSPAN2 Opioid Epidemic 20170307

Which failed to disclose risk factors for addiction as well as evidence of illegal drug trafficking. She has won awards for her exposes on alleged human rights abuses in myanmar and on Health Insurers to rescind coverage for six members. Please give a warm welcome to ms. Lisa girion. I want to introduce the rest of the panel. We are lucky this evening to have a Diverse Group for so many aspects of this problem. Jill horwitz is a scholar at ucla that has done quite a bit of research in the Opioid Epidemic and efforts to fix it. Sam quinones a fantastic journalist i work fo worked fore paper has written many books as put in the amazing chronicle of this epidemic called dreamland and if you have not read it i highly recommend it. It is a fabulous and touching and tragic book. Doctor Larissa Mooney runs and addiction clinic at ucla and helps doctors learn how to cope with some of the victims of the epidemic and has done research into some medication responses to. He has seen quite a bit of the risky and dangerous side of the problem and has endeavored to try to attack it from that and. I will start off by saying i first began looking at the Opioid Epidemic as a Prescription Drug epidemic in 2010. I joined some colleagues at the paper and began looking at the problem. Over the last 15 years more than 200,000 people have died of drug deaths in this country. Most of them are prescription opioids but increasingly on a harrowing and they are closely linked. There are 20 Million People currently addicted in the country to legal and Illegal Drugs and only about 10 of them manage to get treatment underfunded and not that available. I wanted to start the conversation by hearing from each of you your perspectives on the biggest part of the problem and what is driving this problem. I think what is going on with this problem is two things, one is oxycontin was heavily promoted as a kind of cureall. There we go. A weird echo. A cureall for a lot of pain. The difference that has been used before it is vicodin, percocet, acetaminophen, tylenol, you cant develop unhealthy bad habits without destroying your internal organs. Organs. With oxycontin and it is because it was so widely prescribed, massively prescribed all across the country, it had the effect of raising people who got addicted, their tolerance to a level that was unsustainable. After people had to turn to the streets they ended up costing a dollar a milligram and people were using two or 300 milligrams a day and that is unsustainable. The other part of the story is in the 70s, a lot came from the far east, from turkey, thailand, etc. Thats what the French Connection was all about. That changed in the 1980s. And from the 1980s on came from colombia or mexico and heroine is a commodity its not like red wine or marijuana. It really the price depends on how far you have to travel with it and heroine is coming up from mexico was potent and cheap. The proble problem is no one pad attention to the change when it happened because it wasnt a problem in the 1980s or 90s. We grew to recognize how big a deal it was in the geographic switch that have happened to how the heroine from mexico and colombia basically outcompeted from the far east when we begin to create with this massive prescribing of pills for every kind of pain, for a wisdom tooth extraction and not just a few, but 60 vicodin, 90 oxycontin. Huge amounts of these pills and what you get then is a huge number of addicts looking for an alternative to very expensive pills and the heroine coming from mexico provides that alternative. Its potent, cheap and extraordinarily mortal, deadly. That is what we are seeing all across the country. Its a combination of those two historic kind of changes that created the issue that we have today all over the country and where it is heading the most is in white families, families and communities that are not used to this, families that were not prepared for this and that didnt do anything to deserve this and it is in the heartland and the suburbs and rural areas. Its a very different thing and its also deadlier than any epidemic that we have ever had. I think heroine and the pills, can you talk a little bit about what Law Enforcement is doing about this and what role you are playing right now and how you are trying to attack this whether it is doctors were pharmacies . I will answer the first question how lawenforcement lat fits into that if you dont mind. Basically, one of the reasons for the problem is it is so big right now and hard to tackle that its a multifaceted issue and there are so many to cut off. Theres the issue of corruption, medical practitioners negligence over prescribing the drugs come and the public what they are, vicodin, oxycontin, heroine and there is the issue of the fact that you can stop doctors from prescribing the drugs but you still have a black market of heroine addicts to deal with which is why when we plateaued if it is the abuse of the drugs the last three or four years of this skyrocketed exponentially and then you also have the Public Safety issue of fentanyl being imported from china and like others it is purely synthetic which means you can have labs in china and mexico import it and its 50 times more powerful than heroine and its leading to massive amounts of death and there are analogs that are even more powerful, elephant tranquilizers that are now being abused and causing the deaths that we are seeing when it is cut with heroine or counterfeit hospitals in West Virginia and New Hampshire. So we obviously have a lot of different people between regulators and educators involved where Law Enforcement comes into play is obviously deterring the corruption of doctors, a corrupt doctor with a prescription pack can sell as much into pill form and poses a massive part of this