By tim on the impact of economic recession in modern america he received the James Cameron prize he was awarded the prize for journalism for recording the version of events and told an unpalatable truth and hes the longtime staff writer in the paris review and the office of Standard Operating Procedure from 2008 and we wish to inform you including the National Book critics circle award. Facebook short fiction essays have been translated into a dozen languages. Hes at work on a new book. Please join me now in welcoming chris. [applause] this one works. [laughter] a long time ago at the border in 1996 or maybe earlier than that and in those days chris is doing some of the truly outstanding reporting from there as he has them everywhere that he has reported that ive ever had the pleasure to read. I guess i want to just start tonight, you have written about american overdose. It is just a terrific book, terrific reporting, writing, exceptional read and urgent story. How did you get into it, youve been in this country for a while reporting now. How did you settle in on this as the thing to focus on and how did you get into West Virginia . Good evening. How did i get into this. I was a washington correspondent and after that i decided i didnt want to be any more because i spend far too much time writing about sarah palen. So i then started wandering around the country and writing about places that didnt get written about in the marginalized communities particularly about poverty and that drew me down the path towards this epidemic because once you travel through appalachia or parts of the midwest, you constantly come from this impact on society. Out of the news reports came the state questions that you dont really answer in daily journalism and the questions that haunted me were you kept hearing from people how is it that an epidemic can run for 20 years and get actually here we are talking about this now because i would imagine most of you five years ago probably had no idea of the scale of this thing. But in these communities, the data. They were living with it and it was invisible to large part of the state, but how was that possible. And the other question is when you look at the statistics and this is very much a uniquely american phenomenon it can be about 80 to 85 of the prescription opioids and i thought theres obviously something very american going on here. Theres something about the system, the people, the place, whatever that might be and that is what drew me into trite answer that question and into this book. Williams and West Virginia was a smalltown i ended up focusing on quite a lot in the very southwest of the states and if you look at the map the cdc has online at the opioids overdoses that goes back to 1995 there is a little do dots that begins in that part of West Virginia and you watch it expand year after year it grows through West Virginia and Eastern Kentucky into southern ohio and different places like maine and new england. The poor o working class communities often where unemployment is very laborintensive, but it all begins down there in southern West Virginia. Williamson is this town of 3. 5000 people where a decade into the epidemic, you have 20 million pills a year going through this one town they are being prescribed by phil mills also dispensed by pharmacies that are all part of what becomes a very widespread publication to deliver opioids on behalf of the Drug Companies against central appalachia and up into ohio and parts of iowa. There are so many questions that come out of that which are for instance why is it that we are only hearing about it now . One of the questions you address and dont totally buy that you obviously see a lot in this is this is a group of people dismissed as hillbillies. They are not in the inner city population people can stigmatize them one way or so but they are written off and this is a population who was sort of presumed to be wretched and so the prey to the Drug Companies is they dont have advocates that are going to look out for them. Is that the issue that they are written off as disposable or how did it get to be that a single place could be that kind of an epicenter under the radar for so long . Theres a couple of things that work. What is described in this country that didnt happen anywhere else if you go back to immediately after the civil war there were a lot of the soldiers that were very badly wounded and morphine becomes a common means of dealing with trade. It comes along with a hypodermic needle so it is much easier to use. Doctors start using it for all kinds of things in this country and it gives rise to americas first morphine epidemic alongside particularly in the west coast device of opium and for the first time, you have a president , Teddy Roosevelt that appoints the drug czar and does the commission of the opioids and he describes america as the worlds worst drug feet. New laws are introduced to combat the use of opioids in any form and thats leads to a resistance after that within the medical community to any kind of use of morphine or opioids for treating pain. Thats pretty much sustains the situation until around the 1960s. And under the uk comes the movement at the site after watching her husband die of immense pain without any treatment that there has to be a better way of dying and the fear is irrelevant, it doesnt matter if you become hooked on these drugs if they are relieving your pain particularly for Cancer Patients in the last months or years of your life so the movement emerges and comes across the atlantic. As it comes across the atlantic, it coincides with the rise of a group of doctors in the 1980s who think opioids can be used in a much wider scale than just endoflife care and they start to push the idea that you can use them to treat pain so postsurgery riposte injury you can take them for quite a long time until your fingers away or if you are living with chronic pain whatever it might be these could be life enhancing drugs. Doctors see people coming in for chronic pain all the time and there is very little they can do for them. Its quite damaging to your liver and if there were not many answers out there. They decided lets start pushing this idea to fight the stigma and in order to fight the stigma, they start innocence to fabricate evidence and the big thing they have to overcome is the addiction and they take studies and insulates them and theres a couple of key studies there