15.7 OVERDOSED Full Series Uninterrupted

[00:00:00] Hey everybody, thanks for joining me today for a solo recording on a topic that is near and dear to my heart, part of my lived experience, something even in the early stages of my psychiatric career that I consider myself to be very well versed in, the progressively worsening dumpster fire that is the United States drug epidemic.

[00:00:28] Somebody get this guy some help!

[00:00:38] Disclaimer, this podcast is for informational purposes only. The information provided in this podcast and related materials are meant only to educate. This information is not intended as a substitute for professional medical advice. While I am a medical doctor and many of my guests have extensive medical training and experience, nothing stated in this podcast nor materials related to this podcast, including recommended websites, texts, graphics, images, or any other materials should be treated as a substitute for professional, medical, or psychological advice, diagnosis, or treatment. All listeners should consult with a medical professional, licensed mental health provider, or other healthcare provider if seeking medical advice, diagnosis, or treatment.

[00:01:04] I spend a lot of time talking about our broken healthcare system.

[00:01:09] And there is no one specific issue that epitomizes its dysfunction more than the addiction crisis,

[00:01:16] which has taken the lives of millions of Americans since the late 1990s and affected hundreds of millions more.

[00:01:25] You could not grow up in the late 90s or 2000s in Kentucky, Indiana, Ohio, West Virginia, Tennessee, North Carolina,

[00:01:36] and not know somebody afflicted by addiction or a family torn apart by the carnage of their loved one's addictions.

[00:01:46] Purdue Pharmaceuticals, run by the Sackler family, who were implicated as a major causative factor in the Valium epidemic of the 1970s and 1980s,

[00:01:58] specifically targeted rural Appalachians with their marketing of the drug Oxycontin.

[00:02:04] What they claimed was a non-addictive opiate, which, by the way, does not exist.

[00:02:13] The opium poppy is the natural plant form of opiates and has been around since the 3000s BC.

[00:02:21] It was recognized as causing potential fatality with improper dosage as far back as the 10th century

[00:02:28] and was banned by the Yangtze Emperor of the Qin Dynasty in China in the 1700s,

[00:02:36] in part due to its negative impacts on their population.

[00:02:39] In the early 1800s, morphine was isolated from opium as the active pain-relieving and respiration-depressing ingredient in opium.

[00:02:51] Once Purdue managed to get FDA approval for Oxycontin in 1996, which we'll talk about later,

[00:03:00] it didn't take long for the problem of prescription pain pills to spread to the northeast and southwest United States,

[00:03:08] and quickly thereafter, a regional epidemic became a national epidemic.

[00:03:13] A crackdown on opiate prescribing in the late 2000s coincided with a widespread increase in the availability of illicit black tar heroin from Mexico in the early 2010s,

[00:03:27] putting more fuel on the epidemic fire.

[00:03:30] And since the mid-2010s, fentanyl, a synthetic opiate with 100 times the potency of natural morphine,

[00:03:39] that is odorless and lightweight, making smuggling much easier, has accelerated the flame even further,

[00:03:47] leading to perpetually increasing numbers of drug overdose deaths in the United States nearly year over year for the last 30 years.

[00:03:58] From 1999 to 2020, overdose fatalities have increased by more than 500%, and probably even more than that.

[00:04:10] Today, I'll start out by talking about the evolution of mortality with drug overdoses,

[00:04:16] but also discuss some of the other medical and psychiatric consequences of illicit drug use,

[00:04:22] affecting Americans' lives and futures.

[00:04:25] As the University of South Florida 10-year study concluded,

[00:04:31] over one-third of Florida overdose fatalities were not reported to the federal government.

[00:04:37] It's so important to point out that not only are overdose numbers almost assuredly and chronically

[00:04:46] underreporting the annual numbers of drug overdose fatalities,

[00:04:49] they also do not factor in that this problem is not just limited to overdose deaths.

[00:04:57] For people with non-fatal overdoses, the risk of mortality increases from less than 1% at baseline over a 12-month period

[00:05:07] to more than 5% fatality rate in the next 12 months.

[00:05:13] That's for people who overdosed and did not die from it.

[00:05:18] About half of those people end up dying from an overdose.

[00:05:22] But the other half of that 5%,

[00:05:25] you're talking about deaths related to car accidents,

[00:05:30] intravenous drug use related infections like HIV which causes AIDS,

[00:05:37] hepatitis C which can lead to an impaired immune system function as well as liver cancer or liver failure,

[00:05:46] endocarditis which is a heart valve infection that can spread through the circulatory system

[00:05:53] to anywhere in the body, skin and soft tissue infections at the site of injection,

[00:06:00] sexually transmitted infections, pneumonias, and other non-infection related risks

[00:06:06] like depression, suicide, homicide, domestic violence, psychosis,

[00:06:13] chronic lung disease resulting in respiratory failure,

[00:06:17] alcoholic and other drug related liver disease,

[00:06:20] hypertension or high blood pressure related illnesses,

[00:06:25] chronic kidney disease,

[00:06:26] and other organ failures.

[00:06:29] Throughout this series,

[00:06:31] we will track the evolution of the U.S. drug epidemic

[00:06:35] from the time of Oxycontin's emergence

[00:06:38] to widespread fentanyl contamination.

[00:06:42] But we'll also discuss the non-fatal effects

[00:06:45] on people's health and well-being.

[00:06:48] Let's dive in.

[00:06:50] First and foremost,

[00:06:51] nobody pays me to do this shit.

[00:06:54] I have no disclosures.

[00:06:56] I don't receive any funding.

[00:06:58] And I don't think with a lot of the things that I'm saying

[00:07:00] that I will be receiving any pharmaceutical funding anytime soon.

[00:07:05] The reason why I do this

[00:07:09] is because of people like Will.

[00:07:12] Will.

[00:07:13] So, I went to high school with Will.

[00:07:16] And he was one of the funniest and most lighthearted people I've ever known.

[00:07:21] Now, this was supposed to be a very serious exercise.

[00:07:34] The first couple of students gave very heartfelt responses,

[00:07:38] stating,

[00:07:39] I believe in myself and my abilities.

[00:07:43] The next one,

[00:07:44] I believe in my family and the power of community.

[00:07:48] And I believe in God and can do all things through Christ who strengthens me.

[00:07:55] Now, eventually, the baton was passed to Will,

[00:07:58] who in classic stone-faced fashion,

[00:08:02] and referencing a one-hit wonder of the times

[00:08:05] that probably mostly only the students were aware of,

[00:08:12] dryly says,

[00:08:13] I believe in a thing called love.

[00:08:18] Now, while the priests and the older mentors

[00:08:21] bought it hook, line, and sinker,

[00:08:24] gave a somber nod to Will,

[00:08:27] who had buried his head in his hands

[00:08:29] because he was even struggling to keep a straight face,

[00:08:32] while the majority of the rest of us

[00:08:35] did everything we could to disguise our tears of laughter

[00:08:38] as tears of empathy,

[00:08:41] Will always knew how to make people laugh.

[00:08:45] Unfortunately, in April of 2020,

[00:08:49] after a long and tortuous battle with depression and addiction,

[00:08:53] highlighted by a long period of sobriety

[00:08:56] and being engaged in his recovery,

[00:08:59] a month into COVID,

[00:09:01] Will was found dead in his bedroom from an apparent overdose.

[00:09:06] It was absolutely devastating.

[00:09:10] To me,

[00:09:12] to his other friends,

[00:09:14] to his family,

[00:09:15] and it's not just Will,

[00:09:18] unfortunately.

[00:09:20] I can't count on both sets of my fingers and toes

[00:09:23] the number of former classmates

[00:09:26] who have passed away in the last 15 to 20 years.

[00:09:30] Too many parents,

[00:09:33] too many friends,

[00:09:35] too many loved ones

[00:09:36] are finding their sons,

[00:09:38] daughters,

[00:09:39] parents,

[00:09:40] relatives,

[00:09:40] and more

[00:09:41] gone in an instant

[00:09:43] or having their lives derailed by addiction.

[00:09:48] We have got to turn more focus and attention

[00:09:51] as a country,

[00:09:53] as a society,

[00:09:54] to rectifying this problem,

[00:09:57] not continuing to put band-aids on

[00:10:01] our absolutely atrocious addiction care in this country.

[00:10:06] I've got to give a huge shout out

[00:10:08] and thank you to Will's parents

[00:10:09] for allowing me to tell his story,

[00:10:12] trying to raise money in Will's honor.

[00:10:15] It's not easy to do that,

[00:10:17] and there's a lot of stigma surrounding addiction.

[00:10:21] But they,

[00:10:22] as I do,

[00:10:24] understand the importance

[00:10:25] of facing that stigma head-on,

[00:10:28] of honoring Will,

[00:10:30] honoring his memory

[00:10:31] and so many others' memories

[00:10:33] by pushing for positive change.

[00:10:37] Anyways,

[00:10:38] this is why I'm here.

[00:10:41] Will is the symbol to me

[00:10:43] of why this matters.

[00:10:44] And I want to make damn sure

[00:10:47] that his death is not in vain,

[00:10:49] but pushes us towards progress

[00:10:52] in combating this surging epidemic.

[00:10:58] Okay, so,

[00:11:00] newsflash,

[00:11:02] Americans are using illicit drugs.

[00:11:04] This 2019 National Survey

[00:11:07] on Drug Use and Health,

[00:11:09] which represents non-institutionalized

[00:11:12] U.S. civilians

[00:11:13] greater than 12 years old,

[00:11:16] shows that 165 million people

[00:11:20] in the U.S.

[00:11:21] have used an illicit drug

[00:11:22] in their lifetime.

[00:11:24] That's 50 to 60 percent,

[00:11:26] and likely even higher

[00:11:28] if you included

[00:11:31] institutionalized populations.

[00:11:33] More than one out of five Americans

[00:11:36] have used an illicit drug

[00:11:38] in the last year,

[00:11:39] and another 13 percent

[00:11:42] in the last month.

[00:11:43] And all of that

[00:11:45] only represents illicit use.

[00:11:47] So it doesn't count

[00:11:49] the millions of Americans

[00:11:50] who receive

[00:11:51] dangerous prescriptions

[00:11:52] or prescription combinations

[00:11:54] from their doctor or provider.

[00:11:57] We're not winning

[00:11:59] the war on drugs,

[00:12:00] and we've got to be open

[00:12:02] to changing our approach.

[00:12:05] We've got to stop criminalizing

[00:12:08] addiction-related behaviors.

[00:12:11] We certainly can't criminalize

[00:12:13] behaviors under the influence

[00:12:15] of addiction

[00:12:16] that are against the law,

[00:12:18] but we've got to stop

[00:12:20] putting people in jail

[00:12:21] for having drugs

[00:12:23] and be more sympathetic

[00:12:25] and try to understand

[00:12:27] why they are using drugs

[00:12:30] and how we may be able

[00:12:32] to help them.

[00:12:33] But first,

[00:12:34] we need our political candidates

[00:12:36] to turn more attention

[00:12:38] and focus

[00:12:39] to how we can combat

[00:12:41] this epidemic

[00:12:42] and maybe stop arguing

[00:12:44] about who has

[00:12:45] the lower golf handicap.

[00:12:46] That's the biggest lie

[00:12:48] that is a six handicap of all.

[00:12:52] Let's start

[00:12:52] by taking a look

[00:12:54] at some general trends

[00:12:55] since the turn of the century.

[00:12:58] So,

[00:12:59] this is a commonly cited graphic

[00:13:01] showing the drastic

[00:13:03] 500-plus percent increase

[00:13:06] in drug-involved overdose deaths

[00:13:09] from 1999 to 2021.

[00:13:12] Prior to 2000,

[00:13:15] there were less than

[00:13:16] 20,000 overdose deaths

[00:13:18] annually

[00:13:18] with things like

[00:13:20] the HIV and AIDS crisis,

[00:13:22] motor vehicle accidents,

[00:13:24] suicides and homicides,

[00:13:26] or gun violence,

[00:13:27] outpacing overdose deaths

[00:13:29] for decades upon decades.

[00:13:31] And as you can see,

[00:13:33] a slow burn increase

[00:13:35] in prescription-related

[00:13:36] overdose deaths,

[00:13:38] primarily opiate pain pills,

[00:13:41] first Oxycontin,

[00:13:42] followed by several replacements

[00:13:45] of Oxycontin.

[00:13:48] An increase in these

[00:13:49] prescription-related overdose deaths

[00:13:51] in the late 1990s

[00:13:53] into the 2000s

[00:13:54] consistently and steadily

[00:13:56] increased until about

[00:13:59] 2014, 2015,

[00:14:00] when fentanyl burst

[00:14:02] onto the scene,

[00:14:04] leading to the highest

[00:14:05] drug overdose death rates

[00:14:07] in our world today,

[00:14:08] and from what I can tell,

[00:14:10] in the history of the world.

[00:14:13] Now,

[00:14:14] this problem is so bad

[00:14:16] that it is affecting

[00:14:18] our actual life expectancy

[00:14:20] numbers.

[00:14:21] Between 1950,

[00:14:23] coming out of World War II,

[00:14:26] and 2015,

[00:14:28] excluding 1993,

[00:14:29] when we lost

[00:14:31] 0.1 year of life expectancy

[00:14:34] related to homicides

[00:14:35] and HIV,

[00:14:36] there were no decreases

[00:14:38] in life expectancy.

[00:14:40] But in 2015,

[00:14:42] we saw another dip

[00:14:44] of 0.1 years

[00:14:45] related to overdose deaths.

[00:14:47] And in 2020,

[00:14:49] with the combination

[00:14:50] of COVID

[00:14:51] and a massive surge

[00:14:53] in overdose deaths,

[00:14:55] our life expectancy

[00:14:56] dropped by 1.8 years.

[00:15:00] Think about that.

[00:15:01] We had a 70-year period

[00:15:05] of consistent increases

[00:15:08] in life expectancy.

[00:15:10] And then in one year,

[00:15:12] we dropped almost

[00:15:13] two years of life expectancy.

[00:15:16] Now,

[00:15:17] you may think

[00:15:18] or say that

[00:15:19] this is mostly related

[00:15:21] to COVID,

[00:15:22] but it's not just

[00:15:24] isolated to the COVID pandemic.

[00:15:26] Of the 350,000

[00:15:29] COVID-related deaths,

[00:15:31] that's an official CDC number,

[00:15:33] in 2020

[00:15:34] in the United States,

[00:15:36] 93%

[00:15:38] were in people

[00:15:39] over the age of 50

[00:15:40] and 75%

[00:15:42] in people

[00:15:43] over the age of 65.

[00:15:45] On the flip side,

[00:15:47] of the 100,000

[00:15:49] plus overdose deaths,

[00:15:51] and I will argue

[00:15:52] that it is higher than that,

[00:15:54] 90% occurred

[00:15:55] in people younger

[00:15:56] than 65

[00:15:57] with the average age

[00:15:59] younger than 40.

[00:16:01] Not every death

[00:16:02] counts the same

[00:16:04] in terms of its impact

[00:16:05] on life expectancy.

[00:16:07] This crisis

[00:16:09] is killing

[00:16:10] young people

[00:16:11] of every community,

[00:16:13] of every ethnicity,

[00:16:15] of every

[00:16:16] socioeconomic background.

