Excellent place to go. Dave barry has several books, the greatest hits and best state ever, a florida man defends his homeland. Watch in depth live sunday from noon to 3 00 p. M. Eastern on book tv on cspan 2. Next a look at opiod addiction in the u. S. Speakers include the director of an addiction medicine clinic in california. From zokolo Public Square this is an hour. And now its my great pleasure to introduce tonights moderator, ms. Lisa garian, a Top News Editor for americas aters. As a former investigator reporter at the Los Angeles Times she worked on a series of stories that corrected connected drug related deaths to the doctors that with her team that filled them and focused on perdue phrma which failed to include risk factors for addiction as well as evidence of illegal Drug Trafficking. Shes won awards for her exposes on alleged human rights abuses in myanmar and Health Insurers who rescinded coverage for sick members. Please give a warm welcome to miss lisa girian. [applause] i want to introduce the rest of our panel. Were really lucky to have a Diverse Group who can speak to many aspects of this problem. Jill horowitz is a legal scholar at ucla who has done quite a bit of research into the opiod epidemic and efforts to fix it. Sam kinones, a fabulous reporter and journalist who i worked for at the paper and had written many books, has since written an amazing chronicle of this epidemic called dream land. And if you havent read it, i highly recommend it. Its a really fabulous touching and tragic book. Larissa muni runs an addiction unit at ucla and helps doctors cope with some of the victims of this epidemic and shes also done research into some medication responses to the epidemic. And ben baron who i also watched in action is federal prosecutor here in the courthouse in l. A. And as an assistant u. S. Attorney these prosecuted doctors and drug rings and gangs that move drugs and hes seen quite a bit of the risky and dangerous side this problem and endeavored to try to attack it from that end. Ill start off by saying i first began looking at the opiod 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 on Prescription Drugs and prescription opiods but increasingly on heroin and closely linked, as i think sam can tell you about. There are 20 Million People currently addicted in this country to both legal and Illegal Drugs and only about 10 of them manage to get treatment. Its underfunded and just not that available. I wanted to start the conversation by hearing from each of you your perspective on what is really the biggest part of the problem with driving his problem. [inaudible question] i think whats gone on with this problem is two things. , it was contin heavily promoted as virtually nonaddictive in the mid 1990s as sort of a cureall there you go. Weird echo there. A cureall for a lot of pain. The difference between oxycontin and the opiates which have been used before is there was no abuse with it. There was no vicadin or percocet or all these opiates, they have acetaminophen or tylenol and you cant develop an unhealthy bad habit to them without destroying your internal organs. Oxycontin had none of that. What it did was because it was so widely prescribed, massively prescribed all across the country, it had the affect of raising people, who got addicted, raising their tolerance to a very high level, level that was really unsustainable because when people had to turn to the ended up se pills costing a dollar milligram and youre talking people using 200, 300 milligrams a day and is unsustainable. In ther part of the story the late 1970s, a lot of the eroin came from the far east from turkey and thailand and etc. , etc. , thats what the cases were about and all those cases. That changed in the 1980s. Hen all the heroin came from mexico or colombia. Its not like red wine or marijuanaa. It really the price depends on how far you have to travel with it and this heroin is coming up from mexico was potent and cheap. The problem was nobody paid attention because heroin wasnt a problem and we only grew to recognize how big a deal it was, this geographic switch that happened. The heroin from mexico and colombia outcompeted the heroin in the far east when we began to create more opiate addicts with the massive prescribing of pills, pills for every kind of pain and wisdom tooth extraction and not just a few but 60 vicadin and 0 oxycontin and huge amounts of these pills and what you get is a huge number of addicts and looking for an alternative to very expensive pills and the heroin coming from mexico or the colombia heroin provides that alternative. Its potent and cheap and extraordinarily mortal. And deadly. And that is what were seeing across the country. The combination of those two historic kind of changes that created the heroin issue we have today all over the country and where its hitting most is in white families, families in communities that are not used to this, families not prepared for this and really didnt believe they did anything to deserve this and its in the heartland and suburbs and rural areas and is a very different thing and deadlier than any epidemic weve ever had. So i think that the heroin is a good and the pills, can ou talk a bit about what the Law Enforcement is doing about this and what role youre playing now and how youre trying to attack this, whether its gangs or doctors or harmacies . Ill answer your first question about scope of the problem and how Law Enforcement fits into it. The reason the problem is so big and hard to tackle is it is a multifaceted issue and theres so many heads you have to cut off and theres the corruption of medical practitioners, ignorance of the public about what these drugs are, that strike continue and oxy codoan are alopted allotted and heroin and the fact you can stop doctors from prescribing these drugs but you