was a risk of rejection and if that came out of a study that when you look more closely at it, but it turned out to be was a group of patients in a hospital in very controlled circumstances who were given opioids by nurses and it largely unlikely that they would develop addiction. Another example is a doctor that came up with a theory of pseudo addiction and he said what looks like addiction isnt its just your body reacting to the pain and needing more drugs to treat the pain. When you go back and look at the study based on a single patient with a dentist took the studies and inflated them and trusted nobody was going to go back and look too closely and then essentially went out and the markets did the idea that they were completely safe and there was no reasonable stigma around them and you wouldnt really need to worry about mass prescribing of opioids. The idea probably would have floated around for a while if they hadnt latched onto that idea and suddenly thought heres a great opportunity to make a large amount of money. They start mass producing opioids and get them onto the market and then they look at who is already using painkillers and its places like West Virginia. Where they are down in the mine did have to get another shift and so forth. These doctors start as you say putting out evidence that they acknowledge. They were not themselves in on the take at the outset they were not setting out to be Snake Oil Salesman they did take some very serious Snake Oil Salesman to get this thing going. When you talk about it as an american addiction, every country obviously has corrupt scammers and so forth it seems like you found quite a cast in West Virginia of people who were very distinctive hustlers. You have a former undertaker and escorthis quarter on capitol hil that somehow pops up running the pharmacy. You have so many corrupt doctors who seem to flock to this particular epidemic. You have corrupt fire chief family whose family are all drug dealers and there is a kind of nose out there but from the pharmacy family, now to the ground and one of the wonderful things about this book is how much it can connect the dots. They are really sinister in that same there are people that are beyond the mortal watching a great massacre take place as they pocket the money. One of the reasons that happened a is they persuaded themselves that they were doing good. At least some of them did. There were doctors that were prescribing that they were just making money but the Drug Companies persuaded themselves the idea that there was a epidemic of pain out there and this becomes the justification in the early two thousands when you go back and look didnt anybody ring the alarm bells and you discover that in the early two thousands a lot of people were ringing the alarm bells and there was a doctor, there were several heroes in this book. One was doctor named Jane Valentine at Harvard University and its associated hospital massachusetts general. She buys into this whole idea all ive got to do is get my patience these drugs. She starts to notice that they just are not doing well. She starts to see that actually they are in more pain than they were after a few us and starts to see that the personalities changed. Relatives are coming and saying what are these drugs you are giving my husband or my children because they are not doing well but it was hard to get them off the drugs because theyve become dependent. You have the illusion it is a couple of years a really comprehensive study that appears in the new england journal of medicine and essentially says we need to pause these drugs are not really working longterm the industry reacts to others that are ringing the alarm bell by going for the distraction. Theres an epidemic of untreated pain we dont need opioids to treat. People who became addicted are abusers. They stigmatize them and those people shouldnt be abou alloweo take away the drugs from the people that legitimately need them. They originally have prescriptions and follow them legitimately and obscure and create this good and bad scenario. In this town you have those that start the pharmacy through which these vast quantities of disproportionately vast quantities he is not somebody that really has a theory about all this, hes just in on the main chance is. Running this one and that one. Hes running it like the service in washington, d. C. Until he got arrested and thrown in jail. Hes not interested in pain but the main chance of the money. Getting been filled and going out and selling for twice as much pumping it through he has the pharmacies and doctors and what we can only subscribe hilda solis that is going and why was there so little resistance to it. In the end it ends up in the politics. What you have is he comes out of prison and to seize this opportunity and set up a Medical Clinic recruiting doctors. To persuade one of the teenage patients to have sex with her teenage son and this gets reported to the medical board apart from issues of prescribing down there. She starts working in this clinic and the way that it works is somebody will come who once these pills and they come from far and wide they will pay 150 to see her or 250 and she will write him a prescription for a months worth of pills and then never sees them again but they come back every month and collected prescription for 150 cash. Within a period of eight years she prescribed for pills than West Virginias largest hospit hospital. Doctor diane shaver lost her license in West Virginia im sorry, kentucky you end up with several doctors he was the doctor in the present when the police, the fbi eventually raided the clinic, they find hundreds of thousands of dollars just lying around and stuffed under their beds. At one point they were taking a Million Dollars a month into just a single bank account. The clinic itself a profit on top of what the doctors were doing papermaking 4. 