problem. We also obviously are involved in the interaction prosecution of the importation and we cooperate very closely with regulators involved in deterring negligence of medical practitioners and taking licenses or disciplining where this needs to happen. I needed to microphones. I wanted to follow up a little bit on what sam was saying and what i said at the beginning. I started out by saying thereve been 200,000 deaths attributed to opioids over the past 15 years. But sam has a good point, kind of agenesis of all of this order it is closely linked in time at least to the changes in medicine and new drugs like oxycontin coming out in the market in the late 90s. Thats where it starts. When those drugs to market, there were 4,000 approximate drug deaths in the united states. Now theres more than 36,000 a year. In 2009 as my colleagues and i reported, drug deaths actually surpassed Car Accidents as a source of mortality in the country and in an industrialized modern country, one of the goals is to drive down preventable deaths. Thats why we have seat belts and speed limits and childproof pill counts. It is really unusual as i think jill has noted from a publichealth perspectivpublicht mortality charts and see everything going down. Everything we can do something about, we are all invested in that and all of a sudden we see something going up sharply and very clearly that is a byproduct of medicine and therapies. Most of the. I need it again now . Most are actually involved in Prescription Medications but increasingly involving heroine. With that, i think this would be a good time to talk with joe whos studied one of the responses to this crisis as a kind of snuck up on everybody was further states that started more recently with a set of Prescription Drug monitoring programs. The idea is if you are a doctor writing one of these dangerous prescriptions to a patient who is recovering from surgery or a car accident or has bad pain, you want to make sure that person isnt getting that same prescription from three different doctors and is either addicted or selling them and contributing to a Public Health problem. So i think in most of the states jill can tell us about it, the idea is that pharmacy sends a record of a prescription that is dispensed onto a state agency often times the attorney general and the doctor has access to that through a web interface and is supposed to check to see what you are up to before he or she prescribes and she is going to tell us how that is working. One of the things thats interesting about the epidemic is the states were onto it pretty early and there was a ton of activity. So my coauthor published an article on this last summer and we worked with a group of actually sends like the beginning of a joke and economist and a doctor and a lawyer worked together on this paper because we wanted to cover all of the facets and in the period that we studied from the 2006 to 2012, there were 81 separate state laws passed to deal with the opioid prescriptions and abuse and the one that gets all the attention are things like tamperresistant prescription pads so used to be fairly easy to steal a pad and fake prescriptions and now there are special pads that say blade if they get heat on them or certain signatures and they are preprinted into that kind of thing. So the states passed these laws and there was hope that they would make a difference, so we studied a very tough population. The study people who were permanently disabled and on medicare even though they were under 65 because they were disabled and could no longer work. And among that population which is a relatively small population, the u. S. Two to 3 , maybe over 3 now be accounted for about 50 . So the population is very hard hit and when we look at the passage we were thinking we were going to find something because actually if you just look when they were passed and then you look at the trends in prescription abuse, hospitals, all these kind of things you ded a slight slowdown in 2010 but when you look at the states that passed the laws and plan and compared to the states that event, we find no effect for any of these interventions at all and so the lesson could be maybe we had it particularly tough population but we want to be careful how much money we throw in interventions that might not be working. Our results were not woken by the cdc. They wrote a letter saying we did Lousy Research that we wrote a letter back saying theyve got to take the bad news because we have to learn from this so we are going to keep trying and go to different populations but this is not good news. I know the research is important from the perspective of Law Enforcement and regulators, it is essential and its made a huge difference for us and taking bad actors, pharmacies and doctors off the market so i dont want anyone to come out of this. Toe. Its for prosecuting for drug trafficking. We dont know every instance they sold the drugs that we know every single time a doctor has prescribed drugs but its been filled at a pharmacy in california or whatever state and we know the dosages comes with the doctor is prescribing the same drugs and maximum dosages we know the patients are living miles away into the dangerous cocktails of narcotics prescribed together. It is essential and not just for the prosecutions but the medical board regulators and pharmacy board regulators and of course every time we get a conviction and they report that it sends a message to doctors as well so i have to imagine it has had an effect even for negligence so i just want to emphasize how important it is. We shouldnt have these things and the states operate in very different ways. Even in california it isnt so easy to get across the border in places that we had problems in new england particularly hard hit, it isnt so easy or not