addiction medical director and sam quinones, author of "dreamland." this is just over an hour. >> and now it is my great pleasure to introduce two nights moderator, ms. lisa girion. lisa girion is a top news editor for the americas at reuters. as a former investigator reported at the "los angeles times," she worked on a series of stories that connected drug-related deaths to the doctors who wrote prescriptions and the pharmacies filled them. her team also recorded on oxycontin producer purdue pharma which failed to disclose risk factors for addiction as well as evidence of illegal drug trafficking. she has won awards for exposés on alleged human rights abuses in myanmar and on health insurers who rescinded coverage for sick members. please give a warm welcome to ms. lisa girion. [applause] >> i want to just -- can you hear me? now it's back. i want to introduce the rest off her panel. we are really lucky this evening to have a really diverse group that can speak to many aspects of this problem. jill horwitz is a legal scholar at ucla who's done quite a bit of research into the opioid epidemic and efforts to fix it. sam quinones who i work with at the paper and have written many books, has since written an amazing chronicle of this epidemic called "dreamland." and if you haven't read it, i highly recommend it. it's a really fabulous and touching and tragic book. larissa mooney, dr. larissa mooney, runs and addiction clinic at ucla and helps doctors learn how to cope with some of the victims of this epidemic, and she's also done research into some medication responses to the epidemic. and then bayer they are not also watched in action is a federal prosecutor -- benjamin barron -- in the courthouse in l.a., and as an assistant u.s. attorney he has prosecuted doctors and drug rings and gangs that move drugs, and he has seen quite a bit of the risky and dangerous side of the problem, and has endeavored to try and attack it from that end. i'll start out by saying, i first began looking at the opioid epidemic as a prescription drug epidemic in 2010. 2010. i joined some colleagues at the paper and begin 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, prescription opioids, but increasingly on here when. they are closely linked i think sn can tell you about. there are 29 people currently addicted in this country to both legal and illegal drugs. and only about 10% of them managed to get treatment. it's underfunded and just not that available. i wanted just to start the conversation by hearing from each of you your prescriptive -- what's the biggest part of the problem or what's driving this problem -- [inaudible] a lot of people have been touched by this. can you talk about that and what brings people -- >> i think what's going on with this problem is two things. one is, oxycontin. we would not have a heroin problem in this country without oxycontin. oxycontin was heavily promoted as a nonaddictive drug. -- [inaudible] there we go. weird echo. a cure-all for a lot of pain. the difference between oxycontin and the opiates, even this is been used before was that there was no abuse to start with. there was no, vicodin, percocet, all these opiates, so you can't really develop a healthy, and unhealthy, a bad habit through them without destroying your internal organs. oxycontin had none of that. what oxycontin did was, because it was so so widely prescribed, massively prescribed all across the country, it had the effect of raising people who got addicted, raising their tolerance to a very high level, a level that was really unsustainable because on the street after people had to turn to the street -- do you want me to use that? people had to turn to the street, it ended up costing a dollar a milligram. you're talking people using two, 300 milligrams a day. that's unsustainable. the other part of this story that's important to understand is back in the 70s, a lot of our heroin came from the far east, from turkey, burma, thailand, et cetera, et cetera. that's what the french connection is all about and all those heroin cases. that changed in the 1980s. all our heroin from the 1980s on came from either columbia or mexico. and heroin is a commodity. it's not a varietal like red wine or marijuana. it obeys, it really, the price depends on how far you have to travel with it. and as heroin that was coming up from mexico was potent and cheap. the problem was no one paid any attention to this change when it happened because heroin was not a problem in the 1980s, early 1990s. we only grew to recognize how big a deal it was, this geographic switch that happened, how to heroin from mexico and colombia basically outcompeted the heroin from the far east when we begin to great new opiate addicts with this massive prescribing appeals, pills for every kind of pain, pilfering wisdom tooth extraction not just a few pills but 60 vicodin, 90 oxycontin, huge amounts of these bills. what you get than is a huge number of addicts and looking for an alternative to very expensive pills, and the heroin coming from mexico or the colombian heroin provides that alternative. it's potent, cheap, and it is extraordinarily mortal. deadly. and that is what we are seeing all across the country. it's the combination of those two historic changes that really created the heroin issue that we have today all over the country. and where it's hitting most is in white families, families and communities that are not used to this. families that were not prepared for this, believe they really didn't do anything to deserve this, and it's in the heartland, suburbs, rural areas. it's a very different thing and it's also deadlier than any epidemic we have ever had. >> i think that the heroin is a good, and the bills, can you talk a little bit about what law enforcement is doing about this and what role you are playing right now, and now you're trying to attack this, whether it's gangs or doctors or pharmacies? >> i'll answer your first question, how law-enforcement