5 million a year in cash. This is the kind of money in a town of 3500 people. But those people that come in to buy these drugs far and wide need to go to a pharmacy and what happens is the doctors worked out and that will bring too many alarm bells they describe literally throwing them over the bar. By the end of it, youve got essentially the judge, the county judge, the county magistrate, members of the council and various other officials are all on the payroll of this whole system and some of them end up in jail or end up dead. It essentially becomes a financial structure of the town. They worked together and fathers accept it in the minds they come in and give each other pills to help get through the shift. At one point it is destroying us and the few people that are not totally involved in it happening in their family starts to. If a local person cant deal with the congressman or senator should. Oxycontin if i were a member correctly is introduced by 2,000 its making a billion dollars a year it is just a drop in the bucket and gives you a sense of the National Scale and keeps going up from there. Why is it so hard for those people to be heard. But you were down there for a long time. They plundered and did fine it had nothing but the destruction behind and they dont feel heard in washington. There is an accident on the mind and she starts picking lowlevel pills and as it gets worse because he is dependent but he thinks that its of the injury to does is go out and he just says he takes more until he gets to the point that hes going to the clinics, to do pillow else phil mills. It isnt clear where the oldest son began taking the supplies or he was getting his own prescriptions but he had become addicted and i wont tell you what happens to this family but it is a horror story over the years. When you speak about this, the most peaceful of this incredible anger at the doctors come at the medical professions because he said nobody in all of those years said this might be dangerous. They just said if you are in pain, take more of it which is the pseudo addiction idea philosophy and it was still pushed by doctors and still is. There have only been two years he wasnt taking opioids and you meet a lot of people like that. They sensed this because they simply did what their doctor said and then they were led down a route that has destroyed their lives. What changed of course is there are people in the country that do not feel powerless and understand how the systems work. With the experimentation they start to say what is going on here and they know that he can be heard. But even they have to break through the stigma and all of the usual judgments about people that have addicted that they do know how to do that and they feel confident and that is when you start to see the rise of awareness that never really comes out of those parts. Theres this moment it does break through a little bit and the Drug Companies are caught on the back for the first time and suddenly on the defense. And yet, it keeps going. The epidemic numbers, the death toll continues to rise. The statistics keep going up in that direction. And get more and more of it. How do you account for that or explain that, is it just an inevitable that the momentum is so great and then of course be replaced one thing with another and the solution is supposed to be sent in fentanyl so how do we get to that point . Where are the regulators into this country is full of institutions that have responsibilities one way or the other they failed americans and that is what essentially permits this thing to go on even though there is a greater awareness. Digging into that and looking at what went wrong and what you begin to realize after a while is that the Drug Companies were not only Effective Marketing drugs to doctors, but what they do is effectively market to the systems, to the medical authorities of the country. To get them onboard the end of coopting the institutions that are essentially supposed to regulate and monitor and protect the abuse. It hi had a big effect of pushig through something called the joint commission. The joint commission was responsible for the hospitals. You dont get medicaid were medicare money that drug company pushed the idea that pained me to be better monitored. You have your heart rate and Blood Pressure and all that which can he measure but they have to measure it as a viable sign which is why when you see the smiley faces you have to say how bad the pain is or isnt. It became a tyranny obliged to do this they have to be referred for Pain Management into this meant an opioid prescription. The joint commission essentially pushed this through the 40,000 hospitals so that you ended up with a system very quickly in which doctors were obliged to not only monitor but to fall back on it as a default and you watch the prescriptions for the opioids escalate and that was just one element they were able to do. You start to see the states regulate and then you have to monitor pain and it creates the idea that there is an enormous pain issue out there. The resistance is met theres a doctor called Charles Lucas at detroit general and i write about him because he has been a resurgence in the 1960s and said he stopped giving them high levels of what they were doing and find themselves colleagues are taken to the state medical board and said he was able to resist it what are you going to do to wer her just going to do t they want which is i a gazetteer anywhere you just followed the advice and there were a number of other pressures and the Insurance Companies or this is an easy way to deal with pain and it didnt cost money. One institution after another coopted by the industry. In this particular thing is what draws together the different elements is very much on the ground experience. One of the things that really distinguishes what the project was. Who starts out basically as being in charge of looking into oxycontin and avoiding the evaluation and working with perdue and unleashing the Marketing Campaign to actually escalate this thing and they are deeply compromised. They were able to take oxycontin out and market it to doctors and that is addictive ie and more effective than other opioids because the fda allowed to go on what they called it the label which defined with the drug was that they only allowed that because that is what the farmers told them and the fda did no checks itself. It simply does what the company told it but then what the company does is says this is an fda approval, this is what the fda is saying. It is a real turnaround because by that point it has become deeply compromised and deeply complicit for the promotion of opioids with the Drug Companies and in the 1960s it is a global standard it was very widely prescribed and my mother was offered it in 1959 and turned it down and it led to thousands of babies being born with serious deformities. Before the drug tainted the states, it went to the fda for approval. And there was a scientist, the