so hard as i learned growing up to massachusetts to get the things your parents didnt want you to have. The states are right next to each other so it could be working in some places but not others. I thought o on the topic of n perfecimperfect solutions, thisd be a Good Opportunity for you to talk about options. Ive spoken to too many families that exhausted their Retirement Funds and mortgage their homes and sent a Family Member into treatment numerous times only to have them relax, overdose, recover and then in many cases finally die. So whats out there and how well is it working . When it comes to treatment iv with the most important for population. Its for the prevention of Overdose Deaths because nobody can be engaged in the rehabilitation recovery if their illness has caused their death but the Gold Standard for treatment for opioid addiction based on evidence that is emerging from research. We have behavioral skill skillsd the cookietheir cookies that art to learn that the fda approved medications that are available to treat opioid addiction are considered the Gold Standard and we have method on and i can go into a little bit of the differences between the medications, but essentially, some may be aware they are opioid. It is a partial activity and ask a little bit differently than some of the other that weve been talking about and methadone is a long acting, both of them are long acting opioid substitution therapies. What that means is you are giving a medication that can take the place of and break the cycle of intoxication and withdrawal and chasing the high and then trying to recover from below. It is a vicious cycle of addiction and they can stay in the system for more than 20 hours at a steady level and can be lifesavers for many people. They can allow individuals with addiction to improve their functioning and quality of life, get their lives back. Tractracks on bayesian opioid blocker and there is a monthly injectable form that is long acting that seems to be a better option for people with opioid addiction and basically if you are on this and use and opioid, the affects are blocked. So these are the medications that are available and another important issue to discuss is a medication that can rapidly reverse the opioid overdose and has been abused and medical personnel in er settings for a long time and now theres a Public Health movemenpublichear people to have access to the locks on so anybody that is at risinterested in overdose, physicians are encouraged to prescribe it so that a Family Member or loved one or friend could use it in the case of a suspected overdose because the benefits upgrade the. Outweigh the risks. I want to throw out one fact i found interesting. Several years ago when we were really digging into the statistics again, what was really interesting for us was the population at the greatest risk of death and where the greatest risks were. It wasnt k. As you might imagine seeking a thrill, but it was people in their 40s and 50s. That is the hardest hit population in terms of mortality is from opioids so that gives you a little bit of a sense of what we are dealing with. One of the Solutions People talked about lately particularly in the president ial campaign is interdicting the flow of heroin into the country from mexico by building a wall or in improving that. I would like to hear you explain as ive heard you before, how harrowing kind of got into the midwest and what effect you think the walls might have on that. We absolutely need to do something about the heroine coming from mexico. It is an out rage obviously, and i think the fact that most comes from mexico had a lot to do with why donald trump one to key states that were the key to his victory. Ohio, pennsylvania and other. People in that area nowhere they are heroine is coming from and they are not happy with it. The opioids play a big part of that. Heroine is a great trafficking drugs because it is easy to conceal. It isnt like marijuana where it is bulky. You dont need a lot of space in which to traffic and therefore, whats most likely needs to happen isnt a wall. We have a lot of walls if youve been to tijuana, san diego. One starts at 50 yards and one ends at the ocean and goes for 14 miles its a big round in. But we have a lot of walls across the border. They are not everywhere here when, the walls i dont think. Fullstop. They will have stopped people, but not heroine and particularly when you have to size and the demand that weve created since the 1990s across the united states. What will stop the flow was here when is a mexico that starts to change in fundamental ways. Mexico ive written two books about the country and it seems to me that what we really need to do with regards to mexico is not alienate it, but also not value its friendship above all things. We need to be in conversation with mexico and be a constantly relating as one of our most important foreign relations. But we need to be pushing them to do the kind of changes that will make that country a place where people are not dying to leave which is literally the case. And only when mexico begins to change and develop the kind of Law Enforcement capacity that say canada has well we begin to see kind of a modern partner. The way we get there i believe anyway is not by alienating and insulting and in claiming what trump has done more than anything else and allow the leaves of mexico to distract the population with this inflammatory rhetoric while they do nothing to change what is an essential component of a bilateral relationship which is a mexico that has a better Law Enforcement and Justice System with a name so costs can call down to areas where they are growing heroine and be kind of partners with the mexican counterparts. It exists to some degree but not as the example we can probably solve a lot of