[00:16:18] This is killing

[00:16:19] young people

[00:16:20] with their entire

[00:16:21] lives ahead of them.

[00:16:25] So,

[00:16:26] to go back

[00:16:27] to a common theme

[00:16:28] of the podcast,

[00:16:29] all of this

[00:16:31] is happening,

[00:16:31] this drop

[00:16:32] in life expectancy,

[00:16:34] despite us Americans

[00:16:36] spending drastically

[00:16:37] more money

[00:16:38] than any other nation

[00:16:40] per person

[00:16:41] on healthcare.

[00:16:43] The Japanese

[00:16:45] and the Swiss

[00:16:46] are pushing

[00:16:47] towards average

[00:16:48] life expectancies

[00:16:49] around 85 years.

[00:16:52] Australia,

[00:16:53] which has

[00:16:54] similar rates

[00:16:55] of obesity

[00:16:55] and smoking,

[00:16:57] are living

[00:16:58] until about

[00:16:58] the age of 84.

[00:17:00] The United Kingdom

[00:17:01] and Germany

[00:17:02] about 82.

[00:17:04] And here's

[00:17:05] us,

[00:17:06] Americans,

[00:17:08] with an average

[00:17:09] life expectancy

[00:17:11] around 78

[00:17:12] or 79 years old,

[00:17:14] ranking consistently

[00:17:16] outside of the

[00:17:17] top 50

[00:17:18] in the world,

[00:17:19] despite spending

[00:17:20] double

[00:17:21] per person

[00:17:22] compared to

[00:17:24] just the next

[00:17:25] highest healthcare

[00:17:26] spender.

[00:17:27] No offense

[00:17:28] to Czech

[00:17:29] Republicans

[00:17:30] or Antiguans

[00:17:31] and Barbudans,

[00:17:33] Croatians

[00:17:34] or Omanis,

[00:17:35] but with our

[00:17:36] resources

[00:17:37] in this

[00:17:39] so-called

[00:17:39] developed

[00:17:40] nation,

[00:17:42] we should

[00:17:42] not have

[00:17:44] the same

[00:17:45] life expectancies

[00:17:46] as those

[00:17:47] four mentioned

[00:17:48] countries.

[00:17:52] This problem

[00:17:53] shows

[00:17:54] majorly

[00:17:55] in our

[00:17:56] top 10

[00:17:56] leading causes

[00:17:57] of death

[00:17:58] by age group,

[00:17:59] where you'll see

[00:18:00] unintentional injuries,

[00:18:02] which include

[00:18:03] overdoses,

[00:18:04] killing about

[00:18:05] 167,000 people

[00:18:07] in 2008,

[00:18:08] or sorry,

[00:18:09] 2018,

[00:18:10] and it reported

[00:18:11] greater than

[00:18:13] 200,000

[00:18:14] in 2020,

[00:18:16] with more

[00:18:17] than half

[00:18:17] of those

[00:18:18] due to

[00:18:19] direct

[00:18:20] reported

[00:18:21] fatal

[00:18:22] overdoses.

[00:18:24] And if you

[00:18:25] break down

[00:18:25] the unintentional

[00:18:26] injury deaths,

[00:18:28] between the

[00:18:29] ages of

[00:18:29] 15 to 44,

[00:18:33] the most

[00:18:34] likely reason

[00:18:35] for your death

[00:18:36] as an American

[00:18:36] is from a

[00:18:38] drug overdose

[00:18:38] or a suicide.

[00:18:40] The other

[00:18:41] top causes

[00:18:42] of unintentional

[00:18:43] injury death

[00:18:44] likely have an

[00:18:45] addiction subset

[00:18:46] to them as

[00:18:46] well,

[00:18:47] with motor

[00:18:48] vehicle accidents,

[00:18:49] likely with some

[00:18:50] impaired drivers,

[00:18:52] and unintentional

[00:18:53] falls from

[00:18:55] bad medication

[00:18:56] combinations,

[00:18:58] suicides and

[00:18:59] homicides,

[00:19:00] and adverse

[00:19:01] effects of

[00:19:02] medications,

[00:19:03] all in the

[00:19:03] top 10.

[00:19:04] This is not

[00:19:06] to mention

[00:19:07] heart,

[00:19:08] liver,

[00:19:09] kidney,

[00:19:10] brain damage,

[00:19:11] disease,

[00:19:12] or other

[00:19:13] chronic medical

[00:19:14] conditions

[00:19:16] exacerbated

[00:19:16] by illicit

[00:19:17] drug use.

[00:19:20] So in

[00:19:21] 2020,

[00:19:22] unintentional

[00:19:23] injuries were

[00:19:24] the number

[00:19:24] four cause

[00:19:25] of death.

[00:19:26] But again,

[00:19:27] these are

[00:19:27] killing a

[00:19:28] much younger

[00:19:29] population

[00:19:30] than all

[00:19:31] the other

[00:19:31] causes of

[00:19:32] death you

[00:19:32] see on

[00:19:33] there.

[00:19:33] COVID,

[00:19:34] cancer,

[00:19:35] heart

[00:19:35] disease,

[00:19:37] cerebrovascular

[00:19:38] disease,

[00:19:38] or strokes,

[00:19:40] COPD.

[00:19:43] Some of

[00:19:44] these other

[00:19:45] deaths also

[00:19:45] could be

[00:19:46] related to

[00:19:47] addictions,

[00:19:47] or exacerbated

[00:19:48] by addictions.

[00:19:50] It's also

[00:19:51] really important

[00:19:52] to consider

[00:19:53] a stat

[00:19:54] called

[00:19:54] YOL,

[00:19:55] years of

[00:19:56] life lost.

[00:19:58] With an

[00:19:59] average years

[00:19:59] of life

[00:20:00] lost in

[00:20:01] an overdose

[00:20:02] between 30

[00:20:03] and 45

[00:20:03] years,

[00:20:04] we're talking

[00:20:05] about over

[00:20:06] three to

[00:20:07] four and a

[00:20:07] half million

[00:20:08] years of

[00:20:09] life lost

[00:20:10] annually in

[00:20:11] the United

[00:20:11] States to

[00:20:13] just fatal

[00:20:15] overdoses.

[00:20:17] And well

[00:20:18] over one

[00:20:19] million dead

[00:20:20] directly from

[00:20:21] a documented

[00:20:22] reported

[00:20:23] overdose

[00:20:23] since 2000.

[00:20:26] It's so

[00:20:27] bad here

[00:20:28] that according

[00:20:29] to the

[00:20:29] World Drug

[00:20:30] Report

[00:20:30] from 2021

[00:20:31] put out

[00:20:33] by the

[00:20:33] United

[00:20:33] Nations

[00:20:34] Office

[00:20:34] on Drugs

[00:20:35] and Crime

[00:20:35] and not

[00:20:37] including

[00:20:37] alcohol or

[00:20:38] tobacco

[00:20:38] related deaths,

[00:20:39] the U.S.

[00:20:41] claims one

[00:20:41] out of five

[00:20:42] world overdose

[00:20:43] deaths,

[00:20:44] 20% of the

[00:20:46] world's

[00:20:47] overdose deaths

[00:20:48] despite only

[00:20:49] having 4.2%

[00:20:51] of the world's

[00:20:52] population.

[00:20:54] Overdoses,

[00:20:55] which I would

[00:20:56] argue are

[00:20:56] actually the

[00:20:57] third leading

[00:20:58] cause of death

[00:20:59] in the United

[00:20:59] States,

[00:21:01] are not even

[00:21:02] in the top

[00:21:02] 10 causes

[00:21:03] of death

[00:21:03] globally.

[00:21:06] And while

[00:21:07] not the most

[00:21:08] important aspect

[00:21:08] to me,

[00:21:09] the cost

[00:21:10] of the

[00:21:11] epidemic

[00:21:11] on our

[00:21:12] society

[00:21:12] is absolutely

[00:21:14] financially

[00:21:15] draining.

[00:21:16] Yeah,

[00:21:17] you see that

[00:21:17] number up

[00:21:18] there?

[00:21:18] That's not

[00:21:19] $1 million.

[00:21:20] That's not

[00:21:21] $1 billion.

[00:21:23] That's $1

[00:21:24] trillion

[00:21:26] as of

[00:21:28] 2017.

[00:21:30] Who knows

[00:21:31] how high

[00:21:31] that cost

[00:21:32] is now?

[00:21:34] This is a

[00:21:35] very interesting

[00:21:36] study from

[00:21:37] 2018 out

[00:21:39] of Columbia

[00:21:39] University

[00:21:40] and featured

[00:21:41] in JAMA

[00:21:42] Psychiatry,

[00:21:43] a major

[00:21:44] psychiatric

[00:21:44] medical

[00:21:45] journal,

[00:21:46] regarding

[00:21:46] 75,000

[00:21:48] adult Medicaid

[00:21:49] patients

[00:21:50] during their

[00:21:51] first year

[00:21:52] after a

[00:21:53] nonfatal

[00:21:54] opioid overdose.

[00:21:56] What it

[00:21:57] reveals

[00:21:57] is that

[00:21:59] there were

[00:22:00] 5,200

[00:22:01] deaths

[00:22:02] out of

[00:22:03] this

[00:22:04] 75,000

[00:22:05] compared

[00:22:06] compared to

[00:22:07] an expected

[00:22:08] number of

[00:22:08] deaths in

[00:22:09] the general

[00:22:10] population

[00:22:10] of

[00:22:11] 215.

[00:22:13] That's

[00:22:14] nearly a

[00:22:15] 25 times

[00:22:16] increased

[00:22:18] risk of

[00:22:18] death

[00:22:19] for this

[00:22:21] population.

[00:22:22] With 50%

[00:22:23] of those

[00:22:24] deaths

[00:22:24] related to

[00:22:25] substance

[00:22:25] use or

[00:22:26] subsequent

[00:22:27] overdose,

[00:22:28] another

[00:22:29] 13%

[00:22:30] related to

[00:22:31] circulatory

[00:22:32] system

[00:22:32] failure,

[00:22:33] 6%

[00:22:34] related to

[00:22:35] respiratory

[00:22:35] failure,

[00:22:37] 6%

[00:22:37] to

[00:22:38] infections,

[00:22:39] 4%

[00:22:40] to

[00:22:40] suicides,

[00:22:41] 4%

[00:22:42] to

[00:22:43] GI

[00:22:43] system

[00:22:44] issues

[00:22:45] or stomach

[00:22:46] issues

[00:22:46] or colon

[00:22:48] issues,

[00:22:49] 10%

[00:22:50] to

[00:22:50] cancers,

[00:22:52] and 2%

[00:22:53] to cirrhosis

[00:22:54] or liver

[00:22:55] disease.

[00:22:56] There is

[00:22:57] so much

[00:22:58] more to

[00:22:59] this problem

[00:23:00] than just

[00:23:01] overdose

[00:23:01] fatalities.

[00:23:04] Now,

[00:23:05] depression

[00:23:05] and suicide

[00:23:06] are difficult

[00:23:08] to measure

[00:23:09] outcomes

[00:23:09] associated

[00:23:10] with

[00:23:10] prescription

[00:23:11] pills

[00:23:11] and IV

[00:23:12] or

[00:23:13] intravenous

[00:23:13] drug use.

[00:23:14] Some

[00:23:15] overdoses

[00:23:16] are surely

[00:23:17] intentional,

[00:23:18] while some

[00:23:19] suicides

[00:23:19] in drug

[00:23:20] use are

[00:23:21] also

[00:23:21] inevitably

[00:23:22] linked

[00:23:22] to that

[00:23:23] person's

[00:23:23] drug use.

[00:23:25] This

[00:23:26] study

[00:23:27] shows

[00:23:27] that

[00:23:28] suicidal

[00:23:29] thoughts,

[00:23:30] intentions,

[00:23:30] and

[00:23:31] attempts

[00:23:32] are all

[00:23:33] increased

[00:23:34] among

[00:23:34] drug or

[00:23:35] alcohol

[00:23:36] dependent

[00:23:36] persons

[00:23:37] with

[00:23:38] 6 times

[00:23:39] the risk

[00:23:39] of suicide

[00:23:40] attempt,

[00:23:41] 4 times

[00:23:42] the risk

[00:23:42] of serious

[00:23:43] suicidal

[00:23:43] thoughts

[00:23:44] and plans,

[00:23:46] and

[00:23:46] people

[00:23:47] who use

[00:23:47] drugs

[00:23:48] have a

[00:23:49] 10 to

[00:23:50] 14 times

[00:23:50] higher

[00:23:51] risk

[00:23:51] of death

[00:23:52] by suicide.

[00:23:52] But again,

[00:23:54] this is an

[00:23:56] ancient statistic

[00:23:57] as of

[00:23:58] 2012,

[00:23:59] and I

[00:24:00] don't think

[00:24:00] the numbers

[00:24:01] have improved

[00:24:01] to any

[00:24:02] significant

[00:24:02] degree

[00:24:03] and are

[00:24:04] likely

[00:24:05] even worse

[00:24:06] in 2024.

[00:24:09] This

[00:24:10] September

[00:24:10] 2017

[00:24:11] study

[00:24:12] showed

[00:24:12] the rates

[00:24:13] of opioid

[00:24:14] involvement

[00:24:15] in fatal

[00:24:15] car accidents

[00:24:16] increased

[00:24:17] more than

[00:24:18] sevenfold

[00:24:19] in six

[00:24:20] combined

[00:24:21] states.

[00:24:21] California,

[00:24:24] Rhode Island,

[00:24:25] West Virginia,

[00:24:26] Illinois,

[00:24:27] and New

[00:24:27] Hampshire

[00:24:28] between

[00:24:29] 1995

[00:24:29] and

[00:24:31] 2015.

[00:24:33] And

[00:24:34] oftentimes,

[00:24:35] fatal

[00:24:36] car accidents

[00:24:37] may not be

[00:24:37] reported as

[00:24:38] drug-related

[00:24:39] if there's

[00:24:39] no toxicology

[00:24:40] screen or

[00:24:42] if they're

[00:24:43] located in

[00:24:43] an area

[00:24:44] where there's

[00:24:44] a lot of

[00:24:45] stigma attached

[00:24:46] to reporting

[00:24:47] it as a

[00:24:48] drug overdose,

[00:24:49] which is

[00:24:50] exactly what

[00:24:50] it is.

[00:24:51] The driver

[00:24:52] would not

[00:24:52] have been

[00:24:53] swerving

[00:24:54] or lost

[00:24:55] control

[00:24:56] due to

[00:24:56] nodding

[00:24:57] off

[00:24:58] when they

[00:24:59] have an

[00:24:59] opiate

[00:25:00] or a

[00:25:00] depressant

[00:25:01] in their

[00:25:01] system.

[00:25:03] Now,

[00:25:04] there's a

[00:25:05] lot more

[00:25:06] to come

[00:25:06] in this

[00:25:06] series.

[00:25:08] Hopefully,

[00:25:08] I've

[00:25:09] stressed

[00:25:09] the fatality

[00:25:10] part of

[00:25:11] this epidemic

[00:25:11] and the

[00:25:12] likely

[00:25:13] under-reported

[00:25:14] nature of

[00:25:14] drug overdose

[00:25:15] related deaths,

[00:25:17] which I will

[00:25:17] continue to

[00:25:18] do throughout

[00:25:19] the series.