woman at the fda that looked at the data and said theres not enough here, we need more information. They went around her to the senior officials in the fda and said they are difficult and Holding Things up, why didnt we just approve it in europe, everything is fine. A year later, everybody connects this very large number of babies being born with deformities and that obviously kills the drug here saying american women and children are the same thing. She is awarded medals by congress and jfk and is held up as a hero. They control drugs and that holding exists for about 25 years. The fda just sets the standard because they have to do as they are told. To get approval times and with the ability to do this in with the administration to introduce that the Drug Companies have to pay for. In this funds the fda because their income comes from the Drug Companies. And then with the regulator to regulate that and that leverage is not only through the money going into the fda but congress where they spent two and a half billion dollars per year to lobby to say we pay this money but the fda is not delivering and that all this blows up on the fda. Over time you have a situation where the opioids come onto the market in actuality this is essentially working hand in hand and that opens the door for the Drug Companies to call out to the fda to approve these drugs in ways they never should have been approved. You started out this evening saying one of the questions is why this country america has 85 percent of the worlds opioid addiction and 5 percent of the uses from prescription but it is a complicated mixture of structure of high and low. What do you think it is . Why are we susceptible to this . Is at the way the medical system is structured as a business rather than social welfare enterprise is not a public good but a forprofit industry . Is it a set of attitudes we have that allow this to take place with the fda cracks and why did it take so long cracks because it seems like a bipartisan failure to recognize for what we have felt with that. Well. You know thats a lot of questions. The short answer is because it is an industry its not a health service. It is driven by the interest of Drug Companies and the Insurance Companies and the hospitals. It is not driven by the interest of the patient. And that is all the problems with Public Health systems in other countries were they also have financial problems but very different set of priorities. But this is driven by the patients themselves to some degree. The evolution of the past 20 years because of the rising cost with the idea that patients think of themselves as clients they go to the doctor and they tell the doctor what they want. They are far less likely to listen to the doctor but in turn it is partly driven and the only other country other than new zealand strangely that has direct to Consumer Advertising of drugs prior to 1997 when the opioids first came on the market but they will tell you that there is a demonstrable rise of use in this country in part because of the mentality that had been taken hold because those are the answers on the television and that is what they see in the advertising. Particularly older people and doctors will tell you that people complaining of conditions they never knew existed but then they see it on television and its got to the point they are prescribing the pills to offset the effects. But if you are not interested of your doctor sitting there telling you for half hour of your real problem you need to do with your overweight and exercise and your lifestyle but they want to go in and out in ten minutes to prescribe a cheap generic pill. So that is certainly at work. But it is true with the fda relationship. The fda prioritizes the business interest of the Drug Companies. And it specifically does that because that as part of the mandate and going through transcripts in the middle of this epidemic the fda approved more than 50 opioids right through the epidemic and there was one that came onto the market and came up for approval and it was one year after they said there is an epidemic. So there was no doubt about what was going on. Maybe at that point people were dying and everybody knew or at least they should have known what was going on. So the fda has the Recommendation Committee to consider if the drug should be approved with these 13 people on the committee, the epidemic so theyre not asking the right questions like do we really need another drug on the market or what are the chances this will end up being used by people who shouldnt use it it was ten times the power of the average opioid so would have to be effective on the black market and the senior fda official interrupts him and says the department that deals with opioids says that is not your business for go your business is to decide whether this drug is any less safe than the drug already on the market echo and if it is no worse than you have to approve it and this is a phrase he used for the field of industry so that means if that was legal and everybody has a right to do it. There was uproar in the committee to say but surely we have to monitor Public Health first we dont need another highpower drug on the market that will end up in the wrong hands. With this epidemic. The committee voted 11 two to reject approval of the drug and the fda approved it anyway because they can override and to me that is a look at what the fdas priorities were and what it was about and then you later discover that the same doctor head of that position was head of the opioid division. He spent the previous decade in secret meetings that was taking place between the fda and the drug industry that they were paying 40000 for them to be at the table for the approval of opioids and that came out later in the emails that were leaked. But it is an indication of where their head was at and the role that played. You have been a Foreign Correspondent for the last couple decades. You have worked in south africa and the middle east, here, how is it different here . I was it covering the story as a Foreign Correspondent, what kind of advantages and not with those presumptions quicksand also americans like to think from the third world react like it is an anomaly but it seems to me we have structural corruption but you dont have to bribe every cop they may not be drivable or you have to pay the schoolteacher but you do have to put up with his very highlevel Institutional