the marijuana and cocaine. Heroine is so small a pound of very potent heroine could be smuggled across the border very easily and then cut into and stepped on five times and still extraordinarily potent. We need to understand that in order for that to change, we need to treat them as neighbors and not like some kind of dysfunctional family. And this focus on the wall has inflamed that and has not done anything positive in that regard. Weve talked a lot to doctors obviously in our reporting on this issue and many doctors who were trained up until very recently told me they were trained when they went to medical school to be careful prescribing opioids. They are addictive and you have to weigh out the risks of addiction with what youre patients are facing and im so the mid90s, doctors were loathed to prescribe opioids for anything but people with terminal pain and cancer. And in those cases, the calculus was addiction isnt a problem or it is inhumane to let people suffer with cancer. The humanity idea was expanded to include a much broader range of pain and the doctors prescribing tendencies shifted. But it got to the point that doctors were prescribing opioids quite frequently for all kinds of pain including dental extractions and shortterm pain and all kinds of pain. Do you have any ideas on how the transformation went from stay away from opioids they are very dangerous you dont want to get your patient addicted to you are going to have a tooth pulled i will write you a prescription . Im not sure of all of the historical and political reasons behind. I think sam might be able to comment on that a little bit more but i do recall in medical schools exactly when the transformation occurred. It was pretty dramatic. Suddenly pain is a societal sign and doctors are under treating pain. We need to be more aggressive. I am not a Pain Management doctor but in medical school we were hearing exactly what was supposed to be done and i think the pendulum swung the other way and now it is swinging back and there are based on all the problems that have emerged, we were told the opioids for pain are both effective and have minimal risk of addiction in patients with pain. So, we are learning that that is not true and much of the research is showing that i do want to make the point they are a valuable medication. They are highly effective for acute pain and we need these medications if you have a surgery or an injury, they are highly effective. But the efficacy for chronic pain and longterm use is now being questioned and the risks are clear so now there are guidelines shifting back to the need to approach this to managed pain and please consider non opioid Movement Therapy medications, physical therapy and even Cognitive Behavioral Therapy to cope with pain so hopefully we will see a return of more comprehensive pain clinics to manage these problems. I think a lot of it has to do with us. I thought when i was starting my book i was writing about drug traffickers and trafficking but it became a book about america and who we have become. We became particularly i did say at the end of the cold war and 90s and us alon so on a countryt loves to kind of thick salt the private sector. We became a country where people were applauded for making lots of money even though may be the way they raised money didnt do much for the community. The kind of savaged the government and exalted the private sector and became a country that above all wanted comfort and convenience and a lack of pain and you could see this in a lot of ways i think. We have padded playgrounds because god forbid our kids skin their knees. We have trophies for everybody because god forbid somebody should feel left out. We dont want our kids to feel pain and now they are asking for warnings so that when a professor is going to deal with an issue that might be painful, so we go from protection of physical pain to protection from emotional pain and doctors i believe are seeing those particularly in the 1990s patients would come to them and say i cant have any pain. People began to believe we really could not suffer any pain at all. So thats when we began to nod just prescribe these pills for some kind of ailment but massive doses and we believe that they were virtually nonaddictive even after the acute pain as my appendix was out i would have 60 vicodin. There was a pain that is going to last three days and i got 30 days worth. We became also i think a country that went indoors and isolated ourselves. This is a story about isolationism and in america it is about the hallmark of the crack epidemic was the crack house of Public Housing usually a place that had been taken over, rental or what have you. I covered this as a crime reporter. The hallmark to this epidemic is the private sign of our great custody as a country the place where every mother wishes her child shoul should be condoned e outside as child molesters or somebody that will hurt you outside. Stay indoors. Its in those rooms kids are hiding their jokes were shooting up and dying. So doctors picked up on this and begin to see this in the systems with which we wanted to have no pain at all. Doctors were the vectors for this problem but what started this was all of our Health Concerns believing we won the cold war and it was time to kick back. Kids cant possibly not have. They would be unhappy if they didnt get a full snickers bar every house they went to. I think this is all a part of the story and why doctors felt such pressure. All of a sudden they are getting pain specialists telling them yes, we now know that opiates tell them go ahead and thats what they did they went right ahead but it was i think it was our wanting to not be accountable for our own Consumer Choices and our own choice is of a variety of sort that pushed them in that way and i think that is kind