[00:25:21] Based on

[00:25:21] adding up

[00:25:22] all the

[00:25:23] related deaths

[00:25:23] not categorized

[00:25:25] as being

[00:25:25] caused by

[00:25:26] an actual

[00:25:26] overdose,

[00:25:27] I would

[00:25:28] estimate the

[00:25:29] overall number

[00:25:30] of annual

[00:25:31] drug overdose

[00:25:32] deaths and

[00:25:33] related deaths

[00:25:34] is pushing

[00:25:35] beyond 200,000.

[00:25:37] That's not

[00:25:38] even counting

[00:25:39] alcohol or

[00:25:40] tobacco-related

[00:25:41] deaths,

[00:25:42] which jumps

[00:25:43] that number

[00:25:43] up considerably

[00:25:44] further.

[00:25:45] It all

[00:25:46] started decades

[00:25:47] prior to

[00:25:48] increase in

[00:25:49] opiate prescribing.

[00:25:50] We saw in

[00:25:51] the late

[00:25:52] 90s and

[00:25:53] early 2000s

[00:25:55] with

[00:25:55] doctors and

[00:25:57] probably

[00:25:57] pharmaceutical

[00:25:58] companies

[00:25:58] financially

[00:25:59] backing them

[00:26:00] and their

[00:26:00] ideas and

[00:26:02] promoting

[00:26:03] this idea

[00:26:04] that pain

[00:26:06] should be

[00:26:06] treated as

[00:26:07] the fifth

[00:26:08] vital sign

[00:26:08] or considered

[00:26:09] as the

[00:26:10] fifth vital

[00:26:10] sign,

[00:26:10] along with

[00:26:12] respiratory

[00:26:13] rate,

[00:26:13] heart rate,

[00:26:14] temperature,

[00:26:18] and blood

[00:26:19] pressure.

[00:26:21] So in

[00:26:22] the 1970s

[00:26:23] and 80s,

[00:26:24] the idea

[00:26:25] that untreated

[00:26:26] or undertreated

[00:26:27] pain violated

[00:26:28] the ethical

[00:26:29] principles of

[00:26:30] medicine.

[00:26:32] This idea

[00:26:33] was becoming

[00:26:33] more pervasive

[00:26:34] throughout the

[00:26:35] medical community,

[00:26:36] including being

[00:26:38] in medical

[00:26:39] school curriculums

[00:26:40] and hospital

[00:26:41] guidelines.

[00:26:42] Prior to

[00:26:43] 1980,

[00:26:43] opiates

[00:26:45] and their

[00:26:45] synthetic

[00:26:46] counterparts

[00:26:47] opioids

[00:26:47] were used

[00:26:48] primarily

[00:26:49] for end-of-life

[00:26:50] cancer-related

[00:26:51] pain,

[00:26:52] the extremely

[00:26:53] sick,

[00:26:54] or most

[00:26:55] regularly

[00:26:55] in a limited

[00:26:56] duration

[00:26:57] for post-operative

[00:26:58] surgical

[00:26:59] patients.

[00:27:00] As the

[00:27:01] quote-unquote

[00:27:02] pain revolution

[00:27:03] gained popularity

[00:27:05] in academic

[00:27:06] circles

[00:27:06] throughout the

[00:27:07] 1980s

[00:27:08] and the

[00:27:08] 1990s,

[00:27:09] several

[00:27:10] reputable

[00:27:11] organizations

[00:27:12] started to

[00:27:12] tout pain

[00:27:13] as the

[00:27:14] fifth vital

[00:27:15] sign,

[00:27:16] including

[00:27:16] the American

[00:27:18] Pain Society,

[00:27:19] which no

[00:27:20] longer exists

[00:27:20] and was paid

[00:27:21] nearly $1 million

[00:27:22] by Purdue Pharma,

[00:27:24] the Joint

[00:27:25] Commission

[00:27:25] and Veterans

[00:27:26] Health

[00:27:27] Administration,

[00:27:28] which oversees

[00:27:29] the entire

[00:27:29] VA system,

[00:27:31] and Purdue

[00:27:32] was even

[00:27:32] kind enough

[00:27:33] to fund

[00:27:34] pain management

[00:27:35] educational

[00:27:35] programs for

[00:27:37] the Joint

[00:27:37] Commission.

[00:27:38] So,

[00:27:42] shortly

[00:27:42] thereafter,

[00:27:44] these charts

[00:27:45] started showing

[00:27:46] up in hospitals

[00:27:47] across the

[00:27:48] United States,

[00:27:49] asking patients

[00:27:50] to rate their

[00:27:51] pain as the

[00:27:53] primary determinant

[00:27:54] of how much

[00:27:55] opiate to give

[00:27:56] that person.

[00:27:58] Now,

[00:27:58] if you aren't

[00:27:59] familiar personally

[00:28:01] with the effects

[00:28:01] of taking an

[00:28:02] opiate,

[00:28:03] they're very

[00:28:04] effective at

[00:28:05] relieving pain

[00:28:06] because they

[00:28:07] block the

[00:28:07] perception of

[00:28:08] pain in the

[00:28:09] brain.

[00:28:09] pain,

[00:28:10] that can

[00:28:11] lead to a

[00:28:12] very euphoric

[00:28:13] experience for

[00:28:14] the user,

[00:28:15] especially early

[00:28:16] in their use.

[00:28:18] But relying on

[00:28:19] a totally

[00:28:20] subjective report

[00:28:21] of a patient,

[00:28:22] especially when

[00:28:23] combined with

[00:28:24] patient satisfaction

[00:28:26] scores,

[00:28:27] which will be

[00:28:28] bad if you

[00:28:28] don't treat

[00:28:29] somebody's pain

[00:28:30] away,

[00:28:31] is a horribly

[00:28:32] imprecise,

[00:28:33] unscientific,

[00:28:35] and dangerous

[00:28:35] way for a

[00:28:36] decade-plus-long

[00:28:38] trained physician

[00:28:39] at minimum

[00:28:40] to determine

[00:28:41] what and how

[00:28:42] much to

[00:28:43] prescribe.

[00:28:44] Addicted

[00:28:45] individuals could

[00:28:46] count 10

[00:28:46] out of 10

[00:28:47] pain in front

[00:28:48] of their

[00:28:48] providers,

[00:28:49] while behind

[00:28:50] closed doors,

[00:28:51] they objectively

[00:28:52] appear to be a

[00:28:53] 1 or a 2

[00:28:53] out of 10.

[00:28:54] We've had

[00:28:55] similar problems

[00:28:56] with treating

[00:28:57] anxiety in

[00:28:57] this country,

[00:28:58] especially with

[00:28:59] so many long-term

[00:29:01] Xanax prescriptions.

[00:29:02] But that's a

[00:29:03] topic for another

[00:29:04] day, or feel

[00:29:06] free to listen

[00:29:07] to our previous

[00:29:07] series on

[00:29:08] benzodiazepines

[00:29:09] with Michael

[00:29:09] Schumann.

[00:29:11] Now, let's

[00:29:13] take a step

[00:29:14] back in

[00:29:16] time to

[00:29:16] the 1980s

[00:29:17] and look at

[00:29:19] one of,

[00:29:20] if not the

[00:29:21] most harmful

[00:29:22] and influential

[00:29:23] pieces of

[00:29:24] medical literature

[00:29:25] of all time

[00:29:27] that made a

[00:29:28] hell of a

[00:29:29] negative impact

[00:29:30] on the medical

[00:29:31] community as

[00:29:32] a whole and

[00:29:33] its patient

[00:29:34] populations.

[00:29:36] Porter and

[00:29:37] Jick's 1980

[00:29:39] letter to the

[00:29:40] editor of the

[00:29:40] New England

[00:29:41] Journal of

[00:29:42] Medicine, or

[00:29:43] NEJM, stating

[00:29:45] that addiction

[00:29:46] is rare in

[00:29:48] patients treated

[00:29:49] with opioid

[00:29:50] narcotics.

[00:29:51] Now, if you've

[00:29:52] read a scholarly

[00:29:53] article or paper

[00:29:54] in a medical

[00:29:55] journal, they

[00:29:56] can be dense

[00:29:57] with a one-page

[00:29:58] abstract explaining

[00:29:59] the purpose of

[00:30:00] the study, the

[00:30:02] methods used or

[00:30:03] the methodology

[00:30:04] of the study, the

[00:30:06] results, and the

[00:30:08] discussion or

[00:30:09] conclusions at a

[00:30:11] minimum.

[00:30:13] And usually, that

[00:30:14] full article or

[00:30:16] paper consists of

[00:30:17] 10-plus pages

[00:30:19] expanding on the

[00:30:21] abstract and

[00:30:22] listing a litany

[00:30:23] of source

[00:30:24] material.

[00:30:25] journal.

[00:30:25] This is not

[00:30:27] that.

[00:30:28] This is a one-paragraph,

[00:30:32] five-sentence,

[00:30:35] 100-word letter

[00:30:37] to the editor

[00:30:38] based on a chart

[00:30:40] review by a

[00:30:42] graduate student,

[00:30:43] Jane Porter,

[00:30:44] not to be confused

[00:30:46] with Tarzan's

[00:30:47] Jane Porter,

[00:30:48] in collaboration

[00:30:49] with an academic

[00:30:50] drug researcher

[00:30:51] and Harvard

[00:30:52] graduate,

[00:30:53] Herschel

[00:30:54] Jick.

[00:30:55] It claimed that

[00:30:56] out of nearly

[00:30:57] 12,000

[00:30:58] hospitalized patients

[00:30:59] who obtained at

[00:31:00] least one narcotic

[00:31:02] preparation,

[00:31:03] that there were

[00:31:03] only four cases

[00:31:05] of reasonably

[00:31:06] well-documented

[00:31:07] addiction in

[00:31:09] patients without a

[00:31:10] history of addiction

[00:31:11] and one case of

[00:31:13] major addiction.

[00:31:14] Wow!

[00:31:15] Only four cases

[00:31:17] cases of reasonably

[00:31:19] well-documented

[00:31:20] addiction,

[00:31:22] whatever the

[00:31:22] hell that means,

[00:31:24] and also

[00:31:25] does not comment

[00:31:27] on how many

[00:31:28] patients in

[00:31:29] those 12,000

[00:31:31] had a history

[00:31:32] of addiction

[00:31:32] and were not

[00:31:33] included in

[00:31:34] those results.

[00:31:35] What a dangerous

[00:31:37] conclusion to

[00:31:38] come to

[00:31:38] based on a

[00:31:40] review of

[00:31:40] patients that

[00:31:41] were isolated

[00:31:43] to hospital

[00:31:43] care without

[00:31:45] any clear

[00:31:46] discussion of

[00:31:47] how these

[00:31:47] patients were

[00:31:48] followed over

[00:31:48] time or if

[00:31:49] they were

[00:31:50] followed over

[00:31:50] time.

[00:31:51] The fact that

[00:31:52] they likely did

[00:31:53] not have

[00:31:54] access to

[00:31:55] narcotics on

[00:31:56] discharge from

[00:31:56] the hospital

[00:31:57] and it's

[00:31:58] difficult to

[00:31:59] become addicted

[00:32:01] to something that

[00:32:01] you don't have

[00:32:02] any access to

[00:32:03] and there's

[00:32:05] no other

[00:32:06] information about

[00:32:07] how many

[00:32:08] patients received

[00:32:09] more than one

[00:32:10] narcotic

[00:32:11] preparation or

[00:32:12] what the

[00:32:13] indication was

[00:32:13] for or

[00:32:14] anything like

[00:32:15] that.

[00:32:16] But this

[00:32:18] turned into

[00:32:19] the perfect

[00:32:19] weapon for

[00:32:20] Purdue and

[00:32:22] other opiate

[00:32:23] making

[00:32:23] pharmaceutical

[00:32:24] companies to

[00:32:25] latch on to.

[00:32:26] In 2017,

[00:32:28] Herschel Jick

[00:32:29] was quoted

[00:32:30] as saying,

[00:32:31] if I knew

[00:32:32] then what I

[00:32:33] know now,

[00:32:34] I never would

[00:32:35] have published

[00:32:35] it.

[00:32:36] Let's look

[00:32:37] and see what

[00:32:38] happens in

[00:32:39] the three

[00:32:40] subsequent

[00:32:40] decades with

[00:32:42] other papers

[00:32:43] citing this

[00:32:44] letter to

[00:32:44] the editor

[00:32:45] evidence

[00:32:46] quote-unquote

[00:32:48] that opiates

[00:32:49] are not

[00:32:49] addictive.

[00:32:54] So the

[00:32:55] number of

[00:32:56] other papers

[00:32:57] affirming

[00:32:58] Porter and

[00:32:58] Jick's

[00:32:59] quote-unquote

[00:33:00] research is

[00:33:01] astounding

[00:33:02] with over

[00:33:04] 200 citations

[00:33:05] and only

[00:33:07] three negations

[00:33:08] of those

[00:33:09] 200

[00:33:10] between

[00:33:10] 1996

[00:33:11] and 2004.

[00:33:14] Even long

[00:33:15] after the

[00:33:16] prescription

[00:33:16] opiate

[00:33:17] epidemic

[00:33:17] was in

[00:33:18] full swing

[00:33:19] in the

[00:33:19] early to

[00:33:20] mid-2000s

[00:33:21] and into

[00:33:22] the 2010s,

[00:33:23] there were

[00:33:24] still

[00:33:24] researchers

[00:33:25] affirming

[00:33:26] the study's

[00:33:27] results and

[00:33:28] way more

[00:33:29] researchers

[00:33:30] affirming

[00:33:30] it than

[00:33:31] negating it,

[00:33:32] creating a

[00:33:33] type of

[00:33:33] scientific

[00:33:34] cyclical

[00:33:35] reasoning

[00:33:36] without any

[00:33:37] sort of

[00:33:41] genius out

[00:33:42] there is

[00:33:42] still

[00:33:42] affirming

[00:33:43] this

[00:33:43] study as

[00:33:44] of

[00:33:44] 2016.

[00:33:46] Now,

[00:33:47] retrospective

[00:33:48] analyses

[00:33:48] or looking

[00:33:50] back,

[00:33:51] researchers

[00:33:52] that are

[00:33:52] looking back

[00:33:53] on the

[00:33:53] results of

[00:33:54] this paper

[00:33:55] of the

[00:33:56] original

[00:33:56] study,

[00:33:58] I hate

[00:33:58] even calling

[00:33:59] it a

[00:33:59] study,

[00:34:00] showed that

[00:34:01] these were

[00:34:01] inpatients

[00:34:02] who received

[00:34:03] all of their

[00:34:04] opiates in

[00:34:05] the hospital

[00:34:06] where medications

[00:34:07] were administered

[00:34:08] to them

[00:34:09] and were

[00:34:10] not discharged

[00:34:11] with a

[00:34:12] prescription

[00:34:12] as an

[00:34:13] outpatient.