fits into it if you don't mind. but basically one of the reasons this problem is a big right now and so hard to tackle is that it really is a multifaceted issue. are so many different heads to cut off. there's the issue of corruption in medical practitioners, negligence and over prescribing these drugs, england of the public of what these drugs are, that vicodin and oxycontin are -- the fact you can stop doctors from prescribing these drugs but you still have a black market of heroin addicts to deal with, which is why as we plateaued the abuse of the prescription drugs over the last three or four years, heroin abuse has skyrocketed exponentially. then you also the public safety issue, fentanyl, being imported from china. fentanyl unlike other opiates is purely synthetic which means you can have a super labs and china come in mexico import it and fentanyl is 50 times more powerful than heroin. it's leading to mass amounts of death and the are analogues of fentanyl that are more powerful, elephant tranquilizers that are being abuse and causing a 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 deterring corruption in doctors, corrupt doctor with a prescription pad can sell as much heroin as any gang and poses a massive part of this problem. we also are involved in the interdiction and prosecution of the heroin importation and they fit no importation problem, and we cooperate very closely with regulators involved in determining negligence among medical practitioners and taking licenses or disciplining where that needs to happen. >> so i just wanted to -- okay. i need to microphones. i want to follow up on what sam was saying and what i said at the beginning. i started out by saying there than 200,000 deaths attributed to opioids, legal and illegal over the past 15 years. what sam has a good point. kind of the genesis of all this or it's closely linkedin time at least to changes in medicine, and new drugs like oxycontin coming on the market in the late '90s. that's where it starts. when those drugs hit the market there were 4000, proxima, drug deaths in the united states every year. now there's north of 36,000 a year, and in 2009, as my as my colleagues and i reported, drug deaths actually surpassed car accidents as a source of mortality in this country. in an industrialized, modern country, one of the huge goals is to drive down preventable death, right? that's why we have seatbelts. that's why we at speed limits and childproof hellcats, right? it's really unusual -- hellcats -- as jill has noted to look at mortality charts and see everything going down, cancer, heart disease, everything we can do something about we are working, all of this and that is that ellison 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 involve prescription medications, but increasingly they are involving heroin. with that i think this with a good time to talk to jill. jill has studied, one of the responses to this crisis as it snuck up on everybody was for states, some of them were, set up things called prescription drug monitoring programs. the idea is that if you're a doctor writing one of these dangerous prescriptions to a patient who has, is recovering from surgery or a car accident or has really bad pain, you want to make sure that that person isn't 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, and jill can tell us more about it come in most of the states the idea is that the pharmacy sends a record of a prescription that's 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 you're up to before he or she prescribes. jill will tell us how that is working. >> one of the things that's interesting about this epidemic is that this dates were onto a pretty early and there was a ton of activity. my co-authors and i published a paper on this in "the new england journal of medicine" last summer. i worked with a group, it sounds like the beginning of a joe, an economist, a doctor, a librarian and me, a lawyer worked together on this paper because he wanted to get, cover all the facets of it. in the. we study from 2006-2012, there were 81 separate state laws passed to deal with opioid prescriptions and abuse. the one that gets all the attention, things like tamper-resistant prescription pads. it used to be fairly easy to steal a bad and fake prescriptions. now their special pads that safy void if they get heat on them or you have to be certain number of signatures, preprinted, and those states pass these laws and does a lot of hope they were going to make a difference. we studied a very tough population can we studied people who were permanently disabled and on medicare, even though they were under 65. because they were disabled and couldn't -- could no longer work. among the population which is relatively small population of the u.s., about two to 3%, they account for about 60% of the opioid deaths. it's a population that is very hard hit. when we look at the passage of these laws we were thinking we are going to find something because if you just look at when the laws were passed on average and then you look at the trends in prescription abuse, what you find is a slight slowdown in 2010. but when you look at the states that passed the loss when they passed the laws and you convert to state that didn't, we found no effect for any one of these interventions at all. so the less -- the lesson here could be that we had a particularly tough population but we want to be careful about how much money we thought interventions that might not be working. our results were not welcomed by the cdc. they wrote a letter saying we had done a lousy research. we wrote back and said yet to take the bad news, too, because we have to learn from this. we are going to keep trying, look at different populations, but this is not good news. >> i just want to make sure, that research is important but from the perspective of law enforcement and regulators, data is essential and it is made a huge difference for us in taking extremely bad