Corruption does that make a difference as a Foreign Correspondent even just working in West Virginia . And is that an advantage in many ways cracks you talk about the doctor in rwanda who committed genocide. You hear a lot of these in different forms. Where people suffer in the policy is out there. Does that feel it is different for the rest of us quick. Yes it certainly helps to be the outsider. First they assume you dont know anything which may be true. [laughter] but i guess what it does its that idea that if you are judging them but but to be judged by other americans and particularly by people of the east coast and what they regard because they feel so badly let down by politicians and institutions and talked about his people they are talked about so i come in from the outside so that definitely helps but i think people think we dont have an agenda. I did want to find out what was going on but that definitely makes it easier. But yes i have been struck by the institutionalized corruption in america over the years. I didnt really understand until i went to washington just how many affects the policy in congress and you see this here. One of the Reasons Congress didnt act for so long because so much money comes from the Drug Companies for Campaign Contributions what they bought was not the policy but in action they didnt want anything to happen they wanted the drugs to be prescribed. But also how many people recognize that. If youre dealing with Law Enforcement or prosecutors or in the case of West Virginia a corrupt former attorney general certainly not anticorporate but to talk about what had happened in the Drug Companies and the institutions and those as corrupted. They definitely talk about the former head of the dea division responsible for preventing this stuff that drugs being diverted and with those drug distributors very vigorously. But this is a man who was a former pharmacist and a lawyer but he is antiestablishment and i heard this time and time again. And i was struck that they see the system as structurally compromised. And its true. And i do think there was so much money involved that what the drug industry was able to do in a more sophisticated way is if they coopted institutions into going along with this policy. Not only in very sophisticated ways but that is what it is. Federal institutions have a responsibility to weighin but they wont until the cdc weighs in. Now Pablo Escobar is on trial what about him being on trial and others are not . What about oxycontin fentanyl . At about those factors themselves undoubtedly they knew what was going on but the rest of the family they became millionaires i dont know how much they did or did not know but time and time again the conservative people including the elected mayor republicans in these towns and cities have just been devastated by this epidemic including people like the republican congressman from Eastern Kentucky. They think that once they were warned and it just kept going. And the corporations have spent the past 15 years to buy their way out of accountability and with this massive civil settlements without reaching liability is the cost of doing business. Basically this will not stop or prevent it again until the individuals who make these individuals stop one start going to jail and now there is followup pressure building up for that to be interesting to see where that goes with the federal prosecutor making a name and parts of this country i could see someone start going after these guys. I would love to take some questions but i want to quickly get to the one question which is where are we with this at the policy level . Trumpet said we have an Opioid Epidemic we will deal with it. Then there was another new cycle five minutes later so is an end in sight . Are policies waiting to be approved . Are there policies out there just not enacted cracks what can be done and what is or is not being done and why as we sit here and talk about this but to suggest that it is a big part of it. And you talk about the parents in this book have been very courageous. With that suburban and middleclass and those who died at college. But that translates to large parts of the country and what you see is a resistance to those ideas to blame for their addiction and that was powerful to assist that drug company narrative. It has become a political issue in congress finally. But the biggest change was in the absence of any federal action, the cdc stepped up. And it came when the doctor who in the mid 2000s was responsible for looking at all forms of accidental deaths in the country except Car Accidents he thought it would be interesting if they are going up or down so he gathers statistics in every form of accidental death in this country have been falling for years. With the exception of drugs. When he dug into it, it was opioids so he makes noise inside the cdc and nobody wants to hear it until obama appoints a new head of cdc and then looks at this and says in my interview the numbers were reminiscent of an epidemic its like you see in africa hour after the First World War and nothing else creates those kind of numbers. So he stood up one year later to say this is an epidemic and it was the first time anybody took notice. That was because of his position. And the cdc really got in trouble for this but really they were the pacesetters for getting other institutions and they had resistance until last year they issued guidelines of doctors prescribing and they were told this is it your business. This is the practice of medicine other people are responsible and essentially said nobody else is doing it. And the objection for the fda and elsewhere it has a huge impact they all took notice. Finally they were telling someone this is the scale that shouldnt be your default means of prescribing. And more importantly they have no evidence to say they are effective longterm. So that led to a shift in thinking and also prompted a number of states to prescribe those opioids. And actually the full amount isnt as dramatic as it needs to be but still prescribing three or four times as the european country. But to be injected into the conversation consciousness of the levels at which they were prescribing. Affecting appointing the Opioid Commission on those deep origins of the epidemic and what fed into it so now you have the 8 million spending bill. For those who are addicted but its a fraction of what is needed. When you consider the White House Committee concluded that probably once it has run its course it will cost 1,000,000,000,000. 