[00:34:14] So,

[00:34:15] of course,

[00:34:15] they didn't

[00:34:16] get addicted

[00:34:16] because,

[00:34:17] one,

[00:34:17] they didn't

[00:34:18] have any

[00:34:18] access to

[00:34:19] opiates

[00:34:19] after discharge

[00:34:20] and,

[00:34:21] two,

[00:34:22] they weren't

[00:34:23] even followed

[00:34:23] up after

[00:34:24] discharge.

[00:34:24] So,

[00:34:24] if they

[00:34:25] did become

[00:34:25] addicted,

[00:34:26] the researchers

[00:34:27] wouldn't have

[00:34:27] known it.

[00:34:28] It wasn't

[00:34:29] until 2017,

[00:34:32] 20-plus years

[00:34:34] into the

[00:34:35] opiate epidemic,

[00:34:37] that the

[00:34:37] New England

[00:34:37] Journal of

[00:34:38] Medicine

[00:34:38] finally added

[00:34:40] a clause

[00:34:40] above the

[00:34:41] letter stating,

[00:34:43] for reasons

[00:34:43] of public

[00:34:44] health,

[00:34:44] readers should

[00:34:45] be aware

[00:34:45] that this

[00:34:46] letter

[00:34:47] has been

[00:34:47] heavily

[00:34:47] and uncritically

[00:34:49] cited

[00:34:49] as evidence

[00:34:50] that addiction

[00:34:51] is rare

[00:34:52] with opiate

[00:34:53] therapy.

[00:34:54] Hmm.

[00:34:55] It's almost

[00:34:56] like these

[00:34:57] major medical

[00:34:58] journals receive

[00:34:59] funding from

[00:35:01] pharmaceutical

[00:35:01] companies.

[00:35:03] Real head

[00:35:04] scratcher on

[00:35:05] that one.

[00:35:06] Now,

[00:35:08] here are

[00:35:09] some of the

[00:35:10] excerpts from

[00:35:11] papers that

[00:35:12] cited Porter

[00:35:14] and Jick's

[00:35:14] letter as

[00:35:15] evidence.

[00:35:17] And,

[00:35:18] as you can

[00:35:18] see,

[00:35:20] the pain

[00:35:20] population

[00:35:21] with no

[00:35:22] abuse

[00:35:22] history is

[00:35:23] literally at

[00:35:24] no risk

[00:35:25] for addiction.

[00:35:26] shame on

[00:35:28] you,

[00:35:28] Kowal.

[00:35:30] The medical

[00:35:31] evidence

[00:35:31] overwhelmingly

[00:35:32] indicates that

[00:35:34] properly

[00:35:34] administered

[00:35:35] opioid

[00:35:36] therapy

[00:35:36] rarely,

[00:35:37] if ever,

[00:35:38] results in

[00:35:39] accidental

[00:35:39] addiction

[00:35:40] or opioid

[00:35:41] abuse.

[00:35:42] Shame on

[00:35:43] you,

[00:35:43] Libby.

[00:35:44] Doctors

[00:35:45] were acting

[00:35:46] as drug

[00:35:46] dealers during

[00:35:47] the initial

[00:35:47] phases of

[00:35:48] the prescription

[00:35:49] pain pill

[00:35:49] epidemic.

[00:35:51] The risk

[00:35:52] of addiction

[00:35:53] with opium

[00:35:54] goes back

[00:35:55] a long,

[00:35:57] long time.

[00:35:59] The risk

[00:36:00] of morphine

[00:36:01] addiction

[00:36:02] after World

[00:36:03] Wars,

[00:36:04] after

[00:36:04] Vietnam,

[00:36:06] these are

[00:36:07] well-known

[00:36:07] things that

[00:36:09] occurred in

[00:36:09] history,

[00:36:10] even outside

[00:36:11] of medicine.

[00:36:13] I mean,

[00:36:14] to say

[00:36:15] that there

[00:36:16] is no

[00:36:17] evidence that

[00:36:18] this occurs

[00:36:18] when prescribing

[00:36:20] opioids for

[00:36:20] pain,

[00:36:21] shame on

[00:36:22] you,

[00:36:23] Isles,

[00:36:23] Caterol,

[00:36:24] and Hanks.

[00:36:25] You're using

[00:36:26] opioid

[00:36:27] analgesics

[00:36:28] or pain

[00:36:29] relievers

[00:36:29] chronically

[00:36:30] for abdominal

[00:36:31] pain.

[00:36:32] Now,

[00:36:33] one of the

[00:36:34] major side

[00:36:34] effects of

[00:36:35] opiates

[00:36:35] is

[00:36:36] constipation.

[00:36:38] It's

[00:36:38] almost like

[00:36:39] causing

[00:36:41] or worsening

[00:36:42] their

[00:36:42] abdominal

[00:36:42] by slow

[00:36:44] GI

[00:36:44] transit

[00:36:45] and causing

[00:36:46] constipation.

[00:36:48] Now,

[00:36:49] here's another

[00:36:50] one.

[00:36:50] Only four

[00:36:51] of 11,882

[00:36:53] cases showed

[00:36:54] psychological

[00:36:55] dependency

[00:36:56] in Porter and

[00:36:57] Jicks'

[00:36:58] study.

[00:36:59] Shame on

[00:37:00] you,

[00:37:00] Lou,

[00:37:01] for citing

[00:37:01] a study

[00:37:02] that was

[00:37:03] not an

[00:37:03] actual

[00:37:04] study,

[00:37:04] just

[00:37:05] essentially

[00:37:06] a comment

[00:37:07] to a

[00:37:07] major

[00:37:07] journal.

[00:37:09] Though,

[00:37:09] not as

[00:37:10] much shame

[00:37:10] thrown on

[00:37:11] you as

[00:37:12] these other

[00:37:12] researchers

[00:37:13] as cancer

[00:37:13] pain treatment

[00:37:14] is a

[00:37:15] legitimate

[00:37:15] reason for

[00:37:16] utilizing

[00:37:16] opioids.

[00:37:18] And again,

[00:37:19] we continue.

[00:37:20] Addiction rarely

[00:37:21] evolves in the

[00:37:22] setting of

[00:37:23] painful

[00:37:23] conditions,

[00:37:24] according to

[00:37:25] studies

[00:37:26] not cited.

[00:37:28] Shame on

[00:37:29] you,

[00:37:29] Curtis,

[00:37:30] Morell,

[00:37:31] and Todd.

[00:37:32] I wonder

[00:37:33] if they

[00:37:33] would hold

[00:37:34] true to

[00:37:34] that stance

[00:37:35] on opiates

[00:37:36] risk for

[00:37:36] addiction

[00:37:37] now that

[00:37:38] hundreds of

[00:37:38] thousands

[00:37:39] of people

[00:37:39] are dying

[00:37:40] every year

[00:37:41] and millions

[00:37:43] have died

[00:37:43] since the

[00:37:44] onset

[00:37:44] as a

[00:37:45] result

[00:37:46] of

[00:37:46] opiate

[00:37:47] and

[00:37:47] other

[00:37:47] drug

[00:37:47] addiction.

[00:37:48] And lastly,

[00:37:50] citing that

[00:37:50] the Boston

[00:37:51] Drug Surveillance

[00:37:52] Program

[00:37:53] reviewed the

[00:37:54] charts of

[00:37:54] nearly 12,000

[00:37:56] cancer pain

[00:37:57] patients

[00:37:58] treated over

[00:37:59] a decade

[00:37:59] and found

[00:38:00] only four of

[00:38:01] them could

[00:38:01] be labeled

[00:38:02] as

[00:38:03] addicts,

[00:38:04] which is

[00:38:04] a shitty

[00:38:04] term by

[00:38:05] the way,

[00:38:06] seems like

[00:38:07] a convenient

[00:38:07] conclusion

[00:38:08] for

[00:38:08] Levy's

[00:38:09] paper.

[00:38:10] I've

[00:38:11] worked in

[00:38:11] research

[00:38:11] and when

[00:38:12] you have

[00:38:13] an expectancy

[00:38:13] bias,

[00:38:14] you may

[00:38:15] even

[00:38:15] unknowingly

[00:38:16] cite

[00:38:17] evidence

[00:38:17] that

[00:38:18] doesn't

[00:38:18] exist.

[00:38:20] Such as

[00:38:21] the claim

[00:38:21] that the

[00:38:22] Boston Drug

[00:38:22] Surveillance

[00:38:23] Program

[00:38:23] reviewed

[00:38:24] 12,000

[00:38:25] cancer

[00:38:25] pain

[00:38:26] patients

[00:38:26] charts,

[00:38:27] which is

[00:38:28] just not

[00:38:29] the case

[00:38:29] and is

[00:38:29] never

[00:38:30] stated

[00:38:30] in that

[00:38:30] original

[00:38:31] Porter

[00:38:32] and Jick

[00:38:32] letter

[00:38:32] to the

[00:38:33] editor.

[00:38:34] There's

[00:38:35] nothing

[00:38:35] saying

[00:38:35] that

[00:38:36] all

[00:38:36] 12,000

[00:38:37] reviewed

[00:38:37] were

[00:38:38] cancer

[00:38:38] patients.

[00:38:39] So

[00:38:40] in

[00:38:41] reality,

[00:38:42] the

[00:38:42] VA

[00:38:43] and

[00:38:43] the

[00:38:43] Department

[00:38:44] of Defense

[00:38:44] in

[00:38:45] 2017

[00:38:45] clinical

[00:38:46] practice

[00:38:47] guidelines

[00:38:47] for

[00:38:48] opioid

[00:38:48] therapy

[00:38:49] even

[00:38:49] for

[00:38:50] chronic

[00:38:50] pain

[00:38:50] cites

[00:38:52] that

[00:38:52] long-term

[00:38:53] opiate

[00:38:54] treatment

[00:38:54] does not

[00:38:55] have

[00:38:56] evidence

[00:38:56] for long-term

[00:38:57] efficacy

[00:38:58] and reveals

[00:38:59] that

[00:38:59] no study

[00:39:01] using

[00:39:01] opiates

[00:39:02] for

[00:39:02] chronic

[00:39:02] pain

[00:39:03] lasted

[00:39:04] longer

[00:39:04] than

[00:39:04] 16

[00:39:04] weeks.

[00:39:05] Sounds

[00:39:06] very

[00:39:06] similar

[00:39:07] to some

[00:39:07] of the

[00:39:08] benzo

[00:39:08] studies

[00:39:09] lasting

[00:39:09] 6-8

[00:39:10] weeks

[00:39:10] reducing

[00:39:11] anxiety

[00:39:12] only to

[00:39:13] have

[00:39:13] that

[00:39:14] anxiety

[00:39:14] worsen

[00:39:15] in the

[00:39:15] long-term.

[00:39:16] Now

[00:39:17] actual

[00:39:18] validated

[00:39:18] studies

[00:39:19] on the

[00:39:19] risk

[00:39:20] of

[00:39:20] addiction

[00:39:20] with

[00:39:21] prolonged

[00:39:21] opiate

[00:39:22] use

[00:39:22] prescription

[00:39:23] and

[00:39:24] outpatient

[00:39:25] prescription

[00:39:26] hover

[00:39:27] around

[00:39:27] 28%.

[00:39:29] So

[00:39:30] what

[00:39:32] follows

[00:39:32] is

[00:39:33] Purdue

[00:39:34] Pharma

[00:39:35] touting

[00:39:35] to their

[00:39:36] pharmaceutical

[00:39:37] sales reps

[00:39:37] that

[00:39:38] the

[00:39:39] risk

[00:39:39] of

[00:39:39] addiction

[00:39:40] with

[00:39:41] chronic

[00:39:41] opiate

[00:39:41] treatment

[00:39:42] is

[00:39:43] less

[00:39:44] than

[00:39:44] 1%,

[00:39:45] which

[00:39:46] you'll

[00:39:46] hear a lot

[00:39:47] about

[00:39:47] in the

[00:39:47] Hulu

[00:39:49] show

[00:39:50] Dope

[00:39:51] Sick,

[00:39:51] which

[00:39:52] jumps

[00:39:52] between

[00:39:53] storylines

[00:39:53] revolving

[00:39:54] around

[00:39:54] individual

[00:39:55] struggling

[00:39:56] with

[00:39:56] addiction

[00:39:56] both

[00:39:57] doctors

[00:39:58] who

[00:39:58] recognized

[00:39:59] what

[00:39:59] was

[00:39:59] going

[00:39:59] on

[00:40:00] and

[00:40:00] those

[00:40:00] who

[00:40:00] participated

[00:40:01] in

[00:40:01] the

[00:40:01] carnage

[00:40:02] as well

[00:40:03] as

[00:40:03] the

[00:40:03] legal

[00:40:03] battle

[00:40:04] between

[00:40:04] U.S.

[00:40:05] of

[00:40:06] the

[00:40:06] Western

[00:40:06] District

[00:40:07] of

[00:40:07] Virginia

[00:40:08] John

[00:40:08] Brownlee

[00:40:09] and his

[00:40:09] team

[00:40:09] and

[00:40:10] Purdue

[00:40:11] Pharma

[00:40:11] and

[00:40:11] the

[00:40:12] FDA

[00:40:13] in

[00:40:14] late

[00:40:14] 1995

[00:40:15] Oxycontin

[00:40:16] got FDA

[00:40:17] approval

[00:40:17] for treating

[00:40:18] chronic

[00:40:18] pain

[00:40:19] after

[00:40:20] an

[00:40:20] initially

[00:40:21] staunch

[00:40:22] regulator

[00:40:22] Dr.