actors, pharmacy and doctors come off the market. what anyone to come out of this -- >> tell people how you use that data. >> if we're prosecuting again for drug trafficking, we don't know every instance they sell drugs but with apd mp you know every single time a doctor has prescribed drugs that's been filled at a pharmacy in california or whatever state is running that. we know the dosages so that the doctors arts prescribing the same, we know if patients are living miles away we know dangerous cocktails of narcotics and senses are being prescribed together. it's essential notches or prosecutions but for medical boarboard regulators and pharmay board regulators in combating the problem. of course every time we get a conviction at the "l.a. times" report on it that sends a message to doctors as well. i have to imagine it's had a different effect even for negligence. i just want to emphasize just how important the data is. [inaudible] >> and that pdmp is not a pdmp, is not a pdmp. the states operate within very differently pick some states are beginning to mandate cross-border checks of these and that makes a big difference, not so much in california, it's a big stick because that's so easy to get across the board abut and place it will get some of the biggest problems like to england as a good hard hit, it is not so easy or not so hard as i learned growing up in massachusetts to doctor new hampshire to get the think your parents didn't want you to have, right? states are right next to each other. so could be working in some places and not in others. >> so i thought on the topic of imperfect solutions this would be a good opportunity, dr. mooney, for you to talk about treatment options. i know i've spoken to way too many families who exhausted their retirement funds and mortgaged their home and sent a family member into treatment numerous times, only to have them relapse can overdose, recover, and in many cases then finally died. so what's out there and how well is it working? >> so 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 their illness has caused their death. the gold standard for treatment for opioid addiction based on evidence that's emerging from research is medication treatment. that doesn't mean that's the only type of treatment. in fact, often accompanied to approach is very beneficial. we have different types of treatment and behavioral therapies and skills that are important to learn, but the fda approved medications that are available to treat opioid addiction are considered the gold standard. we have methadone and naltrexone, and i can go into a little bit about the differences between these medications but essentially given offering an methadone some may be aware of opioids. buprenorphine is let's call it, has partial activity and axl bit differently than some of the other opioids we've been talking about. an methadone is a long acting, both of them are long acting opioid substitution therapies. what that means is your getting a medication that can take the place and really break the cycle of intoxication withdrawal and chasing the high and then trying to recover from the low. that's a vicious cycle of addiction. 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 opioid addiction to improve the functioning, their quality of life, get their lives back. naltrexone is an opioid blocker and there is a monthly injectable form that's long acting that seems to be a better option for people with opioid addiction. and basically if you're on naltrexone and use an opioid effects are blocked. so these are the medications that are available. another important issue to discuss is my locks on narcan which is a medication that can rapidly reverse opioid overdose and has been used by medical personnel, er settings for a long time another public health movement for laypeople to have access to my locks on. but his risk of an overdose, physician are encouraged to prescribe naloxone so that a family member or a loved one, a friend could use it in the case of a suspected overdose because the benefits far outweigh the risks. >> great. i have a question for you, sam, the first i want to throw out one more fact that i found very interesting several years ago when we were really digging into the mortality statistics again. and what was really interesting for us was that the population at greatest risk of death where the greatest desk -- death rates were, it wasn't kids as you might imagine seeking a thrill but it was people in their 40s and 50s. that's the hardest hit population in terms of mortality from opioid. so package you a little sense of what we're dealing with. sam, one of the solutions that people have talked about lately, particularly in the presidential campaign, is also just stopping interdicting the flow of heroin into this country from mexico, and by building a wall or improving the wall. tell us a little bit, i would like to hear you explain as i've argued before how the heroin kind of got into the midwest, and what effect you think a wall might have on that. >> yeah, i mean, we absolutely need to do something about the heroin coming from mexico. it's an outrage honestly. i think the fact that most of our heroin comes from mexico had a lot to do with why donald trump one very key states that were key to his victory. ohio being one pennsylvania another. people in that area know where the heroin comes from and are not too happy with it. one of the opiates played a big part in that. heroin though it's a great traffickers and drug because it's easy to conceal. it's not like marijuana which is a bulky or cocaine that is very bulky. you don't need a lot of space in which to traffic heroin. and, therefore, what was most likely needs to happen is not a wall. we have a lot of lost actual on the border. around san diego to welcome one the start 50 yards into the ocean, goes for 14 miles until it hits a big mountain. but we have a lot of walls all around the border. we don't have walls everywhere