The final part of our American healthcare series, painKiller brings together everything we've learned the past two weeks and beyond in Ashes Ashes to explore how the opioid crisis was created and how it is perpetuated to fulfill a single ultimate goal: profit. Pharmaceutical companies, the insurance industry, hospitals, doctors, and politicians - all which ostensibly exist to serve the public have instead mostly contributed to our modern day hellscape of pain, addiction, and increasingly death.

This isn't a show about how the end of the world is looming, this is a look at the ugly truth of collapse affecting people all around us right now.

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This is part three of a three part series on the American healthcare system:

  1. Episode 45 - Bill of Health
  2. Episode 46 - Pill of Sale
  3. Episode 47 - painKiller

Chapters

  • 4:40 Pharma companies create misuse
  • 11:25 Pill Mills
  • 13:42 The modern day problem
  • 19:09 Chronic pain
  • 24:18 Physician frustration
  • 30:16 Making sense of it all
  • 43:21 What can we do?

Thank you Nick for completing this transcript!


David Torcivia:

I'm David Torcivia.

Daniel Forkner:

[0:00] I'm Daniel Forkner.

David Torcivia:

[0:03] And this is Ashes Ashes, a show about systemic issues, cracks in civilization, collapse of the environment, and if we're unlucky, the end of the world.

Daniel Forkner:

[0:13] But if we learn from all of this, maybe we can stop that. The world might be broken, but it doesn't have to be.

Lori:

[0:20] Hi. I am Lori, and I'm from Arkansas. I actually worked in the healthcare field. I worked in it when kind of the opiate thing really started--you know, when the pharmaceutical companies were pushing the doctors to prescribe the opiates--and I worked in the emergency room where we were constantly kind of curious as to why every patient that came in left with Vicodin, and so I saw that really begin, and then, of course, my personal experience started when I was put into pain management 13 years ago, and so I've seen it change, I've seen it--I've been through it as they come out and declare this a crisis, when actually, you know, pulling back on the narcotic prescriptions is what's causing more problems. It's what's sending chronic pain patients to the street, you know, where they're having the turn to heroin because they can no longer get the medicines they need and that they were formerly prescribed, you know, and then we have overdoses due to fentanyl, and so I've kind of seen it all happen.

Daniel Forkner:

[1:24] We just heard from Lori, and we'll be hearing from her throughout this episode as we trace the history of what is referred to as the opioid crisis in America. And David, this is the final chapter of our three-part series on the American healthcare system, part one being "Bill of Health," where we discussed the direction healthcare in America has gone, from one of social good to one of profits; part two, "Pill of Sale," is where we talk about pharmaceutical companies; and, of course, we encourage all of you to check these episodes out if you haven't heard them yet, but for now, stick with us.

David Torcivia:

[1:58] This episode in particular is what really drove us to produce those other two episodes, and, honestly, a lot of the ones that we've had so far in this show, because the opioid crisis--and yes, it absolutely is a crisis; in fact, more people die from these drug overdoses than die from gun violence, including suicides in the U.S. in the past year. In 2016, in a single year, deaths from this opioid crisis were more than the total combined U.S. military deaths of the Vietnam War and the Iraq War combined. So this should be clear, it's absolutely a national crisis, and what brought this crisis on--there are so many of the topics that we've addressed in this show: the American healthcare system; the way our doctors and hospitals run; the pharmaceutical industry and the growth incentives that exist in that field that allow these companies to take advantage of people and deny them the treatments they need by making them simply too expensive; the global trade that exists around the world allowing these dangerous drugs to flood from one country to another; the work conditions that push people to force themselves to work through pain, acquiring these drugs in the first place. There are so many elements of this story, and it's really, like Daniel mentioned, a microcosm of our world today and the crisis and collapse that we are absolutely all facing every single day.

