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 t