8 million is a small amount to pay. And the administration with regulation and you think how do you dial this back . The argument about guns is why you couldnt regulate guns theres too many out there but obviously people dont consume guns so thats a little bit of a different analogy but there is that idea is just out there. People will be in pain and want drugs but or the alternative i know heroin addiction on the street methadone although harder to get as a substitute addiction but people can live on it and its left on less destructive is anything waiting in the wings that others are resisting . Know there is no magic bullet because of the nature of addiction. There are drugs that help some people but not others. Very large numbers of people who have been to the process tell you have to go through about five or six times before finally you are able to live post addiction but youre never completely passed it. That there are two elements to this because it is the value of the treatments there are two or 3 Million People out there dependent on drugs which is a huge number of people we get locked into the fax 72000 people died last year of drug overdoses those that had a huge impact on their families if your drug dependent seriously you not looking after your children so family and social services and now sending children into care. So several of us in the 19 nineties you will go to uganda you would see the grandparents looking after the grandchildren there are places in West Virginia more children are in care of their grandparents and grandparents parents because of this because they could not be functional as parents. And then another way for people to become addicted. So if its at this level you will continue to create another generation there will be awareness but if people are using these pills at the level that has been described in the past i had my acl replaced last year i came home with 15 days worth of hydrocodone and a needed about two the advice grind them up in the coffee grinder and buried them in the garden thats how you get rid of the drug that has a high value on the street. You need to ensure there is not another way coming down the road that they turn to heroin and fentanyl. Because they are already hooked. Its a big task. Can you talk about the underground drug market and how much is that with the heroin addiction now it is prevalent . You never quite know but you see statistics but you never know if its a statistic thats been pushed around but 70 percent of people who overdose on heroin began on a prescription drug. Now some of those are from injuries or chronic pain because they sit in medicine a medicine cabinet at home. And with those dangers to be passed around as a painkiller. But the cdc did a study that said you can become addicted to these pills in five days. You dont have to take them very long. And now because of two things. And on the market for many years were fed by the pill mills. By shutting those down to West Virginia and eventually to become the biggest in the country. And then to allow doctors to dispense those prescriptions and in florida they allow the doctor to give the pill straightaway. So those pill mills and they just have the pills 24 7. So because they were there it was so dangerous so the doctors began carrying guns to protect themselves. But now hes doing 30 years in prison but at one time he was prescribing more than any other place. But you have a situation where the dealers could work make thousands of dollars a month and parts of the country where they had difficulty. Whl that is supposed to control, obviously it is wrong for somebody to do 200 in the course of a week or a month, but they are practicing medicine in theory and if the cbc isnt able to regulate that, and they are not facing the civil charge amount practiced, what is the crime and who is responsible for enforcing the crime . Is it legal for that period of time . A lot of doctors were prosecuted because they were not going to g the medical practice and procedure. Particularly one has to see the patient and one must fill the entire prescription at that time. You cant fill it out and date if later and what they were doing is mass writing prescriptions and leaving them at the front desk for people to pick up every month in return for a cash payment in the cities are those that have been criminally prosecuted it was that kind of thing. The dea would go after them and the fbi because of the way they handled prescriptions and that was often the armor if they could walk into a pill mill and discover which they did at West Virginia they are not following the procedure by which you prescribed a the fbi manages to get into the pellmell one of the prescriptions goes out to walmart and taken a day notice the different handwriting. Theyve got no reason when they go in. But that is how in the end because one of the reasons they were able to get away with it for so long as they were reluctant to go after them. They knew they were prescribing. Theres a doctor in california serving 30 years and they say she was the first dr. Connected of murder for prescribing opioids and they have her on the regulations in the show her breach of the regulations led to five deaths and that she wasnt following medical practice or the regulations on how you write prescriptions it becomes the fifth Vital Statistics so the heart rate and Blood Pressure and other things that theres a metric for and its this sort of smiley faces or the doctor says nine out of ten or seven out of ten and you are like i dont know, what have you got. Theres also the prescriptions of antidepressants and all sorts of other drugs which arent necessarily cover they may or may not be in the same way that you could argue maybe people become dependent on them but they are not destroying those peoples lives. You are supposed to check in with them once a year and you go in for a few questions and they get another prescription. Then theres an attitude that goes with the pill fixes everything that isnt strictly of the opioids and i wonder if there is a correlation between the two just the idea that there ought to be a pill to fix things and some of them are a godsend in some of them are a nightmare. But it goes back to a pill for every ill so they say ive got this problem. Its because you are badly overweight and you dont do