have a black market of heroin addicts to deal with and why as we plateaued the abuse of the Prescription Drugs over the last three or four years, heroin abuse has skyrocketed exponentially and you have the Public Safety issue of fentanyl and imported from china you can have superlabs import it and its 50 times more powerful than heroin and leading to mass amounts of death and there are analogs of are more powerful and causing the massive deaths were seeing when cut as heroin and counterfeited as pills in West Virginia and New Hampshire. We have a lot of different people involved and where Law Enforcement comes into play is obviously deterring corruption and doctors and a corrupt doctor with a prescription pad can sell as much heroin in the pill form as any gang and pose as a massive part of this problem. We also, obviously, are involved in the interdiction and prosecution of the heroin importation and the fentanyl importation problem and cooperate very closely with regulators involved in deterring negligence among medical practitioners and taking licenses or disciplining here that needs to happen. I tried to follow up a bit on what sam was saying. I started out by saying there have been 200,000 deaths attributed to opiods, believe it or not, over the past 15 years. But sam makes a good point, kind of the genesis of this or its closely linked in time to changes in medicine and new drugs like coxy coten coming on he market in the late 1990s with oxycontin coming on the market in the late 1990s. There were approximate 4,000 drug deaths every year when they hit the mark and had been very flat. Now theres north of 36,000 a year. And in define as my colleagues and i reported, drug deaths surpassed Car Accidents in 2009 as a source of mortality in this country. And in an industrialized moderate country one of the huge goals is to drive down preventative deaths and why we have seat belts and speed limits and childproof pill caps, right . And its really unusual as i think jill noticed from a Public Health perspective to look at mortality charts and see everything going down, cancer, heart disease, everything we can do and were 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, right . Most of the i need it again . Most of the drug deaths are actually involved Prescription Medications but increasingly theyre involving heroin. With that, i think its a big attempt to talk to jill. Jill has studied, one of the as it s to this crisis snuck up on everybody was for estates to some of them were very old well go back to the 1930s but others have within started recently to set up things called Prescription Drug monitoring programs and the idea is that if youre a doctor writing one of these dangerous prescriptions to a patient who has is recovering from surgery or car accident and has really bad pain, you want to make sure that person isnt getting the same prescription from three different doctors and is either addicted and selling them to a Public Health problem. So i think in most of the states and jill can tell us more about it. In most of the states the idea is that the pharmacy sends a record of a prescription thats dispensed to a state agency, oftentimes the attorney general, and the doctor has access to that through a web interface and is supposed to check to see what youre up to before he or she prescribes. Jill will tell us how thats working. Jill one of the things interesting about this epidemic is that the states are on to it pretty early and there was a ton of activity. My colleagues published in the new england journal of medicine and worked with a group, is sounds like the beginning of a joke, a doctor, a economist, a librarian and me, a lawyer, and we worked on the paper to cover the facets of it and in the period we studied from 20062012 there were 81 separate state laws passed to deal with opiod prescriptions and abuse. And the one that gets all the attention, these pdmps and also things like tamper resistant prescription pads. It used to be fairly easy to steal a pad and fake prescriptions, now there are special pads that say void if they et heat on them or have certain number of signatures and the states passed laws that would make it hard to do. And we studied people who were permanently disabled and on medicare though they were under 65 because they were disabled and could no longer work. And among that population which is a relatively small population of the u. S. , about 2 to 3 , maybe a little over 3 now, they accounted for about 50 of the opiod deaths. Its a population thats very hard hit. And when we looked at the passage of these laws, we were thinking we were going to find something because if you just look at when the laws were passed in average and then you ook at the trends in prescription abuse, all these things, what you find is a slight slowdown in 2010. But when you look at the states that passed the laws when they passed the laws and you compare it to states that didnt we found no affect for any one of hese interventions at all. The lesson we could have is we had a tough population but we have to be careful. The results werent welcomedly the c. D. C. And wrote a letter saying we did Lousy Research and we wrote a letter saying you have to take the bad news, too, because you have to learn from this. Well keep trying and looking at different populations but this is not good news. That research is important but from the perspective of Law Enforcement and regulators, pmdp information is essential difference in taking pharmacies and doctors in the market. Tell people how you use that data tell people how you use that data. In Drug Trafficking, we dont know when they sell drugs but with pdmp you know every time a doctor has prescribed drugs that have been filled at a pharmacy in california and we know the dosages so if the doctor is prescribing the same drugs or mass of