[00:40:24] Curtis

[00:40:24] Wright

[00:40:24] denied

[00:40:25] it

[00:40:25] multiple

[00:40:26] times

[00:40:26] but

[00:40:27] he

[00:40:27] magically

[00:40:28] changed

[00:40:29] his

[00:40:29] mind

[00:40:29] in

[00:40:29] December

[00:40:30] of

[00:40:30] 1995

[00:40:31] interestingly

[00:40:32] he was

[00:40:33] working for

[00:40:34] Purdue

[00:40:34] Pharma

[00:40:35] one year

[00:40:35] later

[00:40:36] making

[00:40:37] three

[00:40:37] acts

[00:40:37] or

[00:40:52] atrocious

[00:40:53] details

[00:40:54] and

[00:40:54] misrepresentations

[00:40:56] of

[00:40:56] science

[00:40:56] committed

[00:40:57] by

[00:40:57] Purdue

[00:40:57] the

[00:40:58] FDA

[00:40:59] and

[00:40:59] others

[00:41:00] if

[00:41:01] you

[00:41:01] want

[00:41:01] to

[00:41:01] learn

[00:41:01] more

[00:41:02] about

[00:41:02] the

[00:41:02] legal

[00:41:02] battles

[00:41:03] check

[00:41:03] out

[00:41:04] Dope

[00:41:04] Sick

[00:41:04] on

[00:41:04] Hulu

[00:41:05] painkiller

[00:41:06] on

[00:41:06] Netflix

[00:41:07] read

[00:41:07] the

[00:41:08] book

[00:41:08] Empire

[00:41:08] of

[00:41:09] Pain

[00:41:09] chronicling

[00:41:10] the

[00:41:10] multiple

[00:41:10] investigations

[00:41:11] of

[00:41:12] the

[00:41:12] Sacklers

[00:41:12] and

[00:41:13] their

[00:41:13] company

[00:41:13] or

[00:41:14] just

[00:41:15] look

[00:41:15] online

[00:41:15] for

[00:41:15] one

[00:41:16] of

[00:41:16] the

[00:41:16] many

[00:41:16] detailed

[00:41:17] articles

[00:41:17] outlining

[00:41:19] what

[00:41:22] that

[00:41:23] paved

[00:41:23] the

[00:41:24] way

[00:41:24] for

[00:41:24] America's

[00:41:25] addiction

[00:41:25] crisis

[00:41:28] so

[00:41:28] Purdue's

[00:41:29] job

[00:41:30] is to

[00:41:30] make

[00:41:31] money

[00:41:31] for

[00:41:31] shareholders

[00:41:32] and

[00:41:33] they

[00:41:33] were

[00:41:33] damn

[00:41:34] good

[00:41:34] at

[00:41:34] it

[00:41:34] they

[00:41:35] hired

[00:41:35] so-called

[00:41:36] experts

[00:41:36] who

[00:41:37] would

[00:41:37] tout

[00:41:37] legitimate

[00:41:38] and

[00:41:39] metadata

[00:41:39] to

[00:41:42] promote

[00:41:43] the

[00:41:43] drug

[00:41:43] to

[00:41:44] doctors

[00:41:44] and

[00:41:45] other

[00:41:45] providers

[00:41:46] one

[00:41:47] example

[00:41:47] of

[00:41:47] this

[00:41:48] is

[00:41:48] evidence

[00:41:48] in

[00:41:49] the

[00:41:49] graph

[00:41:49] that

[00:41:49] you

[00:41:49] see

[00:41:50] on

[00:41:51] the

[00:41:51] top

[00:41:51] of

[00:41:51] this

[00:41:51] slide

[00:41:52] you

[00:41:52] can

[00:41:52] see

[00:41:53] the

[00:41:53] y-axis

[00:41:55] represents

[00:41:55] the

[00:41:55] concentration

[00:41:56] of

[00:41:56] the

[00:41:56] drug

[00:41:57] and

[00:41:57] it

[00:41:58] is

[00:41:58] compressed

[00:41:58] to

[00:41:59] make

[00:42:00] it

[00:42:00] look

[00:42:00] like

[00:42:00] Oxycontin

[00:42:01] has

[00:42:01] a steady

[00:42:02] release

[00:42:03] effect

[00:42:03] over

[00:42:03] 12

[00:42:04] hours

[00:42:04] in

[00:42:05] reality

[00:42:06] as

[00:42:07] you

[00:42:07] can

[00:42:07] see

[00:42:07] on

[00:42:07] the

[00:42:07] bottom

[00:42:08] chart

[00:42:08] that

[00:42:08] is

[00:42:09] not

[00:42:09] compressed

[00:42:10] true

[00:42:11] and

[00:42:11] moral

[00:42:11] researchers

[00:42:12] conducting

[00:42:13] additional

[00:42:14] studies

[00:42:14] reveal

[00:42:15] the

[00:42:15] actual

[00:42:16] concentrations

[00:42:17] of

[00:42:17] Oxycontin

[00:42:18] in

[00:42:18] the

[00:42:18] body

[00:42:19] with

[00:42:21] the

[00:42:21] peak

[00:42:21] effect

[00:42:21] around

[00:42:22] hour

[00:42:22] 1-2

[00:42:23] and

[00:42:23] an

[00:42:24] exponentially

[00:42:24] decreasing

[00:42:25] pain

[00:42:26] relieving

[00:42:26] and

[00:42:27] euphoric

[00:42:27] effect

[00:42:28] shortly

[00:42:28] afterwards

[00:42:29] doctors

[00:42:30] and

[00:42:31] providers

[00:42:31] do

[00:42:32] bear

[00:42:32] some

[00:42:32] of

[00:42:32] the

[00:42:32] responsibility

[00:42:33] based

[00:42:34] based

[00:42:34] their

[00:42:34] ignorance

[00:42:35] as

[00:42:35] well

[00:42:35] I

[00:42:36] mean

[00:42:36] come

[00:42:37] on

[00:42:37] anytime

[00:42:38] you

[00:42:39] see

[00:42:39] a

[00:42:39] graph

[00:42:39] that

[00:42:39] is

[00:42:40] compressed

[00:42:40] or

[00:42:40] stretched

[00:42:41] out

[00:42:41] you

[00:42:42] should

[00:42:42] be

[00:42:42] immediately

[00:42:43] skeptical

[00:42:43] about

[00:42:44] the

[00:42:44] stated

[00:42:45] conclusions

[00:42:46] Purdue

[00:42:47] was not

[00:42:47] the only

[00:42:48] bad actor

[00:42:48] contributing

[00:42:49] to the

[00:42:49] opiate

[00:42:50] epidemic

[00:42:50] several

[00:42:51] other

[00:42:51] opiate

[00:42:52] makers

[00:42:52] including

[00:42:53] SpecGX

[00:42:54] a subsidiary

[00:42:55] of

[00:42:55] Malincrot

[00:42:56] who

[00:42:57] makes

[00:42:57] oxyan

[00:42:58] hydrocodone

[00:42:59] activists

[00:43:00] slash

[00:43:00] Teva

[00:43:01] who

[00:43:01] makes

[00:43:02] Norco

[00:43:02] and

[00:43:03] several

[00:43:03] distributors

[00:43:04] including

[00:43:05] McKesson

[00:43:05] who

[00:43:07] at one

[00:43:07] time

[00:43:07] was

[00:43:07] distributing

[00:43:08] more

[00:43:09] oxycodone

[00:43:10] than

[00:43:11] there

[00:43:11] were

[00:43:11] people

[00:43:12] in

[00:43:12] a

[00:43:12] small

[00:43:13] West

[00:43:13] Virginia

[00:43:13] county

[00:43:15] Walgreens

[00:43:16] CVS

[00:43:17] Walmart

[00:43:18] all

[00:43:19] of

[00:43:19] these

[00:43:20] big

[00:43:20] corporate

[00:43:21] entities

[00:43:21] profited

[00:43:22] from

[00:43:23] Oxycontin

[00:43:23] except

[00:43:25] the

[00:43:26] people

[00:43:26] promised

[00:43:27] the

[00:43:28] benefits

[00:43:28] the

[00:43:29] American

[00:43:29] people

[00:43:30] they're

[00:43:31] the ones

[00:43:31] who

[00:43:31] suffered

[00:43:32] this

[00:43:32] is

[00:43:32] a

[00:43:32] huge

[00:43:33] reason

[00:43:33] why

[00:43:34] I

[00:43:34] don't

[00:43:34] see

[00:43:34] any

[00:43:35] need

[00:43:35] and

[00:43:36] have

[00:43:36] no

[00:43:36] desire

[00:43:37] to

[00:43:38] spend

[00:43:38] time

[00:43:38] with

[00:43:38] pharmaceutical

[00:43:39] drug

[00:43:39] reps

[00:43:40] how

[00:43:41] in

[00:43:41] the

[00:43:41] fuck

[00:43:41] could

[00:43:41] they

[00:43:42] know

[00:43:42] more

[00:43:42] about

[00:43:42] how

[00:43:43] a

[00:43:43] drug

[00:43:43] works

[00:43:43] and

[00:43:44] the

[00:43:44] nuances

[00:43:45] of

[00:43:45] its

[00:43:45] interactions

[00:43:46] and

[00:43:46] indications

[00:43:47] than

[00:43:48] a

[00:43:48] doctor

[00:43:48] with

[00:43:49] at

[00:43:49] minimum

[00:43:50] nearly

[00:43:50] 10

[00:43:51] years

[00:43:51] of

[00:43:51] training

[00:43:51] and

[00:43:52] experience

[00:43:53] all

[00:43:54] before

[00:43:54] that

[00:43:54] doctor

[00:43:54] is

[00:43:55] allowed

[00:43:55] to

[00:43:55] prescribe

[00:43:55] independently

[00:43:56] shame

[00:43:57] on

[00:43:58] the

[00:43:58] key

[00:43:58] opinion

[00:43:58] leaders

[00:43:59] for

[00:43:59] neglecting

[00:44:00] their

[00:44:00] Hippocratic

[00:44:00] oaths

[00:44:01] to

[00:44:01] not

[00:44:02] harm

[00:44:02] our

[00:44:02] patients

[00:44:04] as

[00:44:04] I

[00:44:05] alluded

[00:44:05] to

[00:44:05] earlier

[00:44:05] in

[00:44:06] 2019

[00:44:07] while

[00:44:08] investigating

[00:44:09] the opiate

[00:44:10] epidemic

[00:44:10] the

[00:44:11] house

[00:44:11] energy

[00:44:12] and

[00:44:12] commerce

[00:44:12] committee

[00:44:13] found

[00:44:14] that

[00:44:14] between

[00:44:15] 2006

[00:44:16] and

[00:44:16] 2016

[00:44:17] in

[00:44:18] Williamson

[00:44:19] West

[00:44:19] Virginia

[00:44:19] on the

[00:44:20] Kentucky

[00:44:20] border

[00:44:21] around

[00:44:22] Hatfield

[00:44:22] McCoy

[00:44:23] territory

[00:44:24] 21

[00:44:25] million

[00:44:26] pain

[00:44:26] pills

[00:44:26] were

[00:44:26] dispensed

[00:44:27] to

[00:44:28] a

[00:44:28] population

[00:44:28] of

[00:44:29] 3200

[00:44:30] people

[00:44:30] in

[00:44:31] a

[00:44:31] county

[00:44:31] that

[00:44:32] only

[00:44:32] had

[00:44:32] two

[00:44:33] pharmacies

[00:44:33] that

[00:44:34] amounts

[00:44:35] to

[00:44:35] about

[00:44:35] 6500

[00:44:36] pills

[00:44:37] per

[00:44:37] resident

[00:44:38] of

[00:44:38] the

[00:44:38] county

[00:44:39] or

[00:44:40] roughly

[00:44:40] two

[00:44:40] pills

[00:44:41] per

[00:44:41] day

[00:44:41] over

[00:44:42] 10

[00:44:42] years

[00:44:42] for

[00:44:43] every

[00:44:44] resident

[00:44:44] of

[00:44:45] that

[00:44:45] county

[00:44:46] it

[00:44:47] would

[00:44:47] be

[00:44:47] one

[00:44:47] thing

[00:44:48] if

[00:44:48] a

[00:44:49] substantial

[00:44:49] number

[00:44:50] of

[00:44:50] people

[00:44:50] were

[00:44:50] benefiting

[00:44:51] from

[00:44:51] this

[00:44:52] drug

[00:44:52] but

[00:44:53] not

[00:44:54] only

[00:44:54] did

[00:44:55] the

[00:44:55] number

[00:44:55] and

[00:44:55] dose

[00:44:56] of

[00:44:56] prescriptions

[00:44:56] see a

[00:44:57] steep

[00:44:57] increase

[00:44:58] in

[00:44:58] the

[00:44:58] 2000s

[00:44:59] all

[00:45:00] of a

[00:45:00] sudden

[00:45:00] Americans

[00:45:01] required

[00:45:02] higher

[00:45:02] and

[00:45:03] higher

[00:45:03] dosages

[00:45:03] to

[00:45:04] manage

[00:45:04] their

[00:45:04] pain

[00:45:05] and

[00:45:06] Purdue

[00:45:06] had an

[00:45:06] answer

[00:45:07] for

[00:45:07] that

[00:45:07] as

[00:45:07] well

[00:45:08] labeling

[00:45:09] it

[00:45:09] breakthrough

[00:45:10] pain

[00:45:12] and

[00:45:13] you

[00:45:13] know

[00:45:13] what

[00:45:13] the

[00:45:13] answer

[00:45:14] was

[00:45:14] more

[00:45:15] oxy

[00:45:16] cotton

[00:45:16] now

[00:45:18] ironically

[00:45:19] more

[00:45:20] oxy

[00:45:20] cotton

[00:45:21] was

[00:45:22] associated

[00:45:22] with

[00:45:23] more

[00:45:23] chronic

[00:45:23] pain

[00:45:24] in

[00:45:24] Americans

[00:45:24] a

[00:45:25] drug

[00:45:26] that

[00:45:26] was

[00:45:26] supposed

[00:45:27] to

[00:45:27] last

[00:45:27] 12

[00:45:28] hours

[00:45:28] quickly

[00:45:29] became

[00:45:30] an

[00:45:30] every

[00:45:30] 8

[00:45:30] hour

[00:45:30] pill

[00:45:31] and

[00:45:32] later

[00:45:32] every

[00:45:32] 6

[00:45:32] hours

[00:45:33] as

[00:45:33] it

[00:45:34] is

[00:45:34] today

[00:45:34] if

[00:45:35] you've

[00:45:36] ever

[00:45:36] taken

[00:45:36] an

[00:45:37] opiate

[00:45:37] prescription

[00:45:37] then

[00:45:38] you

[00:45:39] know

[00:45:39] how

[00:45:39] powerful

[00:45:40] these

[00:45:40] medications

[00:45:40] can

[00:45:41] be

[00:45:41] in

[00:45:41] any

[00:45:42] given

[00:45:42] person

[00:45:43] 20

[00:45:44] milligrams

[00:45:44] of

[00:45:45] oxy

[00:45:45] codone

[00:45:45] in

[00:45:46] an

[00:45:46] opiate

[00:45:46] naive

[00:45:46] person

[00:45:47] could lead

[00:45:48] to fatal

[00:45:49] respiratory

[00:45:49] depression

[00:45:50] and was

[00:45:51] a common

[00:45:52] starting

[00:45:52] dose

[00:45:53] for people

[00:45:53] Purdue

[00:45:55] even

[00:45:55] made

[00:45:56] for a

[00:45:56] time

[00:45:57] probably

[00:45:58] until

[00:45:58] too many

[00:45:59] people

[00:45:59] died

[00:46:00] from it

[00:46:00] a

[00:46:01] 160

[00:46:02] milligram

[00:46:03] oxy

[00:46:04] cotton

[00:46:05] pill

[00:46:05] which

[00:46:06] is

[00:46:06] just

[00:46:07] an

[00:46:07] absurd

[00:46:08] and

[00:46:08] extremely

[00:46:09] dangerous

[00:46:10] amount

[00:46:10] now

[00:46:13] some

[00:46:13] people

[00:46:14] tell me

[00:46:14] that I

[00:46:14] should

[00:46:15] be

[00:46:15] more

[00:46:15] political

[00:46:15] more

[00:46:16] professional

[00:46:17] when

[00:46:17] discussing

[00:46:18] this

[00:46:18] crisis

[00:46:19] and

[00:46:19] the

[00:46:20] players

[00:46:20] involved

[00:46:20] but

[00:46:21] fuck

[00:46:22] that

[00:46:22] this

[00:46:24] company

[00:46:24] intentionally

[00:46:25] preyed

[00:46:26] on

[00:46:27] my

[00:46:27] region

[00:46:28] my

[00:46:29] community

[00:46:29] my

[00:46:30] friends

[00:46:31] my

[00:46:31] people

[00:46:32] they

[00:46:33] initially

[00:46:34] targeted

[00:46:35] economically

[00:46:35] down