any exercise thats why your knees hurt or you could have a pill and they often walk into these appointments expecting them not to give a lecture. They will tell you it is a hard conversation patient after patient when they wants you to call them through ten minutes at a time that they don but they o hear about the lifestyle so there is a plaintiff mentality, absolutely. But the pain that it is contributed to people that were genuinely did and didn dependee system because there is no mean for the doctor judging on the whole eight out of ten particularly with Emergency Department they learn to walk into the Emergency Department and say im in terrible pain, i need the pills. That became a very common way that a third of all the pills being dispensed were coming through hospital Emergency Departments if they learned that is where they could get the pills. Theyve become dependent on these pills and those that come poor and unemployed managed to keep taking the pills have been dispensed for 20 years and that is as i understood from what you were saying a person involved in the black market or wasnt doing anything illegal. Wasnt legitimate. It wasnt legitimate. Where does the money come from . You could go from one doctor to another because there were no monitoring. There is a degree of it now but no monitoring of the different prescriptions and so you could literally go to three doctors in the same hospital and get three opioid prescriptions. A lot of the workers that initially came under the compensation schemes they pay for it so for a while you are from dead. He describes how the money that should have gone to the children and other things that also contributes to a crime bill and there are small towns in Eastern Kentucky where people will tell you 20 years ago we never locked the door and everything was safe around here. He went home one day and he had been robbed. He lost everything including she had a knife and gun collection. The levels of distrust in the communities people are so desperate they will basically do anything. This part of Eastern Kentucky and women involved in prostitution but younger and younger. The other thing that happens is of course you start dealing. For the users in boston they fund the entire thing and its popping up in florida for a lot cheaper. Until like many people they become so addicted it takes over their lives and that they can no longer properly function. A lot of people for many years to actually function and its why that may not necessarily be true, but the mayor of West Virginia told me that a couple of years ago they would punch him on the nose, throw him in jail and then they discovered there were eight people on staff and he started to say okay we need to think about this and he has been very successful leading the effort to change the mindset of both institutions like the police but also ordinary people in huntington bringing down the stigma and how you think about it as he has to go through that process himself. Thanks for doing that i look forward to doing it. If we think about structurally what is happening we dont deal well with pain or addiction they say this is what needs to be done. Its usually controlled for vaccinations. With opiates is difficult and i think youve made an important point here that we have to think differently about the two or 3 Million People that are addicted today and everybody else because any different approach to reduce the risk one is to release the guidelines that you mentioned weve gotten a lot of pushback and lawsuits with the group that ended up being industry funded we were forced to delay it for additional administrative procedures to respond to the comments but what we learned in that process is not only is there good evidence that they help in a medium or longterm but there ilong termbut there id evidence they make it worse than the people that take of the its become kind of acclimated to pain relief and they feel more pain with the same stimulus in the future and they are less able to go on with their lives so almost no role ever for these medicines and chronic pain and too often for addiction you see the change frankly from when it was black and hispanic people and when it was white people with the disease. Its always been a disease. It changes the way that your brain works and it does longterm. One of the things we started when i was in the cbc it would take a few years to come out is what works in terms of treatment . Im a Infectious Disease physician so what is the longterm success rate, but has never been done in the actual living world for all of the different localities of treatment of opiate addiction and so the cdc has begun a study to look at that over the last two to five years. Many of us expect drugfree programs with very low success rates. Most people whose changes are going to need something whether it is methadone or any other drug, so one question for you. One of the things that is always frustrating is the role of the Substance Abuse and Mental Health administration. They actively oppose efforts to make it easier to prescribe. They spend most of the resources to programs unlikely to be helping people who are addicted and they ran a Surveillance System so that wasnt commercial interest. There were definitely commercial interest involved in here that overregulating not looking at some of the treatment outcomes, that maybe the Treatment Industry as it is, but did you have a sense of what the role they could and should have played for the functions of how that could have been better done in the federal government lacks nothing was back on as far as you could make out. A doctor who was on the president s Opioid Commission said when she looked at all of these federal institutions on what they could have done they spend a lot of time looking at what they could do and they never did anything. She had to sense that that was partly a failure of Political Leadership and there really wasnt any national, there was a lack of the leadership and there was no political interest. Because of that, the institutions on the whole were not going to take it up. She felt they were not motivated because nobody was motivating them and they had their own, the National Institute is a good example of this. It took the attitude that it was only going to deal with treatment and thats fine there was a point they could have played an Important Role in prevention as well and they decided that it was too much