but heroin, walls i don't believe will stop heroin. they will stop people. they have stopped people in fact but they won't stop heroin. and ticket when you have the size of the men we have created since the mid 1990s across the united states. what will stop the flow of heroin is a mexico that is beginning, that starts to change in fundamental ways. mexico faces, i lived 10 years in mexico, wrote two books about the country, and it seems to me that 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 and we need to be constantly using, relating to mexico as one of our most important foreign relations. but we need to be pushing them to do the kinds of changes that will make that country a place where people are not dying to leave, which is literally the case. only when mexico begins to change and develops the kind of law enforcement capacity that say canada has, what we begin to see kind of a modern partner. the way we get there i believe anyway is not by alienating and consulting and inflaming, really what trump has done is really more than anything, and allow the elites of mexico to to start the population with his inflammatory rhetoric while they do nothing to change what is an essential component of a bilateral relationship, which is a mexico that has better law enforcement, a criminal justice system worth the name so that cops here can call down to areas where they are growing heroin and be kind of partners with their mexican counterparts. that does not exist, it exists to some degree but not to the degree it ought to. the problem with heroin is a perfect example of this because we could probably stop a lot of the mirror when. we could probably stop a lot of the cocaine. heroin is so compensable, so small. a pound a very, very potent heroin could be smuggled across the border very easily and cut into, step and five times and it still extraordinarily potent. we need to understand that in order for that to change, mexico needs -- we need to treat them as neighbors and not as some kind of like a dysfunctional family, that kind of thing. this focus on the wall has inflamed that aniston will i don't believe anything positive in that regard. >> we talk a lot with doctors obviously in our reporting on this issue, and many doctors who were trained up until very recently, they've all told me they were trained when you went to medical school, you know, be really careful prescribing opioids. they are addictive and you really have to weigh the risk of addiction with what your patients are facing. and until the mid '90s, doctors really were loath to prescribe opioids for anything but people in terminal pain and with cancer. and those cases the calculus was well, they're either going to die, so addiction isn't a problem, or is not humane to let people suffer with cancer. the humanity idea was expanded to include a much broader range of pain. the doctors prescribing tendencies shifted. but how does, but it got to the point where doctors were prescribing opioids quite frequently for all kinds of pain, including dental extractions and short-term pain, all kinds of pain. doctor, do you have ideas on how the transformation went from stay way from opioids, they are very dangerous, you don't want to get your patient addicted, two oh, you're going to have a twofold, i'll write you a prescription for an opioid? >> i'm not sure of all of the historical and political reasons behind. i think sam can comment on that more but i do recall a medical school exactly when that transformation occurred. it was pretty dramatic. it was suddenly pain is a sign, doctors are under treating pain. we need to be more aggressive. i'm not a pain management doctor, but in med school we were hearing exactly what was supposed to be done. i think the pendulum completely swung the other way, and fortunately now it is swinging back. based on all the problems that have emerged, doctors were told actually that opioids for paint are both effective and have minimal risk of addiction in patients with pain. so we're learning that that is not true. much of the research is showing that opioids, they are actually, i do want to make a point. opioids are a valuable medication appear highly effective for acute pain. we need these medications. if you have a surgery or an injury, for acute pain they are highly effective, but their efficacy for chronic pain after long-term use in the management of long-term pain are now being questioned, and the risks are very clear. now there are new guidelines shifting back to we need new approaches to manage pain and please consider non-opioid movement therapy, non-opioid medications, physical therapy and even cognitive behavioral therapy to cope with pain. hopefully we will see a return of more comprehensive pain clinics to manage these problems. >> i think a lot of it had to do with us. i thought when i started my book that is writing a book about drug traffickers and drug trafficking. really what it became was a book about america and who we have become. we became, particularly i was after, the end of the cold war, the '90s and so on, a country that loved, that loved to kind of exalt the private sector. we became a country where people were applauded for making lots of money, even though maybe the way they made their money didn't do much for the community. we kind of savaged government. we exalted the private sector and we became a country that really above all wanted comfort, convenience, and a lack of pain. you can see this and a lot of ways i think. we have padded playgrounds because god for bid our kids skin their knees, right? we have trophies for everybody because, god for bid, should feel left out. we don't want our kids to feel pain. now they're asking for in college, they're asking for trigger 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, from physical pain to to emotional. doctors i believe were seeing this. particularly in the 1990s. patients would come to them and say, doc, i just can't have anything. people