[00:46:36] and out

[00:46:37] Appalachian

[00:46:38] populations

[00:46:39] with high

[00:46:40] unemployment

[00:46:41] and poverty

[00:46:41] rates

[00:46:42] after many

[00:46:43] steel

[00:46:44] coal

[00:46:44] and textile

[00:46:45] factory jobs

[00:46:46] dried up

[00:46:47] in the

[00:46:47] 1980s

[00:46:48] and 1990s

[00:46:49] where work

[00:46:50] was hard

[00:46:51] to find

[00:46:52] and despair

[00:46:53] was common

[00:46:54] place

[00:46:54] a place

[00:46:55] where

[00:46:55] 99%

[00:46:57] of the

[00:46:57] Appalachian

[00:46:58] population

[00:46:58] owns

[00:46:59] less than

[00:47:00] half

[00:47:00] of the

[00:47:01] Appalachian

[00:47:01] land

[00:47:02] I

[00:47:03] grew up

[00:47:04] in a

[00:47:04] region

[00:47:04] with the

[00:47:05] highest

[00:47:06] prescription

[00:47:06] painkiller

[00:47:07] rates

[00:47:07] not just

[00:47:09] in the

[00:47:09] United

[00:47:09] States

[00:47:10] but in

[00:47:10] the world

[00:47:11] you had

[00:47:12] previously

[00:47:13] red flagged

[00:47:14] physicians

[00:47:14] who had

[00:47:15] committed

[00:47:16] insurance

[00:47:16] fraud

[00:47:17] medical

[00:47:17] malpractice

[00:47:18] had their

[00:47:19] own personal

[00:47:20] struggles

[00:47:20] with addiction

[00:47:21] or inappropriate

[00:47:22] sexual

[00:47:23] relationships

[00:47:23] with patients

[00:47:24] who had

[00:47:25] lost their

[00:47:26] license

[00:47:26] in one

[00:47:27] state

[00:47:27] and traveled

[00:47:28] to the

[00:47:29] next

[00:47:29] state

[00:47:30] teaming

[00:47:30] up with

[00:47:31] morally

[00:47:31] aloof

[00:47:32] entrepreneurs

[00:47:33] to open

[00:47:34] up pill

[00:47:35] mills

[00:47:35] throughout

[00:47:36] Appalachia

[00:47:37] and the

[00:47:37] deep

[00:47:37] south

[00:47:38] with

[00:47:39] providers

[00:47:39] regularly

[00:47:40] spending

[00:47:41] less than

[00:47:41] five minutes

[00:47:42] with patients

[00:47:43] and prescribing

[00:47:45] Oxycontin

[00:47:46] to hundreds

[00:47:46] of people

[00:47:47] per day

[00:47:47] for mostly

[00:47:49] minor aches

[00:47:50] and pains

[00:47:50] they knew

[00:47:52] people were

[00:47:52] abusing

[00:47:53] the drug

[00:47:53] nicknamed

[00:47:54] by Appalachian

[00:47:56] users

[00:47:56] as

[00:47:57] hillbilly

[00:47:58] heroin

[00:47:58] and actually

[00:48:00] down the

[00:48:02] road

[00:48:02] legally

[00:48:02] Purdue

[00:48:03] got into

[00:48:04] legal trouble

[00:48:05] as internal

[00:48:06] documents

[00:48:06] and emails

[00:48:07] revealed

[00:48:08] that they

[00:48:09] were aware

[00:48:09] patients

[00:48:10] were abusing

[00:48:11] the drug

[00:48:12] by allowing

[00:48:13] the outer

[00:48:14] coating to

[00:48:14] dissolve in

[00:48:15] their mouths

[00:48:15] then crushing

[00:48:17] the remaining

[00:48:17] pill

[00:48:18] and snorting

[00:48:18] it

[00:48:19] effectively

[00:48:20] turning

[00:48:20] what was

[00:48:20] supposed

[00:48:21] to be

[00:48:21] an

[00:48:22] extended

[00:48:23] release

[00:48:23] medicine

[00:48:24] into

[00:48:25] an

[00:48:25] immediate

[00:48:26] release

[00:48:26] medicine

[00:48:27] magnifying

[00:48:28] the risks

[00:48:28] of

[00:48:29] dependence

[00:48:29] and

[00:48:31] magnifying

[00:48:31] the risks

[00:48:32] of fatal

[00:48:32] overdose

[00:48:33] as the

[00:48:34] drug

[00:48:34] tells

[00:48:35] users

[00:48:35] brains

[00:48:35] to stop

[00:48:36] breathing

[00:48:38] so

[00:48:39] you had

[00:48:40] in this

[00:48:41] area

[00:48:41] hillbilly

[00:48:42] entrepreneurs

[00:48:43] some just

[00:48:45] looking for

[00:48:45] a way to

[00:48:46] support their

[00:48:46] families

[00:48:46] who would

[00:48:48] scoop up

[00:48:48] those who

[00:48:49] had developed

[00:48:49] addictions

[00:48:50] to the

[00:48:50] opiates

[00:48:51] and drive

[00:48:52] them to

[00:48:52] multiple

[00:48:53] doctors

[00:48:53] and pharmacies

[00:48:54] or when

[00:48:56] the federal

[00:48:56] government put

[00:48:57] restrictions

[00:48:57] in place

[00:48:58] that didn't

[00:48:59] allow people

[00:49:00] to visit

[00:49:00] multiple

[00:49:01] doctors

[00:49:01] or

[00:49:01] pharmacies

[00:49:02] pharmacies

[00:49:02] that

[00:49:03] they would

[00:49:04] drive

[00:49:04] from

[00:49:05] Kentucky

[00:49:06] all the

[00:49:07] way down

[00:49:07] I-65

[00:49:08] to Florida

[00:49:08] where

[00:49:09] they hadn't

[00:49:11] quite caught

[00:49:11] up with

[00:49:12] the

[00:49:13] prescription

[00:49:13] drug

[00:49:14] monitoring

[00:49:14] systems

[00:49:15] that would

[00:49:16] prevent

[00:49:16] them from

[00:49:17] seeing a

[00:49:17] provider

[00:49:18] in

[00:49:18] Kentucky

[00:49:18] and

[00:49:19] Florida

[00:49:19] this

[00:49:20] created

[00:49:21] a

[00:49:21] secondary

[00:49:21] market

[00:49:22] and a

[00:49:23] trickle-down

[00:49:23] economy

[00:49:24] for resale

[00:49:25] and redistribution

[00:49:26] of these

[00:49:26] pills

[00:49:26] criminals

[00:49:27] I have

[00:49:28] to note

[00:49:29] at this

[00:49:29] point

[00:49:30] that many

[00:49:31] of those

[00:49:32] criminals

[00:49:32] were prosecuted

[00:49:34] long before

[00:49:35] the true

[00:49:36] instigators

[00:49:37] working in

[00:49:37] the upper

[00:49:38] echelons of

[00:49:39] Purdue Pharma

[00:49:39] or a lot

[00:49:41] of these

[00:49:41] entrepreneurs

[00:49:42] who opened

[00:49:43] these pill

[00:49:43] mills

[00:49:45] now I

[00:49:46] agree

[00:49:46] they should

[00:49:47] be

[00:49:48] prosecuted

[00:49:49] and punished

[00:49:49] and they

[00:49:50] did play

[00:49:51] a part

[00:49:51] in many

[00:49:53] people's

[00:49:53] fatal

[00:49:54] overdoses

[00:49:54] but they

[00:49:56] didn't play

[00:49:56] the same

[00:49:56] part

[00:49:57] that these

[00:49:58] people

[00:49:58] in the

[00:49:58] upper

[00:49:59] echelons

[00:49:59] of the

[00:50:00] pharmaceutical

[00:50:00] company

[00:50:01] did

[00:50:03] now

[00:50:03] if you've

[00:50:04] watched

[00:50:05] the pharmacists

[00:50:06] on Netflix

[00:50:06] you'll remember

[00:50:08] Jacqueline

[00:50:08] Clegett

[00:50:09] an opiate

[00:50:10] addicted

[00:50:11] physician

[00:50:11] operating a

[00:50:12] pain clinic

[00:50:13] in Louisiana

[00:50:13] with lines

[00:50:15] of patients

[00:50:16] extending out

[00:50:17] the door

[00:50:17] at 2

[00:50:18] in the

[00:50:18] morning

[00:50:19] there were

[00:50:20] no limitations

[00:50:21] to how many

[00:50:22] prescriptions

[00:50:23] a doctor

[00:50:23] could write

[00:50:24] nor any

[00:50:26] way to

[00:50:26] prevent

[00:50:26] multiple

[00:50:27] visits

[00:50:27] to multiple

[00:50:28] doctors

[00:50:28] and multiple

[00:50:29] prescriptions

[00:50:30] one doctor

[00:50:31] could see

[00:50:32] as many

[00:50:33] patients

[00:50:33] as they

[00:50:34] possibly

[00:50:34] could

[00:50:35] without

[00:50:36] any

[00:50:36] limitations

[00:50:37] on the

[00:50:37] time

[00:50:38] restraint

[00:50:38] with each

[00:50:39] patient

[00:50:41] now

[00:50:41] let's

[00:50:43] watch what

[00:50:43] happens

[00:50:43] to the

[00:50:44] number

[00:50:44] of

[00:50:45] deaths

[00:50:45] well

[00:50:46] below

[00:50:47] 20,000

[00:50:48] prior to

[00:50:48] Oxycontin's

[00:50:49] emergence

[00:50:50] over the

[00:50:51] decade

[00:50:51] that

[00:50:51] followed

[00:50:53] a

[00:50:54] problem

[00:50:54] that

[00:50:55] started

[00:50:55] out

[00:50:55] primarily

[00:50:56] in

[00:50:56] Appalachia

[00:50:57] slowly

[00:50:58] spreads

[00:50:58] like a

[00:50:59] virus

[00:50:59] with a

[00:51:00] nearly

[00:51:01] 40%

[00:51:01] increase

[00:51:02] in

[00:51:02] overdose

[00:51:03] deaths

[00:51:03] between

[00:51:03] 2003

[00:51:04] and

[00:51:04] 2006

[00:51:07] and

[00:51:08] in

[00:51:09] 2009

[00:51:09] we

[00:51:10] watch

[00:51:11] it

[00:51:11] steadily

[00:51:12] spread

[00:51:12] out

[00:51:12] to

[00:51:12] the

[00:51:12] southwest

[00:51:13] in

[00:51:13] the

[00:51:13] western

[00:51:14] United

[00:51:14] States

[00:51:15] and a

[00:51:16] steady

[00:51:16] increase

[00:51:16] in the

[00:51:17] numbers

[00:51:17] of

[00:51:18] dark

[00:51:18] red

[00:51:18] counties

[00:51:19] representing

[00:51:20] a 20

[00:51:20] plus

[00:51:21] person

[00:51:21] out

[00:51:22] of

[00:51:22] 100,000

[00:51:23] death

[00:51:23] rate

[00:51:23] from

[00:51:24] fatal

[00:51:24] overdoses

[00:51:25] by

[00:51:26] 2012

[00:51:27] we had

[00:51:27] surpassed

[00:51:28] double

[00:51:29] the number

[00:51:30] of deaths

[00:51:30] at

[00:51:31] 41,500

[00:51:32] that we

[00:51:33] had before

[00:51:34] Oxycontin

[00:51:35] came in

[00:51:35] onto the

[00:51:35] market

[00:51:36] and by

[00:51:37] 2014

[00:51:38] Appalachia

[00:51:39] was no

[00:51:39] longer

[00:51:40] alone

[00:51:40] with

[00:51:41] huge

[00:51:41] swaths

[00:51:42] of

[00:51:42] the

[00:51:42] United

[00:51:42] States

[00:51:43] addicted

[00:51:43] to

[00:51:44] Oxycontin

[00:51:44] and other

[00:51:45] prescription

[00:51:45] opiates

[00:51:46] and

[00:51:47] outside

[00:51:47] of a

[00:51:47] thin

[00:51:48] sliver

[00:51:48] of

[00:51:48] addiction

[00:51:49] resistant

[00:51:49] Midwesterners

[00:51:50] nearly

[00:51:51] every

[00:51:52] corner

[00:51:52] of

[00:51:52] America

[00:51:53] was

[00:51:53] affected

[00:51:54] by

[00:51:54] the

[00:51:54] opiate

[00:51:55] crisis

[00:51:57] so

[00:51:57] let's

[00:51:58] briefly

[00:51:58] hop

[00:51:58] back

[00:51:59] to

[00:51:59] 2006

[00:51:59] for

[00:52:00] a

[00:52:00] minute

[00:52:00] I

[00:52:01] want

[00:52:01] to

[00:52:01] break

[00:52:02] down

[00:52:02] the

[00:52:03] crude

[00:52:03] cost

[00:52:04] without

[00:52:05] insurance

[00:52:05] of

[00:52:06] 180

[00:52:07] milligram

[00:52:08] the

[00:52:09] highest

[00:52:09] dosage

[00:52:10] form

[00:52:10] of

[00:52:10] Oxycontin

[00:52:11] when

[00:52:11] the

[00:52:11] 160

[00:52:12] milligram

[00:52:12] tablets

[00:52:13] were

[00:52:13] taken

[00:52:13] off

[00:52:13] the

[00:52:14] market

[00:52:15] 80

[00:52:16] milligram

[00:52:16] pills

[00:52:16] 100

[00:52:17] of

[00:52:17] them

[00:52:17] was

[00:52:18] about

[00:52:18] $1,000

[00:52:19] but

[00:52:20] with

[00:52:21] a

[00:52:21] Medicaid

[00:52:21] card

[00:52:22] the

[00:52:23] copay

[00:52:23] for

[00:52:23] 100

[00:52:24] pills

[00:52:24] was

[00:52:25] less

[00:52:25] than

[00:52:25] $5

[00:52:26] in

[00:52:27] this

[00:52:28] secondary

[00:52:28] market

[00:52:29] the

[00:52:30] value

[00:52:30] was

[00:52:31] $1

[00:52:31] per

[00:52:32] 1

[00:52:32] milligram

[00:52:33] of

[00:52:33] Oxycontin

[00:52:34] a

[00:52:35] 100

[00:52:35] pill

[00:52:36] 80

[00:52:36] milligram

[00:52:37] prescription

[00:52:37] would

[00:52:38] yield

[00:52:39] up to

[00:52:39] a

[00:52:39] street

[00:52:40] value

[00:52:40] of

[00:52:40] $8,000

[00:52:41] multiply

[00:52:43] that

[00:52:43] by

[00:52:44] 125

[00:52:44] patients

[00:52:45] and

[00:52:46] you

[00:52:46] just

[00:52:46] netted

[00:52:46] $1,000,000

[00:52:47] It's

[00:52:50] not

[00:52:50] that

[00:52:51] there

[00:52:51] weren't

[00:52:51] whistleblowers

[00:52:52] within

[00:52:53] Purdue

[00:52:54] and

[00:52:54] government

[00:52:55] agencies

[00:52:55] like the

[00:52:56] FDA

[00:52:56] and

[00:52:57] the

[00:52:57] DEA

[00:52:57] but

[00:52:59] they

[00:52:59] were

[00:53:00] stymied

[00:53:00] they

[00:53:01] were

[00:53:01] silenced

[00:53:01] personal

[00:53:03] local

[00:53:03] and

[00:53:04] state

[00:53:04] lawsuits

[00:53:04] against

[00:53:05] Purdue

[00:53:05] were

[00:53:06] settled

[00:53:06] out

[00:53:06] of

[00:53:06] court

[00:53:07] requiring

[00:53:08] those

[00:53:08] involved

[00:53:09] to

[00:53:09] sign

[00:53:10] non

[00:53:10] disclosure

[00:53:11] agreements

[00:53:12] or

[00:53:12] NDAs

[00:53:13] in order

[00:53:14] to reap

[00:53:14] the

[00:53:14] financial

[00:53:15] rewards

[00:53:15] of their

[00:53:16] settlements

[00:53:16] FDA

[00:53:18] and

[00:53:18] DEA

[00:53:18] officials

[00:53:19] were

[00:53:20] groomed

[00:53:20] for

[00:53:21] high-end

[00:53:21] easy

[00:53:25] pharmaceutical

[00:53:26] companies

[00:53:26] making

[00:53:27] exorbitantly

[00:53:28] more

[00:53:29] money

[00:53:29] than

