Abuses, and on Health Insurers who resent the coverage for six members. Welcome to a warm miss lisa to lisa. [applause] i want to just [laughter] introduce most of our panel. We are really lucky this evening to have a really Diverse Group that can speak to many aspects of this problem. Scholarwitz is a legal at ucla who is quiet a bit of research into the open epidemic and efforts to fix it. Of who has written many books. And has since written this amazing chronicle of this epidemic called dreamland. I highly recommend it. It is a really fabulous and touching and tragic book. Runs andooney addiction clinic at ucla and helps doctors learn how to cope with some of the victims of this epidemic. And she has also done research into some medication responses to the epidemic. And Benjamin Barron who i have watched an action is a federal prosecutor down in the courthouse in l. A. As an assistant u. S. Attorney, he has prosecuted doctors and drug rings, and gangs that moved drugs, and he has seen quite a dangerous risky and side of this problem, and has endeavored to try and attack it from the end. Saying, irt out by first began looking at the opiate epidemic is a Prescription Drug epidemic in 2010. I joined colleagues at the paper and began looking at the problem. Years, moret 15 than 200,000 people have died of drug deaths in this country. Are Prescription Drugs, prescription opioids, but increasingly, on heroin. They are closely linked, as sam continue about. There are 20 Million People currently addicted in this country to illegal and legal drugs. Only about 10 of them manage to get treatment. It is underfunded and just not that available. I wanted to stop the conversation by hearing from each of you, your perspective on what is the biggest part of the problem, or what driving or what is driving this problem . There are a lot of people who live in touched by this. Can you talk about that . What is going on with this problem are two things one, was heavily promoted as a nonaddictive drug. There we go. A cureall for a lot of pain. The difference between oxycontin and the opioids that it been used before, was there was no abuse before it. Vicodin, percocet all of these opioids had acetaminophen or tylenol. Cannot develop a healthy an unhealthy bad habit without destroying your internal organs. What i think undead because sobecause of the cotton was heavily prescribed, it had the effect of raising peoples there raising peoples tolerance to a level that was unsustainable because on the street after people had to turn to the these pills costed a dollar a milligram. Story is part of this back in the late 1870s, a lot of our heroin came from the far berlin, taiwan, etc. That is what the French Connection was all about. That change in the 1980s. On, heroin came from either columbia or mexico. And heroin is a commodity. It is not like red wine. The participant on how far you have to travel with it. Heroin was coming up from mexico and it was potent and cheap. The problem was no one paid attention to the change because he wrote it was not a problem in the early 1990s. Recognize how to big a deal it was when the geographics which happened. When the heroin from mexico and colombia outcompeted the heroin from the far east. A wisdom tooth extraction, pills for pain, 60 vicodin, 90 oxycontin. What you get is a huge number of addicts and looking for an alternative to very expensive pills, and the heroin coming from mexico for the colombian heroin provides that alternative. It is potent, cheap, and it is extraordinarily mortal and deadly. That is what we are seeing all across the country. It is a combination of those two historic changes that really created the heroin issue we have today all over the country. And where it is hitting most is in white families. Families and communities that are not used to this families in communities that are not used to this. And it is in the heartland, suburbs, rural areas. It is a very different thing and it is deadlier than any epidemic we have ever had. That the heroin and the pills can you talk a little bit about what lawenforcement is doing about this and what really you are playing right now, and how you are trying to attack this whether it is gangs, doctors, pharmacies . I will answer your first question. Basically, the reason the problem is so hard to tackle is is a multifaceted issue. There are so many heads you have to cut off. There is the issue of corruption with medical practitioners, negligence, and overprescribing these drugs and ignorance of the public of what these drugs are. Issue of the fact that you can stop doctors from prescribing these drugs, but you still have a black market of heroin addicts to deal with. , the abuse ofd the Prescription Drugs, heroin abuse has skyrocketed. Then you have the Public Safety issue. Fentanyl being imported from china. Unlike other opiates, fentanyl is purely synthetic. You can have super labs in china imported. Fentanyl is more powerful than heroin. Elephant tranquilizers are now being abused. And it is causing a massive deaths we are seeing when cut with heroin or counterfeited as pills in West Virginia and New Hampshire. We have a lot of different people between regulators and educators involved, and where Law Enforcement comes into play is obviously to turn corruption in doctors. With apt doctor prescription pad can sell as many Prescription Drugs as any gang. We are involved in the prosecution of this heroin importation and the fentanyl importation problem, and we cooperate very closely with regulators involved in deterring negligence among medical practitioners, and taking licenses, and disciplining were that needs to happen. To ok. Just wanted i need to go mics. I just wanted to followup on what sam was saying. I started out by saying that there have been 270,000 deaths with opioids. Sam has a good point. Kind of the genesis of all this, or closely linked in time to changes in medicine, and new drugs like oxycontin coming on the market in the late 1990s, that is where it starts. Window structure the