begin to believe that we really could not suffer any pain at all. so that's when we began to, not just prescribed these bills for some kind of ailments, but prescribed massive dosages. we believe they were virtually not addictive. even after acute pain, i had my appendix how can i get 60 vicodin. that was a pain is going to last three days. i got 30 days worth of dope, right? we became also i think the country that went indoors and when isolated ourselves. this is a story about isolation. it's about the end of community and isolation in america. it's about, the hallmark of the crack epidemic was the crack house, a public house, usually a place that i think they can overcome our rental or what have you, i covered this when i was a crime reporter in stockton early in my career. the hallmark to this epidemic is the private bedroom, this bedroom that is a hallmark of kind of the site of our great prosperity as a country, the place for every mother wishes her child should be. don't be outside, there's child molesters, someone's going to hurt you outside. stay indoors. it's in the private bedrooms where kids are hiding their dope, shooting up and dying. doctors i believe picked up on this. they begin to see this insistence when we won to have no pain at all. doctors were the vectors for the sole problem, but my feeling that really what started this was all of our come help consumers, americans in general believing that we'd won the cold war, it was time to get back, you know, huge cars, huge houses, huge halloween candy. do you see what halloween candy looks like now? its massive because kids can't possibly not have -- there would be unhappy if they didn't get a full snickers bar every house they went to. i think this is all part of what this story honestly and why doctors felt such pressure pick all of a sudden they are getting pain specialist telling them yes, we now know that opiates from the opium poppy, the oldest medicine we know of is we now know these drugs are not addictive when used to treat pain so go right ahead. that's what they did. they went right ahead. it was all wanting to be non-accountable for our own consumer choices, our own choices of a variety of sorts that push them in that way. i think that's kind of what led us to where we are today. this is not a story about dope. this is a story about who we are as a country, who we are as americans and what we think will lead us to happiness. >> one of the things i haven't heard as discussed yet is some of the systemic drivers of why doctors prescribed in this amount in these kinds of drugs. we have to look at what our insurance system is and how doctors get reimbursed. it's very hard to get reimbursed an adequate amount for your time to do the kind of slow, careful intervention to do alternative treatment for pain. even though some of them have been shown to be quite effective. the insurance system tells our doctors through reimbursement to write the prescription. it furthermore tells the doctor to write a prescription for a lot of pills because you don't do so well at the patient keeps coming back. that takes a lot of time. i think there are some fixes we could easily put in what we set up a system where you get a certain number of pills and you calling to get a certain number of more. would solve -- that would not solve the problem but it would slow down some things. there are some systemic changes we can make. i'm not sure i agree with you about the candy bars and all, but -- laugh i do agree about some of the cultural drivers of this. our practice patterns in medicine that it showed up in all kinds of treatments. if you look across the country that are really different levels of prescription, really different kinds of treatments for the same illnesses, and that has to do with the culture of practice. ironically, this is a problem, a prescription drug problem is a robber of white america, one of the few ways in which racism has helped minority groups because doctors won't prescribed them, the prescriptions to people of color. so in some respects they have been saved from some of this. those are cultural, the cultural causes of some of this problem really need to be looked at from the doctor and, from the patient and, from the community and pick and i think probably larissa is the person who can speak directly about this. i think we need to think as a culture, what happens in our society that makes an 18-year-old take our grandmothers pills from the medicine cabinet? what's happening at this point in time that someone doesn't that when it wouldn't otherwise do that? i know a large part of bob of people get addicted, they get treated and then there on this stuff. but what about all these young people come in some states people being harder hit than in others but what makes people so desperate that they think okay, between this and that, i choose reaching for this bill? >> i will say one element is lack of perceived risk. so yes yes, now this pump is geg a lot of media attention, are starting to talk about it, but there was a perception that all, this is a medicine prescribed by a doctor, it's not a street drug, therefore, it must be safe. so that's one component. that's not the whole story, but for sure a lot of experimenting with the pills, taking it out. people do seek, people to experiment with drugs and they seek a high. recreational use of all sorts of substances and experimentation is very common in young people. but certainly, there were years when high school students, the use of prescription opioid pills for recreational drug use was rising exponentially. in one element there is a lack of perceived risk i can get a buzz and feel good, and what do opioid to do? they block pain. they are analgesic. they cause euphoria. and make you feel really good, and the memory, so talk about the lonely person and people are struggling with depression, anxiety, stress. the memory associate with taking that pale and the immediate relief, we want