[00:53:29] they

[00:53:29] were

[00:53:29] making

[00:53:30] in

[00:53:30] their

[00:53:30] government

[00:53:30] regulatory

[00:53:31] jobs

[00:53:32] At

[00:53:33] this

[00:53:33] point

[00:53:33] in

[00:53:34] 2009

[00:53:35] due

[00:53:36] to

[00:53:36] public

[00:53:37] backlash

[00:53:37] and

[00:53:38] year-over-year

[00:53:38] worsening

[00:53:39] overdose

[00:53:39] numbers

[00:53:40] the

[00:53:41] federal

[00:53:41] government

[00:53:42] realized

[00:53:42] that

[00:53:43] they

[00:53:43] had

[00:53:43] allowed

[00:53:44] an

[00:53:44] absolute

[00:53:45] mess

[00:53:45] of a

[00:53:46] public

[00:53:46] health

[00:53:47] crisis

[00:53:47] to

[00:53:47] emerge

[00:53:48] so

[00:53:49] they

[00:53:49] reacted

[00:53:50] and

[00:53:51] in

[00:53:51] typical

[00:53:51] federal

[00:53:52] government

[00:53:53] fashion

[00:53:53] they

[00:53:54] made

[00:53:55] the

[00:53:55] problem

[00:53:55] worse

[00:53:56] so

[00:53:58] as

[00:53:59] the

[00:54:00] prescription

[00:54:01] Oxycontin

[00:54:02] and opiate

[00:54:03] pain pill

[00:54:03] crisis

[00:54:04] worsened

[00:54:04] and

[00:54:05] drug overdose

[00:54:06] deaths

[00:54:06] rose

[00:54:06] quickly

[00:54:07] year-over-year

[00:54:08] the

[00:54:09] government

[00:54:09] scrambled

[00:54:10] to intervene

[00:54:11] they

[00:54:12] worked

[00:54:12] to

[00:54:13] shut

[00:54:13] down

[00:54:13] the

[00:54:13] pill

[00:54:14] mills

[00:54:14] installed

[00:54:15] PDMPs

[00:54:17] or

[00:54:17] prescription

[00:54:17] drug

[00:54:18] monitoring

[00:54:18] programs

[00:54:19] that

[00:54:21] restricted

[00:54:21] so-called

[00:54:22] doctor

[00:54:23] shopping

[00:54:23] or

[00:54:24] visiting

[00:54:24] multiple

[00:54:25] doctors

[00:54:25] in a

[00:54:26] day

[00:54:26] for

[00:54:26] the

[00:54:26] same

[00:54:26] problem

[00:54:27] or

[00:54:27] the

[00:54:27] same

[00:54:27] desired

[00:54:28] prescription

[00:54:28] and

[00:54:30] users

[00:54:31] hitting up

[00:54:32] multiple

[00:54:32] pharmacies

[00:54:33] in a

[00:54:33] day

[00:54:33] by

[00:54:33] copying

[00:54:34] their

[00:54:34] prescriptions

[00:54:36] with

[00:54:37] some

[00:54:37] pharmacies

[00:54:37] probably

[00:54:40] they

[00:54:41] were

[00:54:41] profiting

[00:54:41] from

[00:54:42] increased

[00:54:42] drug

[00:54:43] sales

[00:54:43] too

[00:54:43] many

[00:54:45] states

[00:54:45] had

[00:54:45] PDMPs

[00:54:47] installed

[00:54:47] prior

[00:54:48] to

[00:54:48] the

[00:54:48] opiate

[00:54:48] epidemic

[00:54:49] however

[00:54:50] not

[00:54:50] all

[00:54:51] states

[00:54:51] implemented

[00:54:52] them

[00:54:52] expeditiously

[00:54:53] or

[00:54:53] created

[00:54:54] legal

[00:54:54] mandates

[00:54:55] for

[00:54:55] their

[00:54:55] use

[00:54:56] by

[00:54:56] doctors

[00:54:56] and

[00:54:57] pharmacies

[00:54:58] so

[00:54:59] for

[00:54:59] several

[00:55:00] years

[00:55:00] in

[00:55:00] the

[00:55:00] mid

[00:55:01] to

[00:55:01] late

[00:55:01] 2000s

[00:55:02] states

[00:55:03] would

[00:55:03] gradually

[00:55:04] adopt

[00:55:04] and

[00:55:05] utilize

[00:55:05] PDMPs

[00:55:06] but

[00:55:10] for

[00:55:10] example

[00:55:11] in

[00:55:11] 2010

[00:55:12] only

[00:55:13] five

[00:55:13] states

[00:55:14] had

[00:55:14] mandatory

[00:55:15] PDMP

[00:55:16] query

[00:55:16] laws

[00:55:17] while

[00:55:18] today

[00:55:19] 40

[00:55:19] states

[00:55:20] have

[00:55:20] mandatory

[00:55:20] PDMP

[00:55:21] laws

[00:55:22] 70%

[00:55:24] of

[00:55:24] all

[00:55:25] current

[00:55:25] prescription

[00:55:26] drug

[00:55:26] monitoring

[00:55:27] programs

[00:55:27] were

[00:55:28] developed

[00:55:28] in the

[00:55:29] first

[00:55:29] 15

[00:55:30] years

[00:55:30] of

[00:55:30] the

[00:55:30] 21st

[00:55:31] century

[00:55:31] now

[00:55:32] Florida

[00:55:33] was one

[00:55:33] of the

[00:55:33] last

[00:55:34] states

[00:55:34] to

[00:55:34] implement

[00:55:35] a

[00:55:35] PDMP

[00:55:36] in

[00:55:36] 2009

[00:55:37] but

[00:55:38] didn't

[00:55:38] start

[00:55:38] mandating

[00:55:39] providers

[00:55:40] to

[00:55:40] query

[00:55:40] it

[00:55:40] until

[00:55:41] 2011

[00:55:42] and

[00:55:43] like

[00:55:44] most

[00:55:44] state

[00:55:44] or

[00:55:45] federal

[00:55:45] run

[00:55:45] programs

[00:55:46] it

[00:55:46] takes

[00:55:47] time

[00:55:47] to

[00:55:47] enforce

[00:55:48] new

[00:55:48] laws

[00:55:48] with

[00:55:49] providers

[00:55:49] and

[00:55:50] pharmacies

[00:55:50] most

[00:55:52] states

[00:55:52] that

[00:55:53] were

[00:55:53] hit

[00:55:53] hardest

[00:55:53] by

[00:55:54] the

[00:55:54] prescription

[00:55:54] opiate

[00:55:55] epidemic

[00:55:55] already

[00:55:56] had

[00:55:57] PDMPs

[00:55:58] in

[00:55:58] place

[00:55:59] by

[00:55:59] 2009

[00:56:00] 2010

[00:56:02] paired

[00:56:03] with a

[00:56:03] backlash

[00:56:03] against

[00:56:04] providers

[00:56:05] with a

[00:56:05] result

[00:56:05] in

[00:56:06] hesitance

[00:56:06] in

[00:56:07] prescribing

[00:56:07] opiates

[00:56:08] by many

[00:56:08] primary care

[00:56:09] doctors

[00:56:09] this

[00:56:10] led

[00:56:10] to

[00:56:11] a

[00:56:11] lot

[00:56:11] of

[00:56:11] patients

[00:56:12] being

[00:56:12] abruptly

[00:56:13] cut

[00:56:13] off

[00:56:13] from

[00:56:14] their

[00:56:14] oxycontin

[00:56:15] and

[00:56:16] other

[00:56:16] opiate

[00:56:16] supplies

[00:56:17] people's

[00:56:18] brains

[00:56:19] that

[00:56:19] struggle

[00:56:20] with

[00:56:20] addiction

[00:56:20] are

[00:56:21] really

[00:56:21] savvy

[00:56:22] at

[00:56:22] finding

[00:56:23] ways

[00:56:23] to

[00:56:23] get

[00:56:23] their

[00:56:24] desired

[00:56:24] substances

[00:56:25] for

[00:56:26] for

[00:56:26] appalachians

[00:56:27] they

[00:56:28] started

[00:56:28] to

[00:56:28] make

[00:56:29] hillbilly

[00:56:30] pilgrimages

[00:56:31] down

[00:56:32] to

[00:56:32] florida

[00:56:33] scooping

[00:56:34] up

[00:56:34] addicted

[00:56:35] persons

[00:56:35] on

[00:56:35] the

[00:56:36] way

[00:56:36] providing

[00:56:36] transportation

[00:56:37] and

[00:56:38] their

[00:56:38] co-pays

[00:56:39] then siphoning half or more of their prescriptions and bringing back hundreds to thousands of pills to their local community for resale.

[00:56:50] With demand as high as ever and supply limited, entrepreneurs were making a lot of money

[00:56:58] and some users couldn't afford the increasing prices of illicit opiates or didn't have access to them any longer.

[00:57:04] Within a couple of days, users started to experience acute opiate withdrawal symptoms,

[00:57:10] consisting of a severely heightened sensitivity to pain and flu-like symptoms like chills, fevers, body aches, diarrhea, insomnia, nausea.

[00:57:22] And when those acute symptoms started to fade, later psychological and emotional symptoms would take their place.

[00:57:29] Depression, anxiety, irritability, restlessness, insomnia.

[00:57:35] And many users couldn't stomach those symptoms and sought relief from other means.

[00:57:42] By 2012, right around the time PDMPs and other government regulations were really taking hold and reducing

[00:57:50] or at least stagnating the number of opiate prescriptions being doled out like candy from a concession stand at a youth baseball game.

[00:57:58] The cost of heroin per gram hit an all-time low, the cheapest it had been since the 1970s.

[00:58:06] And a group of sons of subsistence Mexican sugarcane farmers, the Jalisco boys, took advantage of users' despair

[00:58:17] and the fact that the poppy plant grew very well in their region, the Nayarit state of Mexico.

[00:58:25] They started cultivating poppy and making black tar, very potent black tar heroin,

[00:58:32] and transporting it to the United States in droves, forming what is now the second most powerful

[00:58:39] and well-known drug trafficking cartel in Mexico, the Jalisco cartel.

[00:58:47] So heroin coming into the United States around the mid-2010s, early 2010s,

[00:58:56] started to shift from primarily a South American influx to a near monopoly by Mexican cartels within a few years,

[00:59:06] jumping from about 50% to more than 90% between 2013 and 2019.

[00:59:14] They methodologically targeted one town or one city at a time,

[00:59:19] starting in the United States West and gradually branching out in every direction.

[00:59:25] Cartel leaders would send dozens of mules across the border, expecting that some of them would be caught.

[00:59:32] But those who were caught knew they couldn't cooperate with the authorities due to the risk of backlash on their families from the cartel leaders.

[00:59:40] And they didn't have enough heroin on them to gain lengthy prison sentences.

[00:59:47] They would serve their time or be deported and return home as a hero.

[00:59:52] If somebody was caught, they'd be easily replaced and not get caught with enough supply to spend very much time in prison.

[01:00:00] This system continues to operate today with hundreds to thousands of drug mules crossing the border every day,

[01:00:11] now with primarily fentanyl, but also heroin, methamphetamine.

[01:00:16] And thinking that we can catch everyone or even the majority of them is wholly unrealistic.

[01:00:23] Now, I throw this back up here just to emphasize the change that occurred between 2009 and 2012.

[01:00:35] It's important to note that many older Americans who were previously receiving opiate prescriptions for chronic pain

[01:00:43] did not have as hard of a time obtaining their prescriptions from doctors.

[01:00:47] But 20-year-olds and 30-year-olds had more and more of a difficult time convincing their doctors

[01:00:54] that they had painful conditions that indicated the need for Oxycontin.

[01:01:02] So, while Appalachians were still relying on secondary market prescriptions

[01:01:08] and the second wave of heroin was starting to cause its own epidemic in the West,

[01:01:13] in pockets of the Pacific Northwest, it was young people who used drugs who really got hit the hardest.

[01:01:20] And the cartels were savvy as fuck, conquering one market at a time,

[01:01:26] starting in New Mexico and Colorado, moving into Arizona and California, Seattle,

[01:01:33] then traversing east across the United States.

[01:01:37] You can almost even see or imagine the route of cities that they conquered one by one

[01:01:44] in the dark red areas of the Midwest seen in this 2012 graph.

[01:01:50] Now, though local law enforcement and DEA officials would catch criminals here and there,

[01:01:58] it took years for the DEA to realize these were not isolated small business operations as initially conceptualized.

[01:02:06] These were interconnected national networks with agents sworn to silence if arrested or convicted.

[01:02:17] New outposts were established by providing free samples to addicted persons outside of homeless shelters,

[01:02:25] outside of halfway houses, detox facilities, something that still happens today.

[01:02:31] And to users, heroin was 10 times more potent in a quarter of the cost of prescription Oxycontin.

[01:02:41] The number of deaths took a drastic upturn.

[01:02:45] It still blows my mind that nearly 11 years ago, I was starting medical school and this was the picture.

[01:02:54] And now, we've more than doubled this number in overdoses alone.

[01:03:02] Here, you can see the drastic increase in heroin overdose deaths until roughly 2015-2016.

[01:03:10] And by 2017, the crisis evolved again with the increased availability of China-produced fentanyl,

[01:03:17] an odorless and colorless synthetic opiate that was 100 times more potent than morphine.

[01:03:25] Now, if you want to learn more about just how the heroin epidemic emerged in the United States,

[01:03:32] I highly recommend journalist Sam Quinones' book, Dreamland,

[01:03:38] which follows the progression of the epidemic from prescription opiates to heroin

[01:03:43] and offers multiple firsthand perspectives and experiences on the topic,

[01:03:49] including what it was like to become addicted from users' perspectives,

[01:03:53] what it was like to operate a pizza delivery system for heroin from drug trafficker perspective,

[01:03:59] how disconnected different branches of the DEA were,

[01:04:03] but eventually discovered the connections between multiple arrests in different towns

[01:04:08] and also from experts in medicine.