Daniel Forkner:

[3:18] And although some of the underlying causes that have led to this crisis are not unique to America, we have, for so long, taken a very unique approach to drug use in this country in ways that really exacerbate these types of problems, and it has truly created a unique situation that no other country has come close to facing. Every single day, close to 200 people die from an opioid overdose, a number that is expected to climb. The United States consumes more opioids than any other country in the world, and by an enormous margin. Our per-capita daily opioid dose is almost 67% higher than the second highest consuming country and close to 100% higher than the third. Of course, David, like so many of our topics, the biggest impacts fall disproportionately on the poor and vulnerable classes of our society. A paper published just this year in the journal "Medical Care" looked at the nationwide pool of disable Medicare beneficiaries, and they found that lower county median household income, higher unemployment rates, and less income inequality were all consistently associated with more opioid prescriptions, with higher daily doses, and, of course, correlating with that are much higher rates of opioid overdose fatalities.

David Torcivia:

[4:41] In part two of this series, "Pill of Sale," we go in depth on pharmaceutical companies in America, but it's worth pointing out the role they have played in specifically spurring the opioid misuse in this country. Pharma Cos Create Misuse

Lori:

[4:54] I definitely feel like there's a lot of misrepresentation out there. I feel like people that don't take opiates or aren't reliant upon them for pain control, I don't think that they understand really anything about how all of this has transpired. I think that they're being sold, you know, that there's an opiate crisis to the point that it's painkillers that are killing people, that it's prescribed medications that are killing people. That's not what's killing people. It's the fact that, you know, the pharmaceutical companies pushed, you know, unnecessary use of them in the '90s and early 2000, and that's when I was working in the medical field, and they pushed the doctors to prescribe them, and they were over-prescribed then. That much is true. But the way that they chose to deal with it is they just decided to stop everything and halt everything, and I think that the pharmaceutical companies now, they're not hurting. They're making up for any loss that they may have suffered in less prescribing of pain meds by being in the recovery business now. You know, they're making up for their loss in Suboxone and methadone. It's really sick what the pharmaceutical companies have done, and I think there's so many people out there that definitely do not understand just how much of a role they played in this, you know? [6:12] And I think that they don't understand that there are people that have true need for, you know, opiate medication, because it's honestly, right now, the best thing that's offered to people in pain to help them. You know, they haven't come out with anything else, and the pharmaceutical companies did that on purpose when all this started because they created addicts, because that was guaranteed customers every month. They knew what they were doing.

Daniel Forkner:

[6:40] If you haven't heard it, you might want to listen to our episode number 11, "Designing Deception," in which we discuss Edward Bernays, the rise of public relations, and the way that companies get us to consume their products not necessarily buy directly marketing them--although that is part of the process--but more importantly, by influencing community leaders and indirectly shaping our entire lifestyles. And the way the pharmaceutical companies went about flooding the public with opioids follows this formula to a T. One of the biggest impacts they had came from influencing the way doctors went about their practice, and for this, these companies pulled out all the stops. First, of course, is the way that these companies marketed to doctors and people who would eventually take opioids for various reasons. Not only did pharmaceutical companies sponsor research that would make the claim that is now discredited that people with addiction could be cured through higher doses of the same medications--I know, pretty crazy, right, David?

David Torcivia:

[7:40] Mm-hmm.

Daniel Forkner:

[7:41] Well, they also regularly sent representatives to doctors' offices to show them misleading charts and material showing that when it came to pain medication, the risks were low, addiction rates were minimal, and the benefits were high.

David Torcivia:

[7:57] Well, in that vein, have you ever wondered why--let's see. You're going to the doctor. They're checking your temperature, your pulse, but then they also ask you, "Well, how much pain are you in on a scale from 1 to 10?" And this isn't something that was always around. This is a relatively recent development, and that's because Purdue Pharma, the big villain in today's episode, helped the American Pain Society establish the idea of pain management within the medical community, and this idea is that pain itself is the fifth vital sign, the others being pulse, temperature, blood pressure, and breathing. So once this idea took hold, we can see that people are in any sort of general pain, and as soon as we know somebody's in pain, well, that's a pain prescription that we can sell.