instant gratification and that's very powerful memory. when you look at the neurochemical changes in the brain that happened over the course of addiction and across addictions, there's a big component of this, what did he opioid end of the sepsis is due to reward system quirks they are very reinforcing pick you feel really good and to form these memories took the next time you're feeling bad and stressed and depressed, the temptation is to quickly obliterate that feeling. so that can drive drug craving and overtime lead to addiction. >> also i think on a lot of school campuses what has driven this is football. football is a gateway to heroin addiction in america today because that's how we've learned to treat pain is by throwing pills at it. most places, many high schools i think football players are kind of like the cool guys, and people watch football players, also la crosse, wrestling, baseball. mainly football though. what i was fighting was an enormous number of football players getting addicted to these pills because it is a pressure to get back on the field. this is how you treat chronic pain is with lots of dope, then there's lots of spillover. you go in for a surgery, everybody on your team knows you're going to get those pills and prett present the pills thau got prescribed are in for a fight of the guys lockers. all across america this is happening i think. football players being the kind of like the leaders popular leaders on campuses i think frequently set that standard as well. it's a hunch. i don't have any evidence or study to show this but but i ws running into it a lot during my research of my book. >> i can completely corroborate what you said about football, wrestling. i usually was in the homes of people had lost someone to an addiction through overdose, and when it was younger kids, you come in their teens and early 20s, almost every case they had a football injury, wrestling entry, a ski accident, motocross, car accident and r 16, 17 years old and put on opioids which is probably the right response in the hospital and immediately after a surgery, but then there's no, we didn't, there was no follow-up. there was no care. .. do you remind me of what it is quite a bit of time at the betty ford center which has a history of treating all kinds of addiction. alcoholism in this country you can kind of chart the history of addiction in america at the betty ford center. , delighted, cocaine, by the early part of 2003, 2005, all of a sudden opioids. oxycontin, vicodin, percocet. that is what is bringing the cases to them. so i was in the office at one of the administrators and he talked about the practice culture. he said i was at my tennis. i had an emergency tooth pulled and he writes me a prescription for 30 days of life they vicodin, but one of these drugs. because what are you doing? you know what i do for a living. the dennis that i now come you don't have to fill it. you don't have to take it, but i don't want to call in the middle of the night that you are in pain. so there you go. >> that right there explains the environment supply story. i used to believe that when i lived in mexico that i'll drop problems begin with the man. this book changed my mind completely. this is a supply story. it starts with supply and it is doctors prescribing my pattern of the guy who gave me 60 vicodin for my two, three days worth of appendix operation pain. and if you multiply that by millions of doctors visits and millions of surgeries over a 20 year period, that is what creates the massive supply of opiate that and of course transitions to herion. >> then, could you talk about how easy it is to obtain the market is availability of herion in los angeles in los angeles and highly seen it evolve over time. >> painfully common l.a. does not have the same level of an opiate problem you see in west virginia, ohio and new hampshire. not to say we don't have a drug album. it is rampant in those areas and is relatively low here. although we start to see sentinel deaths spread east to west. sacramento had to does then overdoses in the matter of a couple weeks. you have only two milligrams, and what it takes to councilman and counterfeit bills created out of it. go to a party and take whatever you care. you think you are just taking vicodin. it's being manufactured by a drug dealer in his basement. you don't know what you're taking. you don't know how strong it is or how safe it is. the ignorance of not only by prescription drug czar, and is feeling a lot of deaths. i'm not sure if that answered your question. it's an interesting point i wanted to make. i did want to make one other point which is the insurance industry was brought up and the public health insurance industry not intentionally obviously and not because of anything medicare and medicaid is doing on his feelings about market for these drugs. again, not because they do anything wrong, but you have people in los angeles and other areas who are not your traffickers. they are not doctors. their sole involvement is to recruit medicare, medicaid patients to go to doubt this. drug addicts, and maybe steal the identities in exchange for $100 cash kickback they get a prescription that they fail. usually these are drug addicts using money for their own drug habits. archer and more complex games involve these recruiters, beneficiaries to divert mind blowing amounts of these pills. hundreds of thousands to the street. three weeks ago we convicted a doctorwhose prescriptions for the number one cause of medicare by double that dr. prescheduled to drugs. this is your taxpayer money going towards this end it is just so tragic. it of course creates also to other issues and it is responsible for so many of the drug spread. >> when i first started looking at this problem, there hadn't been that many prosecutions of doctors for drug dealing. one of the explanations was the nearly possible to convict somebody in a white coat of drug dealing and drug dealing was the