of what led us to where we are today. It isnt a story about dope, it is about who we are as a country and as americans and what we think will lead us to happiness. I think one of the things i havent heard discussed yet is the drivers of why doctors prescribe in this amount and in the east kind of drugs. We have to look at what our insurance system is and how doctors get reimbursed. So, it is very hard to get reimbursed to do the kind of slow, careful intervention to do alternative treatments for pain even though some of them have been shown to be quite effecti effective. The insurance system tells our doctors through reimbursement to write the prescription and furthermore to write a prescription for a lot of pills because you dont do so well if the patient keeps coming back. That takes a lot of time so i think there are some fixes we could easily put in a rare you get a certain number and call in to get a certain number more. That would solve the problem, but it would slow down things. So there are some systemic changes. Im not sure that i agree about the candy bars and allergy that i do agree about some of the cultural drivers. There are Practice Patterns in medicine that have showed up in all kinds of treatments if you look across the country there are Different Levels of prescription and kinds of treatment for the same illnesses and that has to do with the culture of practice. Ironically this is a problem in america and one of the reasons racism has helped minority groups because the doctors wont prescribe these prescriptions to people of color so in some respects, they have been saved from some of this. And those cultural. The cultural causes for some of these problems need to be looked at from the doctors end and patient and Community End and then i think Larissa Mooney is the person to speak most directly about this and we have to think what happens in our society that make and 18yearolds take her grandmothers pills from the medicine cabinet. What is happening at this point in time that someone does that when they otherwise would not do that i know another part of the problem is people get addicted when they have pain and then they are on this stuff but what about all these young people which in some states it is harder hit than others but what makes people so desperate that they seemed okay between this and that i choose reaching for the spill . I will say one element is a lack of perceived risk. So yes now it is getting a lot of media attention. We are starting to talk about it. But there was a perception that this is medicine prescribed by a doctor. It isnt a street drug therefore it must be safer so that is one component. Its not the whole story but for sure, a lot of experimenting with the pill. People do experiment with drugs and seek a high and Recreational Use of all substances and experimentation is common but certainly there were years when High School Students use of prescription opioid pills for recreational drug use was rising exponentially and in one element is a lack of perceived risk. I can get a buzz and feel good. What do opioids do, they block pain, they are analgesics, they cause euphoria, they make you feel good and the memory of air so that talk about the only person and people who were struggling with depression and anxiety and stress. The memory associated with taking the pill and the immediate relief come as a society we want instant gratification and that is a very powerful memory. When you look at the neurochemical changes in the brain that happened over the course of addiction and cross addiction, there is a big component of what did he opioids and others do the rework the system, they are reinforcing, you feel really good and form these memories and the next time you are feeling bad or stressed, depressed, the temptation is to quickly obliterate that feeling so that can drive a drug craving and over time lead to addiction. I think on a lot of School Campuses what has driven this is football. Football is a gateway to heroine addiction today because thats how weve learned to treat pain is by throwing pills at it and most places, Many High School Football Players are kind of like the cool guys and people watch Football Players, lacrosse, wrestling, baseball, mainly football. What i was finding was an enormous number getting addicted because theres a pressure to get back on the field, this is how you treat chronic pain and then theres lots of spillover. You go in for a surgery, everybody on your team does you are getting those pills and the pills you got prescribed are in four or five other guys lockers. All across america this is happening i think. Football players being kind of the leader on campu campuses i k frequently set the standard as well. It is just a hunch. I dont have any evidence or study to show this but i was running into it a lot during the research of my book. I can completely corroborate what you said about football and wrestling. I usually within the homes of people that have lost someone to an addiction through overdose and when it was younger kids, in their teens and early 20s, almost every case they had a football injury, wrestling injury, ski accident, voter cross, car accident and there were 16, 17yearsold put on opioids which is probably the right response in the hospital and immediately after a surgery but then there is no followup. There was no care. You go from the surgeon in the hospital to your family practitioner and rehab and then nobody is paying attention to how many refills got and it doesnt take that long. If they put it in those terms parents would say okay, lets go easy on this. But nobody ever got that talk that i talked to anyway. The thing you reminded me of was i spent quite a bit of time at the Betty Ford Center which as you all know has a long history of treating all types of