dosages and we know if the patients are living miles away or the cage reduce cocktails of sedatives are being prescribed together and its essential not just for board ions but medical regulators in taking care of the problem and every time we get a conviction and the l. A. Times reports on it, it sends a message to doctors as well so i have to imagine it has had a effect even for negligence. I want to emphasize how important the data is. The pdmp is not a pdmp. States do it differently and statesman date cross border checks of these and makes a dig difference. Not so much in california, its a big state and not so easy to get. But in states where we have a big problem, new england is particularly hard hit, its not so easy or not so hard as i learned growing up in massachusetts to drive to New Hampshire to get the things the parents didnt want you to have. States are right next to each other there so it could be working in some places and not in others. On the topic of imperfect solutions this would be a good opportunity, dr. Muni, for you to talk about treatment options. I know i have spoken to way too many families who exhausted their Retirement Funds and mortgaged their homes and, you know, sent a Family Member into treatment numerous times only to have them relapse, overdose, recover a and in many cases then finally die. So whats out there . Nd 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 Deaths because nobody can be engaged in rehabilitation and recovery f their illness caused their death. The Gold Standard for treatment for opiod addiction based on evidence emerging from research is medication treatment. That doesnt mean its the only type of treatment in effect, often a comprehensive approach is very beneficial. We have different types of treatment and behavioral therapies and skills that are important to learn. But the f. D. A. Approved medications available to treat opiod addiction are considered the Gold Standard and we have methadone and now trexdone and i can go into the differences of these medications but bufanofene and methadone, some can be aware are opiods. Bufanorphine has partial activity and acts differently than some of the other opiods weve been talking about. And methadone is a longacting both of them are longacting adam oid opiod substitution therapies. What it means is youre giving a medication that can take the place of and really break the cycle of intoxication, withdrawal, and chasing the high and then trying to recover from the low. Its a vicious cycle of addiction and these medications can stay in the system for more than 24 hours at a very steady level and really can be lifesavers for many people. They can allow individuals of opiod addiction to improve their functioning and quality of life, get their lives back. Now, trexone is an opiod blocker and there is a monthly injectable form thats long acting that seems to be a better option for people with opiod addiction and basically if youre on trexone and use an opiod, the effects are blocked. So these are the medications that are available. Another important issue to narcan, a aloxone, medication that rapidly can reverse opiod overdose and has been used by medical personnel, e. R. Set fogs a long time and now theres a Public Health movement for lay people to have access to naloxone so anybody at risk for an overdose, physicians are encouraged to provide naloxone so a Family Member or loved one could use it in the case of a suspected overdose because the benefits ar outweigh the risks. I have a question for you, sam but want to throw out another fact i found interesting. Several years ago when we were really digging into the deaths, the mortality statistics again and what was really interesting for us was that the population at greatest risk of death, where the greateth death rates were, it wasnt kids as you might imagine, you know, seeking a thrill but it was people in their 40s and 50s and thats the hardest hit population in terms of mortality from open oids and gives you a little sense of what were dealing with. One of the solutions theyve talked about lately, especially in the president ial campaign, is stopping the heroin coming from mexico and building a wall. Tell us a little bit id like to hear you explain as i heard you before how the heroin kind of got into the midwest and what effect a wall might ave on that. We absolutely need to do something about the heroin coming from mexico. Its an outrage, honestly. And i think the fact that most of the heroin comes from mexico had a lot to do with why donald trump won very key states that were key to his victory, ohio being one, pennsylvania another, people in that area know where the heroin is coming from and not too happy with it and i think the openities played a big part in that. Opiates played a great part in that. Its a great traffickers drug because its easy to steal and not because marijuanaa or cocaine is very bulky, you dont need a lot of space in which to traffic heroin. And therefore what really most likely needs to happen is not a wall. You have a lot of walls on the border. Tijuana and san diego, we have two walls and one that starts 50 yards in the ocean and goes for 14 miles until it hits a big mountain. But we have a lot of walls around the border. We dont have walls everywhere. But heroin walls i dont believe will stop heroin. They will and have stopped people in fact but wont stop heroin. Particularly when you have the size of demapped weve created since the mid 1990s across the united states, what will stop flow of heroin is a mexico that starts to change in fundamental ways. Mexico faces i lived two years in mexico and wrote two books about the country. It seems to me what we really need to do with regard to mexico is not alienate it but also not value its friendship above all things. We need to be in conversation with mexico an