Daniel Forkner:

[8:38] And at the same time, there were statements made by the American Pain Society alongside the American Academy of Pain which became incorporated into prescription standards under the Federation of State Medical Boards, which oversees every single state medical board in the country, and these new standards created a situation where doctors that denied patients opioid prescriptions could be disciplined and sanctioned, while there were no consequences at all for over-prescribing them.

David Torcivia:

[9:07] And if all of this doesn't sound sleazy enough, well, Purdue Pharma also marketed their drugs as being healthy not just for adults, but for teenagers and children as well. In one study paid for by Purdue Pharma, in order to measure a child's level of pain, physicians were encouraged to play a game in which children are presented four poker chips representing hurt and told to pick up how many hurts they have. The physicians, of course, were cautioned not to give the children the option of zero hurt, because we're all in some pain all the time, right? And that means one more pill we can sell.

Daniel Forkner:

[9:39] I certainly am, David, especially after all these topics. And so, in true Edward Bernays fashion, this broad public relations campaign caused doctors who previously would never have agreed to prescribe opiates for anything less than serious cancer treatment or end-of-life care to now prescribe them for general pain complaints, and for promoting these false scientific claims and other marketing tactics, Purdue Pharma the company would plead guilty to a felony charge in 2006 and would pay over $600 million in fines, although the executives directly responsible for much of this criminal activity received mere misdemeanors themselves. And these types of lawsuits have continued. Just this year, six states filed new suits against Purdue Pharma, and many other companies are also on the hook for these irresponsible marketing claims and practices.

David Torcivia:

[10:35] And it doesn't take a genius to realize that this marketing had dramatic effects in exactly how doctors were interacting with their patients, their pain, and their prescriptions. Very quickly, we found many doctors were over-prescribing drugs, and we learned from this problem, we made some changes, we might have overreacted and made things even worse, but we'll get to that later on in this episode, but for someone like Lori, who has massive amounts of chronic pain, taking opioids may be the best option for her, but for others, the risks may not justify their use, but the ways that these pharmaceutical companies marketed these drugs gave far too many physicians the illusions that they could be prescribed freely and safely, while doctors with loose moral standards realized they could actually make lots and lots of money by what is essentially dealing opioids. Pill mills

Daniel Forkner:

[11:25] And the most infamous example, of course, comes from Florida's pill mills, and it is impossible to exaggerate just how many opioids have been sold out of these walk-in clinics and pharmacies in Florida.

David Torcivia:

[11:38] Okay, Daniel. "Pill mill." That is a ridiculous name, and I think we really need to clarify, because as silly as that sounds, these are really the factories that got this opioid crisis kicked off, so let's talk about what these are.

Daniel Forkner:

[11:51] Okay, David. Well, it was loose regulations in the state that made them possible in the first place, and essentially what it was is a person could just walk up to a pain clinic--with some cash in hand, of course--complain about experiencing some pain, and then walk out with 600 pills. And because Florida did not have a prescription monitoring database at this time, it was possible to go from doctor to doctor to fill the same prescription over and over. Florida was buying up and distributing so many opioids that people as far north as Ohio would drive down in vans on the "Oxy Express" to bring back drugs from Florida. In Kentucky, up to 60% of all the illegal oxycodone came straight from Florida. In fact, David, by 2010, just about every single state east of the Mississippi River was sourcing the bulk of their opioids from Florida.

David Torcivia:

[12:41] 40% of the country's entire supply of oxy was sold in Florida between 2009 and 2010, and of the country's 50 highest oxy-selling clinics, 49 of them were in Florida, and it's very, very clear that the pharmacies and clinics that sold these drugs knew that they were acting as illegal drug smugglers. For example, a single Walgreens pharmacy--and yes, it's these big chains too--in a small town of just 12,000 people bought 2.2 million doses of oxycodone in 2011. The sixth highest purchased by a Florida Walgreens in 2011 was over 1.1 million doses. For comparison, in the same year, the average U.S. pharmacy bought just 73,000 doses in an entire year. The amounts these pharmacies were buying went way, way beyond the local community need, and it's impossible that they did not know this. These pharmacies were distributing more drugs than their entire local population could possibly ever hope to consume. The Modern Day Problem