addiction, alcoholism in this country and it is really you can kind of chart the history of addiction in america at the Betty Ford Center, heroine, cocaine, and by the early part of 2003, 2005, all of a sudden the opioids, oxycontin, hydrocodone, vicodin, percocet. That is what is bringing the cases to them. So the administrator talked about the practice culture. He said i was at my dentist with an emergency tooth pulled and he writes me a prescription for like 30 days o days of whats ly vicodin or one of these drugs. He said what are you doing, you know what i do for a living and the dentist said i know, you dont have to fill it or take it but i dont want to get a call in the middle of the night that you are in pain, so there you go. That right there explains the enormous supply story. I used to believe when i lived in mexico that all drug problems began with demand and this book changed my mind completely. This was a supply story. It starts with supply and that his doctors prescribing like that or those that gave me 60 vicodin for my two or thre threh of appendix pain. If you multiply that by millions of doctors visits and millions of surgeries over a 20 year period, that is what creates this massive supply of opiates anbut then of course transitions to heroine. Can you talk about how easy it is to obtain a and availabily of heroine and pills in los angeles and how youv youd seet evolve over time . To the extent thankfully los angeles doesnt have the same level of the problem you are seeing in West Virginia and ohio and New Hampshire not to say we do not have a drug problem, but the deaths for example it is rampant in those areas and is relatively low here although we are starting to see them spread east to west and just a couple months ago sacramento had a state of overdoses in just a matter of a couple of weeks and again that has to deal with counterfeiting. You have this incredible powerful opiate, a penny is what it takes to kill somebody. Then you have counterfeit pills being created out of it. You go to a party and take whatever you get and think youre taking vicodin but its manufactured by a drug dealer in a basement and so you dont know what youre taking or how strong istrongit is or how safe it is o again, the ignorance of not only what Prescription Drugs are at the drugs your you are taking t somebody hands you. Im not sure if that answered your question but that is an interesting point i wanted to make. I did want to make another point which is the Insurance Industry was brought up and the Public Health Insurance Industry obviously not because of anything medicare or medicaid is doing wrong is fueling the black market for these drugs and that has outraged everybody here again not because they are doing anything wrong but because you have an industry of people in los angeles and other areas who are not drug traffickers or doctors, their involvement in this is to recruit medicare and medicaid patients to go to doctors, drug addicts, maybe steal the identities of elderly people and cases like that in exchange for a 100dollar cash kickback they get a prescription refilled and usually they are using the money for their own habits. So what we are starting to see our larger and more complex games that involve these recruiters com some of the beneficiaries, doctors, just mind blowing amounts of these pills, hundreds of thousands in the industry. Two weeks ago we conducted a doctor whose prescriptions were the number one cause of billings and medicare more than double the next doctor for scheduling drugs so you should be outraged because this is your taxpayer money going towards this end it is just so tragic and creates other issues for people. When i first started looking at this problem there havent been that many prosecutions. Its nearly impossible to convict somebody and drug dealing was the only flaw i lawe books at least at the federal level you have to go after. Has that changed at all . When i do trainings on cases i tell people who might be afraid these are some of the easiest cases we prosecute. A paper trail exists lefthand right. You can see every drug prescribed. Medicare and medicaid, bank records, doctors who are drug traffickers and businesses who runs the cash business. You are all over the place and then number two there is a very narrow range of conduct that is consistent with legitimate practice. Why are they doing twominute examinations. We have incredible tools for prosecutors and regulators as well which i think is even more important. One big area is pharmacies which are more difficult cases and a regular drug trafficker you prosecute a fungible business and someone can take their pla place. They have to be willing to commit a crime as opposed to making good money between people so there are fewer and fewer doctors doing this and now we have to turn our attention to the pharmacies and we do have an array of criminal tools and handling. There was a doctor in los angeles who was convicted of murder for continuing to prescribe despite rampant deaths of the prosecution. In the last couple of years we get those that need to be treated as such so we have a lot of tools in our toolkits that we have to use them. If you would say your first and last name. It will be broadcast by cspan at a later date. My name is todd kerner. There is a trend going on about drug testing people on public assistance. Twopart question, does it have a catch with Prescription Drugs and the second, does it highlight the incom income thatf these with regards to this epidemic as opposed to other ones . It would be hard to distinguish between a prescription opioid like morphine and heroin that quickly metabolizes. But it might not be able to distinguish these pin something youre taking legitimately which goes to the point it is all the same stuff when it gets down to the chemical