only law in the look of the federal level you had to go after that. has that changed at all? >> it absolutely has. when i get training in some cases can i tell people who might be afraid that these are some of the easiest cases we prosecute. why is that? a paper trail exists left and right. he got the prescription data. you can see every drug prescribed. bank records, doctors who are drug traffickers. although better place. number two, a very narrow range of conduct that is consistent with legitimate pride is. the narrow range of conduct is not consistent with what a doctor is going to do to profit from his trance. the acts described maximum dosages over and over again and dangerous combinations. pfizer pain doctor prescribing maximum strength xanax to everyone who comes in the door. why are they doing two-minute examinations? i could place 50 different things you see in these cases over and over again. we have incredible tools to go after these cases. not just as prosecutors, but his regulators as well, which is even more important in combating corruption. one big area inside the combat corruption in pharmacies which are more difficult cases. with the regular drug trafficker, you prosecute whatever drug dealer. it's a fungible business. the doctor it's not. you have to be licensed, have the education canopy went to commit a crime as opposed to making good money. i think it better prosecutions, fewer and fewer doctors doing this. now i have to turn our attention to the pharmacies. we have an array of criminal to drug charges and safe handling of drugs. there's a doctor in l.a. convicted of murder, manslaughter for continuing to prescribe for rampant acid is a righteous prosecution. [inaudible] >> well, in any event, it was a righteous result. but in the past years has doctors who are murderers and they need to be treated as such. so we have a lot of a lot of tools in our toolkit. we just have to use them. idea back [inaudible] >> -- we are going to take questions. if you please say your first and last name when you ask your question because the program will be recorded in rebroadcast on our website. it will also be broadcast by c-span at a later date. lewis has your first question. >> my name is todd kerner. there is a trend going on but i suspect will intensify the recent election about drug testing people on public assistance. it's sort of a two-part question, which is just that kind of drug testing catch prescription drugs? in fact it, and does it highlight the income disparity with regards to this particular epidemic as opposed to other ones? >> depending how sensitive the drug test is, not very sensitive drug tests would be hard to distinguish between a prescription opioids and morphine and heroin which quickly metabolizes into something that looks just like morphine in the system. i'm not sure what kind of drug test you are talking about, but it may not distinguish between something you're taking legitimately, which goes to sam's point. it's all the same stuff when it gets down to the chemical level. >> i would only catch people who would go in for public assistance. to what extent is the opioid epidemic affect the people who may be able to not be dependent on public assistance? >> i would say that this affects white people, okay? white people. just white people. and that's in appalachia where you can really -- if you pay attention to appalachia, we would not be in the situation today. i was like 98, 99, 2000, those years. but now for my book is in appalachia but also in suburban charlotte, one of the wealthiest parts of america. portland, salt lake on indianapolis. he talked about people who are doing the best in the run-up since the mid-1990s of economic expansion so the bigger question is why it's only way people. i don't have an answer to why that is. they tried to understand the good part of it does have to do with doctors prescribing, but many black people have received these drugs. in the black community it's not. the tino community, part of it may have to do with memory. in the 70s was destroyed by herion. that may have something to do with it. i don't know. this doesn't just affect -- they say that addiction is colorblind. but in this case it's very much not. it is way people and it's all over wherever you find a white person. >> the other role that public assistance plays in this epidemic been alluded to and maybe you did. people with medicare and medicaid may be homeless or, you know, easily manipulated or ssi, that kind of thing. if you have a government card, you can get a prescription for a very low co-pay and your valuable to drug dealers. you become recruited many become a patient. you are driven in a van. you'll probably get lunch. you are taken to a corrupt dr. like ben was talking about and a prescription is written in your name after you pass through the mail and you turn the prescription over to your copper is driving around. you get your lunch. you get -- $100 sounds like a lot. people do this for less. and you are taken back to the homeless shelter. that's the way of saying public assistance play out in this particular epidemic. >> you are paying for drug dealers to get their source of supply. [inaudible] >> hi, thanks for next-line panel. i have a question for sam in particular. i'm writing my dissertation on the opioid epidemic. my question, i love that he could speak more to this great area that exists, sort of reaching the highly regulated official market for prescription drugs on the market for herion. you guys have spoken a lot about medicaid and medicare and these are really important points. but what have you found in your research or bridges the divide in places that suburban charlotte? >> i'm not sure i heard the question. it's kind of echoing here. but basically why is there a market in suburban charlotte for this? >> like you talked about how medicaid ssi in those kinds of things set up this transition between the market for prescription opioids in the market for