market, there were 4000 approximate drug deaths every year. Now, theres upwards of 36,000 a year. 2009, as my colleague and i reported, drug deaths actually surpassed Car Accidents as a cause of mortality in this country. Industrialized, modern country, one of the huge goals is to drive down preventable deaths, right . That is why the of seatbelts, speed limits, childproof, right . Fors really unusual mcculloch health perspective, to look at mortality charts and see everything going down, right . Cancer, heart disease. Everything we can do something about, we are invested in that, and all of a sudden to see , very clearlyg up a byproduct of medicine and therapies, right . I need it again now . [laughter] most of the drug deaths actually involve prescription medications, but increasingly, they are involving heroin. Jill has think studied one of the responses as it snuck up on to setdy, was for states up Prescription Drug monitoring programs. You are as that if doctor writing one of these dangerous prescriptions to a is recovering from surgery, or a car accident, or has really bad pain, you want to make sure that person is in getting that same prescription from three different doctors. So, in most of the states, the idea is the pharmacy sends a of a prescription at is dispensed to a state agency, oftentimes the attorney general, and the doctor has access to a web interface, and is supposed to check to see what youre up to before he or she prescribes. Joe will tell us how that is working jill will tell us how that is working. One of the things that is interesting about this epidemic is that the states onto it pretty early, and there was a ton of activity. Paper in the journal of medicine last summer and i worked with a group an economist, dr. , and a lawyer worked on this paper because he wanted to cover all the facets of it. And the period we studied, there were 81 separate state laws passed to deal with opioid prescriptions and abuse. The one that gets all the liketion are things tamperresistants prescription pads. It used to be fairly easy to still a pad. Now there are special pads that say void if they get heat on them. They are preprinted, all kinds of things. States passed these laws and there was a lot of hope that they would make a difference. We studied a very tough population. We studied people who were primarily disabled and on medicare even though they were under 65 because they were disabled and could no longer work. Among that relatively small population, about two to 3 , they accounted for about 50 of opioid deaths. It is a population that is very hard hit. When we look at the passage of these laws, we are looking to find something. If you look at when the laws were passed on average and then look at the trend in , what youon abuse find is a slight slowdown in 2010. When you look at the states that passed the laws when they passed the laws and compare it to states that didnt, we found no effect for any one of these interventions at all. Be thaton here could maybe we had a particularly tough population, but we want to be really careful in how much money we throw at interventions that might not be working area our results were not welcomed by the cdc. Wey wrote a letter saying dont have research. Were going to keep trying and look at different populations, but this is not good news. Benjamin for this perspective of Law Enforcement, it is essential and has made a huge difference for us in taking pharmacists and doctors off the market. We dont know every instance when they sell drugs, but with the pdm p, you know every time a doctor has prescribed drugs. , so if ahe dosages doctors prescribing the same drugs and the same maximum dosages, we know if the patients are living miles away, if there are dangerous cocktails being prescribed together. It is essential, not just for medicalion, but for board regulators and pharmacy board regulators in combating the problem. Every time we get a conviction and the l. A. Times reports on it, it sends a message to doctors. Us want to emphasize how important the data is. I just want to emphasize how important the data is. Jill the states operate them very differently. Some states are in stating border controls. New england is particularly hard hit. It is not so hard to drive to New Hampshire to get the things your parents didnt want you to have. States are right next to each other there, so it could be working in some places and not and not inrea others. Lisa on the topic of imperfect solutions, this would be a Good Opportunity for you to talk about treatment options. I know i have spoken to way too who exhausted their Retirement Funds and mortgaged their homes and set a Family Member into treatment numerous times, only to have them relapse, overdose, recover, and in many cases, then finally die. There, and how well is it working . In terms of treatment, i view the most important element of treatment for this population, even more so than for other addictions, is prevention of overdose death because nobody can be engaged in rehabilitation and recovery if it has caused their death. The Gold Standard for treatment for opioid addiction, based on evidence that is emerging from research, is medication treatment. That doesnt mean that is the only type of treatment, and fact, a conference approach is very beneficial. We have different types of treatment and behavioral therapies and skills that are important to learn. Approved medications that are available to treat up we had addiction to treat opioid addiction are the Gold Standard. Methadone and naltrexone , and i can go to the differences between these medications, but essentially, norphineor seem bupe and methadone are opioids. Enorphine acts a little differently than some that we have been talking about. Methadone is a longacting opioid substitution therapy. What that means is you are giving a medication that can take the place and really break the cycle of intoxication with drawl intoxication, withdrawal, and a vicious cycle of addiction. These medications can stay in than 24em for