level. So people that go in for public assistance to what extent is the epidemic affecting people who might be able to be dependent on public assistance i would say this affects people it affects white people. If we had paid attention in appalachia we wouldnt be in this position today and i was like 98, 99. But now from my book i was also in suburban charlotte, portland, salt lake, indianapolis, you are talking about people who were doing the best in the runup since the mid1990s with the economic expansions that we have had. The biggest question is why it is only white people in my opinion. I still dont have th a complete answer to why that is. Ive been racking my brain trying to understand it. Part of it has to do with doctors prescribing that ive met many black people that have received these drugs but its not. Part of it may have to do with cultural memory. In the 70s they were destroyed by heroine. They say that addiction is colorblind but in this case it is not. It is all over and its anyplace you find a white person. The role public assistance place in this epidemic people with medicaid and Medicare Coverage to me the homeless aree easily manipulated, if you have a government car you can get a prescription filled for a small copayment and you are valuable to drug dealers and become recruited, you are driven in a band probably get one chance were taketopartake into a corrur and a prescription is written in your name after you pass through the mail and youve turned a prescription over, you get your lunch, 100 sounds like a lot of people do it for less and then you are taken to the homeless shelter so thats the way that id seen public assistance play out in this particular epidemic. You are paying for drug dealers to get their source of supply. Thanks for an excellent panel i have a question for sam in particular. Its your booyour book is supero thank you. I would love if you could speak more in this area that exists raging the highly regulated official for Prescription Drugs and heroine. Youve spoken about medicaid and medicare into these are important planes. Why is there a market in suburban charlotte for this . You talked about medicaid, ssi, the market for the prescription opioids. It gets back to what some of us were saying about doctors accepting this idea they couldnt be prescribed with virtually no risk. That is what the companies did very well to convince an entire generation of drugs they knew were addictive and were not so. It was a magnificent piece of marketing. You have a massive supply in many parts of america and i agree medicaid and medicare were a big part of what happened but it was an entire generation. 1990 i think it was three times and the world supply of hydrocodone 99 was used in our country with similar figures accomplished through marketing. In some areas it is exacerbated by the overall its hundreds of thousands with some of the stuff you are talking about. I want to add we have heard a lot of stories and there are bad apples out there but a lot of this is just sort of participation in a system where we dont like the system decisionmaking and we could see that increasing in the next administration. We have a medical culture and insurance culture that doesnt like taking the evidence into account and forcing people to participate in a system like that then we will end up with a lot of prescriptions in part because they are bad apples and its important that we have Law Enforcement dealing with the bad apples but because thats the way we tell doctors to practice and that is the message we send in the way we structure the insurance and that is how we reward. He ought to have systems that pay people to take those calls and get the right incentives but that would take the reform of the Health Care System part of which obamacare was on the way to doing that we are going to see the problem worsening. I want to say anecdotally i do a lot of cases with addicted africanamericans for example until at least here in la i have not seen it exclusively limited to white people but maybe that is just the case in my purse bt it is a unique issue because it crosses every group and each group and class and is something i can see affecting everybody. We have seen for the first time in 75 years a turnaround of Life Expectancy for white people caused by this. And really not seeing it in the other racial groups. There was up paper that came out that showed this for the first time that was this reduction and that is the opium lead epidemic and is hitting white people in a particular way. If it was another racial group by dont know. We have a fairly lousy history but with this one theres something very dramatic going on. I am mainers practitioner and this is a great panel for the community. But i hear you talk about the doctor patient relationship so what about the nurses . They are pivotal in this fight they are the numberone educators one. Number one population of health care this set the forefront dealing with the patients i have heard that if you mention a nurse. My colleague at the paper interviewed the new Surgeon General of the united states. Earlier this month to drop the report of the problem and what our response should be which is the product of a lot of work. He worked in the same hospital since was of resident and he became Surgeon General the nurses who had known him for his whole career said one request per go do something about the Opioid Epidemic. Absolutely there on the frontline. They can write the script san they do work for the doctors to contribute to the problem and the solution to say that on the frontlines. And with that we will close the program. Thinks for joining us tonight and i invite everyone to join us for the reception after words and finally thanks to the panelists to share your thoughts. [applause] [inaudible conversations]