[01:04:12] I just wanted to include this slide to emphasize just how deadly heroin addiction is.

[01:04:18] This is one of the only longitudinal studies of heroin-addicted persons,

[01:04:22] with about 600 addicted people followed between 1964 and 1997,

[01:04:30] a 33-year period.

[01:04:32] And it found that half, and likely significantly more than half, of them were dead,

[01:04:38] as 10% status unknown.

[01:04:41] Only one-fifth of the original sample was abstinent from heroin,

[01:04:46] with another 21% still using heroin, 14% in jail, and 10% who refused to be tested.

[01:04:54] And that's of the survivors.

[01:04:57] Now, as the heroin epidemic moved eastward, it eventually reached Kentucky,

[01:05:02] where emergency rooms started filling up with heroin and IV drug use-related visits.

[01:05:09] It wasn't just overdoses and deaths or problems that emerged from slowing breathing,

[01:05:15] not enough to kill a person but to cause significant or even permanent brain damage,

[01:05:20] but also that sequela of IV drug use,

[01:05:24] a common method intravenously that many users progress toward from snorting, eating, or smoking,

[01:05:32] due to the immediate and 100% availability of the substance via injection.

[01:05:41] So, in general, IV drug users have a 22 times higher mortality rate than age-adjusted controls.

[01:05:52] There are more than a million intravenous drug users in the last year alone in the United States.

[01:05:58] And for those who don't have compassion for these drug users,

[01:06:02] they're not that much different than you.

[01:06:04] They are products of their genetics and their life experience.

[01:06:08] And having worked in multiple different psychiatric and addiction facilities in my career,

[01:06:14] many of them have survived traumatic experiences that you can't even fathom,

[01:06:20] that you cannot empathize with,

[01:06:23] and that would make you want to escape via using drugs too.

[01:06:29] Now, this is a comprehensive list of complications of intravenous drug use from an emergency medicine textbook.

[01:06:39] We're going to focus on infectious complications here,

[01:06:43] especially HIV, which can progress to AIDS if not treated appropriately,

[01:06:49] hepatitis C, which causes liver disease, including liver failure and liver cancer,

[01:06:54] and endocarditis, or infection of the heart valves,

[01:06:59] which can occur with any type of injection into the circulatory system,

[01:07:03] and is why healthcare providers always use clean needles

[01:07:07] and clean the area of the skin where the injection is taking place beforehand.

[01:07:15] So, people who inject drugs are 22 times more likely to contract HIV.

[01:07:22] Of the 12 million people living globally who inject drugs,

[01:07:27] 2 million are living with HIV.

[01:07:29] There's roughly 30,000 estimated new cases of HIV annually in the United States,

[01:07:35] with about 10% or 3,000 who contract it from injection drug use.

[01:07:41] There's roughly 15,000 to 20,000 deaths annually in the U.S. due to HIV,

[01:07:47] with a spike during COVID as HIV knocks out a person's immune system.

[01:07:53] And we manage HIV better than most countries,

[01:07:57] with a global annual death number hovering around 700,000 deaths,

[01:08:02] due to mostly lack of access to good care,

[01:08:06] such as antiretroviral drugs,

[01:08:09] which are extremely effective at preventing HIV from progressing to AIDS,

[01:08:15] and preventing transmission.

[01:08:19] Preventing transmission is paramount in our fight against HIV and AIDS.

[01:08:24] So, while needle exchange programs and increased education

[01:08:28] have reduced the number of new cases caused by IV drug use,

[01:08:33] that wasn't necessarily the case in 2015.

[01:08:37] About 30 miles north of Louisville,

[01:08:42] where I live, Louisville, Kentucky,

[01:08:45] is a county called Scott County in Indiana,

[01:08:49] which in 2015 had quite possibly

[01:08:53] the worst local outbreak and spread of HIV in U.S. history,

[01:08:58] with the epicenter being the town of Austin, Indiana.

[01:09:02] Austin had a population of roughly 4,000 people,

[01:09:06] and in 2015 registered most of the 142 new cases of HIV in Scott County,

[01:09:14] with over 215 new cases by 2017 related to this same outbreak.

[01:09:21] The prior record high of HIV cases per year in Scott County was five.

[01:09:27] Scott County saw a total of three new HIV cases from 2009 to 2013.

[01:09:36] Now, nearly 250 people in the county are infected with HIV.

[01:09:42] Today, the local community is still reeling from the epidemic,

[01:09:46] with some obstinate folks who think maybe that they're better than IV drug users,

[01:09:53] still restricting access to needle exchange programs.

[01:09:58] That's absolutely absurd.

[01:10:01] So, Kentucky is, unfortunately, also notorious for their HIV rates,

[01:10:07] with eight out of the ten most at-risk counties in the nation for HIV and hepatitis C

[01:10:15] being located in Kentucky,

[01:10:17] with 36 out of the top 100 counties.

[01:10:21] Now, part of that is due to the fact that Kentucky has too many counties.

[01:10:27] But, you'll notice that many of these counties are centered around the mountains

[01:10:33] that surround Appalachia.

[01:10:35] There are still local municipalities that continue to restrict access to needle exchange programs,

[01:10:44] despite widespread evidence that they help to reduce potentially fatal transmission

[01:10:50] of multiple different infections, including HIV, including hepatitis C, and endocarditis.

[01:10:59] With closed-minded local government administrators and officials in some of the worst afflicted areas,

[01:11:06] creating this moral divide between those who use drugs and those who don't.

[01:11:12] It can also cause what's called thrombocytopenia,

[01:11:15] with low platelet counts that are, by the way,

[01:11:19] platelets are constantly working to plug up internal and external bleeds or wounds.

[01:11:24] Without them, patients are at risk for severe bleeding,

[01:11:28] especially in places with high cell turnover, like the GI tract,

[01:11:33] which is particularly prone to bleeding.

[01:11:37] Almost half of IV drug users are positive for hepatitis C,

[01:11:41] and 90% of new cases of hepatitis C

[01:11:45] are related back to IV drug use.

[01:11:50] As you can see here,

[01:11:52] the hepatitis C death rate map from 2017

[01:11:55] looks just like the map of drug overdose deaths,

[01:11:59] further showing that overdose deaths

[01:12:01] are a non-total percentage of overall drug-related deaths.

[01:12:05] If these people don't contract hepatitis C from their IV drug use,

[01:12:10] not nearly as many of them end up dying early.

[01:12:13] Luckily, we have a recent adjunct to previous treatment

[01:12:17] that was FDA-approved in July of 2015,

[01:12:21] and now hepatitis C treatment is extremely effective,

[01:12:25] with an over 90% remission rate after 8 to 12 weeks of treatment.

[01:12:32] But it requires future abstinence from IV drug use,

[01:12:36] or at a minimum, abstinence from sharing needles.

[01:12:40] And we've seen annual deaths attributed to hepatitis C

[01:12:43] fall from close to 20,000 in 2014

[01:12:47] to less than 14,000 in 2021.

[01:12:52] By 2013, Kentucky rose to number one in hepatitis C rates.

[01:12:58] And as you can see,

[01:13:01] the other most afflicted states in the country,

[01:13:05] all border Kentucky and the Appalachian Mountains,

[01:13:08] West Virginia, Indiana, Tennessee,

[01:13:11] Kentucky saw a 730% increase in hep C rate

[01:13:15] from 2007 to 2013.

[01:13:20] And again, hepatitis C is primarily caused

[01:13:23] by direct blood-to-blood transmission

[01:13:26] between one infected user and the next.

[01:13:30] Like HIV, this transmission can be prevented

[01:13:34] with using clean needles on every injection drug use.

[01:13:39] According to the University of Washington,

[01:13:42] you can see the annual cases of hepatitis C

[01:13:47] from 2010, when injection drug use was not as prevalent,

[01:13:51] and hepatitis C infections were just north of 10,000 annually

[01:13:56] to 2021, where new hepatitis C cases per year

[01:14:01] nearly surpassed 70,000.

[01:14:05] And more importantly than the 700% increase

[01:14:08] over 11 years is the fact that the number of infections

[01:14:12] has risen year over year.

[01:14:14] Also, the highest number of new hep C infections

[01:14:19] occurred in people age 30 to 39.

[01:14:23] So again, we're talking about relatively young people

[01:14:27] with their whole lives ahead of them

[01:14:29] being afflicted with a potentially deadly viral infection

[01:14:33] from IV drug use.

[01:14:35] This 2019 World Drug Report graph shows a side-by-side

[01:14:41] of the number of hep C-attributed deaths

[01:14:44] and, probably an even more important statistic,

[01:14:48] the DALYs, or Disability Adjusted Life Years,

[01:14:52] a time-based measure that combines years of life loss

[01:14:56] due to premature death

[01:14:57] and years of life loss due to time lived

[01:15:01] in states of less than full health.

[01:15:04] Globally, as of 2018,

[01:15:07] hepatitis C actually kills more people at this point,

[01:15:11] primarily due to lack of access to effective treatment

[01:15:14] in lesser developed nations,

[01:15:16] than direct opioid overdoses.

[01:15:19] But, hepatitis C also leads to millions of years

[01:15:23] of health life lost.

[01:15:25] If you combine HIV and hepatitis C,

[01:15:28] it amounts to nearly 350,000 global deaths annually

[01:15:32] and 10 million plus years of healthy life lost.

[01:15:38] So, sharing needles

[01:15:42] is the primary cause of infection in IV drug users.

[01:15:46] For hepatitis C especially,

[01:15:48] and a major cause of HIV transmission as well,

[01:15:51] and is totally preventable with clean needles.

[01:15:54] This graph shows how common syringe sharing is,

[01:15:59] especially in younger and more naive IV drug users.

[01:16:04] It also indicates that older IV drug users

[01:16:07] do learn through their experience

[01:16:10] and can be educated,

[01:16:12] even if they continue to use drugs intravenously,

[01:16:15] on ways to use them more safely and reduce their harm.

[01:16:20] Obviously, we've got to better educate our youths

[01:16:25] in regards to how to avoid these complications

[01:16:28] and not just harp on abstinence

[01:16:31] as the only way to reduce harm,

[01:16:36] though obviously it is the best way.

[01:16:38] Now, it's not just about using a clean needle

[01:16:43] in terms of infectious complications

[01:16:45] of injecting things into our bodies.

[01:16:48] There's another very important tool

[01:16:50] in combating other infectious risks,

[01:16:53] and it's using alcohol swabs

[01:16:56] to clean the skin around the area of injection

[01:16:58] prior to injection,

[01:17:00] same as we do in the hospital

[01:17:02] any time an infection or an injection is given.

[01:17:06] Endocarditis is maybe the most acute and serious

[01:17:09] of all IV drug use related infections.

[01:17:13] HIV and hepatitis C can be treated

[01:17:17] and the damage can be minimized,

[01:17:20] as can endocarditis,

[01:17:22] but endocarditis has a mortality rate

[01:17:24] of about 50% if not treated.

[01:17:28] And without proper imaging,

[01:17:31] it can easily be missed

[01:17:33] in somebody who is having a behavioral problem

[01:17:37] in the ER going through opioid withdrawal

[01:17:40] or methamphetamine intoxication.

[01:17:42] Let's take a quick virtual tour

[01:17:45] of how bacteria get to the heart

[01:17:48] during injection drug use

[01:17:49] and then where they can go from there.

[01:17:53] So it doesn't matter

[01:17:56] if someone uses a clean or unused needle

[01:17:58] when injecting

[01:17:59] if they don't clean the area around the skin first.

[01:18:02] Our skin is covered with bacteria

[01:18:05] that acts as a protective layer

[01:18:07] against foreign pathogens.

[01:18:10] Staph aureus is a dominant skin bacteria

[01:18:13] that easily invades into our bloodstream

[01:18:15] and can infect our entire body from there.

[01:18:19] What happens is

[01:18:20] the needle pulls in Staph aureus

[01:18:23] or other skin bacteria

[01:18:25] and is injected into the vein

[01:18:27] with the substance,

[01:18:28] heroin or meth among others.

[01:18:30] Because the bloodstream is like a flowing river,

[01:18:34] that bacteria just bounces along

[01:18:36] through the venous system

[01:18:38] until it reaches the confluence

[01:18:40] of that venous river,

[01:18:41] the right atrium of the heart.

[01:18:46] One of the first places it sees

[01:18:48] where it can latch onto

[01:18:49] is the tricuspid valve

[01:18:52] or the valve between the right atrium

[01:18:54] and the right ventricle

[01:18:56] or the pulmonic valve,

[01:18:58] the valve between the right ventricle

[01:19:00] and its outflow tract

[01:19:01] to the lungs

[01:19:03] where the blood is then oxygenated

[01:19:05] and comes back to the heart.

[01:19:07] This bacteria multiplies

[01:19:09] on these heart valves

[01:19:11] creating what are called vegetations

[01:19:13] or clusters of bacteria.

[01:19:16] These can then break off

[01:19:18] and seed other areas of the body,

[01:19:21] first traveling to the lungs

[01:19:23] and often causing

[01:19:25] what's called a double pneumonia

[01:19:28] and then back to

[01:19:30] the left side of the heart

[01:19:32] infecting the mitral valve

[01:19:34] and or the aortic valve.

[01:19:37] These valves have really important functions.

[01:19:40] Just like the valve on any hose,

[01:19:43] they need to be sealed

[01:19:45] in order for blood

[01:19:46] to travel in the direction

[01:19:48] it's meant to travel

[01:19:49] without back flowing.

[01:19:51] When there's a vegetation on a valve,

[01:19:54] it doesn't open or close as completely.

[01:19:57] It leads to a less efficient heart

[01:20:00] and a heart that has to now work harder

[01:20:03] and pump harder

[01:20:04] to effectively get blood

[01:20:06] to the rest of the body.

[01:20:08] It's a vicious cycle

[01:20:09] because as the heart works hard,

[01:20:12] as the heart works to beat even harder,

[01:20:16] that increased pressure

[01:20:17] works to spread the infection

[01:20:19] further into the systemic circulation,

[01:20:22] aka the rest of the body.

[01:20:24] It can go into the coronary arteries,

[01:20:27] which branch off

[01:20:28] right after the blood leaves the heart,

[01:20:30] causing a heart attack,

[01:20:32] or it can shoot into the brain,

[01:20:34] causing what's called

[01:20:35] a septic cerebral emboli,

[01:20:38] causing a stroke

[01:20:39] as the mixture of clotted blood

[01:20:41] and infectious materials

[01:20:43] plugs up arteries

[01:20:45] trying to provide oxygen

[01:20:46] and nutrients to brain cells.

[01:20:49] These clusters of bacteria

[01:20:51] also love to hide out

[01:20:54] in between the spinal vertebrae,

[01:20:57] causing very painful abscesses

[01:20:59] and can literally go anywhere else.

[01:21:03] The kidneys, the liver,

[01:21:04] the spleen, the colon,

[01:21:06] the skin, the joints.

[01:21:07] Now, I didn't initially understand

[01:21:11] why my endocarditis patients

[01:21:13] had such poor insight

[01:21:15] and would try to go sneak out