herion and people who take that assistance. >> baguettes to what i'm seeing about.yours except in the idea that these bills could not be prescribed with virtually no risk. covers the fundamental change amounts of the pharmaceutical companies did very, very well with pain specialists. they said about to convince an entire generation and more of doctors that the drugs that everybody knew were therefore actually not so. it was a magnificent piece of marketing. we now know that these drugs are not. so you've got massive prescribing of these pills in many parts of america. not just in appalachia. i totally agree medicaid and medicare were a big part of what happened and continue to have been hearing for his parts of the country. but till mal talks and scandalous doctors are not the reason why this happened. it was an entire generation of doctors buying the idea that these bills could not be prescribed with virtually no risk of addiction. we went in 1990. the world supply of hydrocodone you think was three times, went to 43 times in 2010. of those 43 tons, world supply of hydrocodone, 99% of that was used in our country. some of the figures or oxycodone. it's a revolution in thinking was accomplished through marketing. that is why ensure is why in charlotte are salt lake or new mexico or arizona or indianapolis, places all over the country, you have this supply. in some areas it definitely exacerbated. but overall, you talk about just a general change of mind on the part of many, many hundreds and hundreds of thousands of doctors all the country together with something you're talking about. >> i just wanted to add to that the referred stories about mark lambright then i've heard getting the bad guy and there are bad apples out there. a lot of this is just sort of dole, unwitting participation in the system where we don't like regulation. we valorize independent decision-making and i think we will see that increasing in the next administration. when public health experts like me talk about regulation and we get pushback on that. they are called death panels. and so, i think if we have a medical culture, insurance culture that does not like taking evidence into account and forcing people to participate in a system like that. we will end up with a lot of prescriptions because they are bad apples. it's important we have law enforcement dealing with bad apples but also because that's the message we send with the way we structure our insurance. that's how we reward them. the dentist who didn't want to take the call of the middle the night and i don't blame him. we need to pay people to take those calls and get the right incentives in place. that would take a reform of our health care system, part of which obama carries on the way to doing. we will see the problem worsening. >> i wonder if any of you think that the amount of attention given to this issue would be different if that wasn't the case as you describe is more prominent in white communities. >> i just want to say anecdotally, obviously i can't keep statistics on racial demographics, but a lot of cases where they are full of african-americans, for example. at least here in l.a., i haven't seen it being exclusively limited to white people, but maybe that's just l.a. maybe it's just from my days. it's the unique issue because it crosses every ethnic group and age group and class as far as i can see affecting everybody. i don't know if that answered your question. >> we should be careful. it's not that people of color can't get her from this. so don't endure in the informatics. people of color are getting hurt from this. i think what's got the attention is that we've seen for the first time in 75 years he turned around and life expectancy for white people and it's caused by this. and we are not seen in these other racial groups. that's one of the shocking things. there's a paper that came out to show this for the first time this reduction. that is the opioid epidemic and its hating white people in a particular way. if it were another racial group, i don't know. we have a fairly lousy history for dealing with problems that hit only some racial groups and not others. in this one there's something very dramatic going on with this group. >> final question on your left. >> i'm a nurse part cushion her and this is a great panel. it's a great panel for the community. but i hear you talking about the doctor patient relationship. what about the nurses? the nurses are pivotal in this fight. there's a number one educator. they are the number one population and health care in dealing with patients. i for none of you mentioned the nurse. >> so, my colleague at the paper and the surgeon general of the united states, the guy was named dr. murphy anything. earlier this month he dropped a report on the opioid problem and what our response should be. the products of a lot of work. he worked in the same hospital ever since he was a resident. and when he became surgeon general of the united states commit the nurses who have known him for his whole career said they gave him one request. do something about the opioid epidemic. because i can tell you absolutely on the front lines, nurses and the state of california part to shooters can write these into work for.there's so they can, you know, contribute to the problem. they can also contribute to the solution and they are certainly dealing with a end of rehab centers and the addiction treatment centers. i know they see it. they are on the front lines and a lot of them are looking. >> we are going to close our program. i would hate to think ucla, are co-presenter for making this event possible this evening and to thank all of you for joining us tonight. i invite everyone to join us at the reception not your word to continue the conversation over wine and talk to her panelist and can today to pick their brains. finally, thank you to her wonderful panelist for sharing your thoughts. 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