trouble. Part of it was they didnt want to go up against the Drug Companies and congress it was too politically contentious. I think that was a failure of national leadership. What youve had to say about the cdc and how the drugs dont work longterm, i was talking about the new england journal of medicine in 2003 and that is what she was saying in 2003 and 15 years later, finally, it is recognized for what it is which is exactly right and it took the cdc to pick that up again. One of the reasons you talk about the cbc wanting to do studies, there were never the studies. The industry resisted studies that would show anything other than did these drugs work. They must have had their suspicions. But the studies were never done. The fda which could have required of them had the mechanism. Ithere were people that were in the fda who was a very senior person who said we could have done these studies. One of the things that has blinded this is the lack of information that we have seen the outcomes. It seems pretty obvious that its created an epidemic it seems from what James Valentine said and what you are saying the drugs dont work but actually in all of this nobody has really done the studies and that is to my mind because the industry resisted. Have they taken a line on this and do people listen to what their line is . The American Medical Association took the wind they didnt want to do anything that inconvenienced doctors, that was basically it, so there are two members of congress, the one i talked about from kentucky who was a lone voice for quite a long time, and then a congresswoman whose son became hooked and much later she came to this end they pushed through something called the act named after the kid who became addicted and died and what that would have done is required doctors who want to prescribe opioids to have training in comprehensive training and pain treatment and addiction. One of the kind of shocking things i dont expect to hear is in four years of medical training they got a day or two of training on panes eventually doctors know very little about pain which is why they were so susceptible to the Drug Companies selling them because the salesman appeared to know more than they did. So they push for this and leading the fight against oppose the American Medical Association because they said that it would inconvenience doctors that they had a very close relationship with the industry as well and they bought into the lie that we must deny people who need these drugs to 100 million who are in a chronic need and it doesnt deny them access because of these abuses. And to this day, really, i mean they were treated for a lot of the objection and it looks like there would be compulsory training but really it is in the face of the political reality. And they will not discuss their past. They really only want to talk about the future. People have said thank you so much for doing the work told the stories. I up in a community not as severe as what you spent your time and ive seen the devastation of these drugs do and as im sitting here it does sound like a very american epidemic into something that is going to need to present itself. What im curious about the sea that devastation and how egregious it is a Staggering Amount of money a small group of people im always curious where is that money going or what is the vision with the motivation for passing it on to a generation thats an issue of ththecountry has and will contio struggle with. The sort of Institutional Corruption and then influencing the politics in a cycle that is going to keep repeating itself. As people get more and more money they feel they need more and more for human trait. [inaudible] [laughter] theyve made 15 billion from this, so they stamp their names on a lot of the institutions that actually the money that they have given is a tiny fraction of the money that they have made. At one point it may depend the tenth richest family in the country so that is the kind of money that was being made at the top. Oxycontin was pulling in i think by 20,093. 4 billion a year. And it wasnt the only one. There were these lower levels that were also in the system and that was making a billion dollars a year so i think at the height the industry was worth 8 billion a year and everybody takes a cut of it. I dont really know how to explain how the money works its way through the system. It works through the political system in the sense that that is how congress ascended right through Campaign Donations and lobbying and all of the rest. The wealthiest for the industry, the pharmaceutical industry on capitol hill had actually been a congressman. He goes over in the late 2,002 represent the Drug Companies and becomes the highest paid lobbyist in washington, d. C. Which tells you quite a lot about the power of the Drug Companies. The money distorts everything. People talk as if, doctors. At the clinic and in the safe deposit box, just one safe deposit box they found 400,000 in cash, that is a fraction of what she was worth. And the former prison doctor they looked up before Bank Accounts and in one of those accounts alone there was a Million Dollars in cash and then he told police that he didnt know who it belonged to. It might have had his name on it but he neve never set it up whis probably true he got one of his staff to set it up. The receptionist at the williams in center, when they raided her house, they found 480,000 in cash in her house that is how much she was making and her husband was a state policeman. When the fbi said where is all this money coming from he tried to say i do a lot of overtime. [laughter] they tried to seize the house but they could prove they bought it before the money. If you have a collection of 600 guns because the fbi agent said to me he built an area above his garage where he stored all his guns. The fbi agent who said to me when youve got all that kind of money but are you going to do with it, you were going to buy something with it. They would have to be a van to take it all away, but they kept the house. [applause] [inaudible] welcome to the gaithersburg book festival. Im editor in cheech of the independent review of books. We proudly support the arts and humanities and pleased to bring you this fabulous event thanks to generous support of sponsors and volunteers. If you see them say thanks. A few aannouncements, silence your device if youre following us on social media, use the gbf. You can f