more hours at a very steady level. It really can be lifesavers for many people. Individuals with opioid addiction to improve their functioning, the wallaby life, get their lives back their quality of life, get their lives back. There is a monthly injectable form that is longacting that seems to be a better option for people with opioid addiction. If you are on now tracks own if you are on now tracks own naltraxone, younl can stave off the effects. Naloxone can reverse overdose and has been used in ers for a long time. There is a Public Health movement for laypeople to have access to naloxone. Tosicians are encouraged prescribe naloxone so that a Family Member or loved one and use it in the case of a suspected overdose, because the benefits far outweigh the risks. I have a question for you, sam, but i want to throw out one more fact that i found very interesting. When we were really digging into the mortality statistics, what was really interesting for us that the population at greatest risk of death were the it wasnt kids seeking a thrill, it was people in their 40s or 50s. That is the hardest hit population in terms of mortalities from opioids. That gives you a sense of what we are dealing with. One of the solutions that people have talked about lately, particularly in the president ial the flow is stopping of heroin into this country from mexico. Or by building a wall improving the border. Youuld like to hear explain, as ive heard before, how the heroin got into the midwest, and what effect you think a wall might have on that. We absolutely need to do something about the heroine running from mexico. It is an outrage. The fact that most of our heroine comes from mexico had a lot to do with why donald trump one of very key states that were key to his victory. , people inylvania that area know where their heroimn is coming from. Heroin is a great traffickers drub traffickers drug because it is easy to conceal. You dont need a lot of space in , and to traffic heroin what most likely needs to happen is not a wall. We have a lot of walls on the border. Yards intoarts 50 the ocean and goes for 14 miles until it hits a big mountain. We have a lot of walls all around the border. We have them everywhere, but heroin walls wont stop heroin. They will stop stop people, but they wont stop heroin. Sincemand we have created the mid1990s across the united states, what will stop the flow of heroin is a mexico that starts to change in fundamental ways. I wrote two books about the country, and it seems to me that what we really need to do with regards to mexico is not not value its friendship above all things. We need to be in conversation with mexico and the constantly relating to mexico as one of our most important foreign relations. We need to be pushing them to do the kinds of changes that will make that country a place where people arent dying to leave, which is literally the case. When mexico begins to change and develop the kind of Law Enforcement capacity that canada has will we begin to see a modern partner. Believe,e get there, i is not by alienating and insulting and inflaming, what trump has done more than anything, and allow the elites of mexico to distract the population with those inflammatory rhetoric while they do nothing to change what is an essential component of a bilateral relationship. A mexico that has better Law Enforcement, a criminal justice system, so that cops here can call down to areas where they are growing heroin and be partners with their mexican counterparts. It exists to some degree, but not the degree it ought to. Example of perfect this. We could probably stop a lot of the marijuana and cocaine. Oin is so convinced will is so condense a bowl is so able, it is so easy. We need to treat them as neighbors and not as some kind of dysfunctional family. Wall hass on the inflamed that and has done nothing positive. Lisa with weve talked to a lot of doctors on this issue. Many doctors who were trained, up until recently, have all told me they were trained when they met with local school when they went to medical school, be really careful prescribing opioids. You have to weigh the risk of addiction with what youre patients are facing. Until the mid1990s, doctors were loads to prescribe opioids were loathe to prescribe opioids except in cases of internal pain or cancer. The humanity idea was expanded to include a much broader range of pain. The doctors prescribing tendencies shifted. It got to the point where opioidswere prescribing frequently for all types of pain, including gentle extractions and shortterm pain and all kinds of pain. Do you have ideas on how the transformation went from the 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, ill write you a prescription for an opioid russian mark opioid . Sure of all the historical and political reasons. Sam would be able to comment on that more. Recall in medical school exactly when the transformation occurred. It was pretty dramatic. Suddenly, doctors are under treating pain. We need to be more aggressive. I am not a Pain Management doctor, but in med school we were hearing exactly what was supposed to be done. Think the pendulum completely swung the other way, and now it is swinging back. Based on all the problems that have emerged, doctors were told that opioids for pain are both effective and has minimal risk of addiction in patients with pain. We are learning that that is not true. Much of the research is showing that opioids are actually i want to make the point, they are valuable medications. A are highly effective for acute pain. We need these medications. If you have a surgery or an injury, they are highly effective. But their efficacy for chronic pain and longterm use in the management of chronic pain is being questioned. The risks are very clear. Guidelinesre new shifting back to needing new approaches to manage pain and considering nonopioid medications, physical therapy, and even Cognitive Behavioral Therapy to cope with pain. Hopefully we see a return of more conference of pain clinics to manage t