Daniel Forkner:

[13:43] And eventually, around 2011, David, Florida did tighten its regulations, which made it harder for these pill mills to operate, and it made it harder to get unnecessary prescriptions. This did have an immediate effect. The number of pill mills declined, and the rates of prescriptions for opioids also declined. But unfortunately--and this is kind of how we arrive at the monstrous epidemic we have today--cutting people off from a dependency without offering any support merely pushes people to find alternatives on the streets through black market dealers, and if you haven't heard it yet, check out episode 31, "No Entry," specifically at the 14 minute, 24 second mark, where we touch on how walls that purport to stop crime and drug smuggling actually just exacerbate these problems and how the American war on drugs and prohibition in general really just makes everything worse. The economics of drug dealing really only makes sense when it's criminalized, and that's also where the dangers of drug use skyrocket as well.

Lori:

[14:46] I think the true opiate crisis is fentanyl and heroin, and I think that it's pain patients being forced to the streets to get relief for real pain and then dying due to, you know, fentanyl-cut heroin. There's no true education as to what's really going on and what you're really buying when you go. You know, there's pressed pills on the street that are fentanyl, and people don't realize that, so you could take a pain patient that's been cut off from their medications, or even cut down on their medications; they go to get something from the street, they get a pressed pill, and that could mean death.

David Torcivia:

[15:24] Lori makes a great point: if you look at the rates of overdose deaths in this country and you conclude that the problem is that people were given an opioid pill, well, you're not really seeing the full picture and what goes on behind the scenes. If someone has an opioid dependency, whether they're someone like Lori who has a real need or simply someone who developed a recreational dependency, and you suddenly yank that supply away from them without any alternative and without any support, their only option is to turn to a dealer who's going to sell them something they cannot trust, that they're not familiar with, and that likely contains a much higher concentration because of the simple economics of drug dealing. That's obviously a recipe for disaster.

Lori:

[16:08] I think that more care needs to be given, especially to patients that have been in pain management and have lost their pain management or their medications. You know, these are the people that end up on the streets buying heroin laced with fentanyl and having no understanding of the fact that they could die. When I was told that my cancer was stage III, I kind of didn't know how to process that information. It was scary. It was frightening. I didn't know really what to do. I had never done any drugs other than take my prescribed medications and smoke marijuana. I don't drink alcohol. I don't have any history of any other drug use. For one week after I found out that my cancer was stage III, I kind of got very self-destructive and I tried heroin for the first time, and I was underwhelmed, so I tried it one more time, and I overdosed, and I died, and I had to be brought back with Narcan, CPR, and then I had to be given nitroglycerin three times, 'cause I almost had a heart attack after being brought back, and that Narcan that brought me back was the Narcan that was prescribed by my doctor. It taught me a huge lesson. You know, here I'd never even tried drugs like that before. Second time, I ODed due to fentanyl.

Daniel Forkner:

[17:23] And so, David, like you mentioned in the beginning of the episode, more people died from an opioid overdose in 2016 than the total U.S. deaths during the Vietnam and Iraq War combined. Well, as devastating is that was, we had even more deaths in 2017, because as it has become increasingly difficult to get opioid prescriptions, more people are turning to synthetic and illicit forms of opioids like fentanyl and heroin, which are much, much more dangerous.

David Torcivia:

[17:52] And this is where the global trade comes into play. Fentanyl is difficult to manufacture. You really sort of need a pharmaceutical industry in order to produce these. But pharmaceutical industries with looser ideas of what is okay to produce exist in other parts of the world--in, namely, in fentanyl's case, China, huge amounts of these drugs are produced, turned to simple powder, and then are shipped either directly in the mail or by drug runners to Canada, Mexico, and the United States itself, where pill mills, which are often in residential buildings in suburbs and cities, turn these into very potent drugs. These pills, they look just like anything you'd buy from a pharmacy, but these are just made in a kitchen somewhere, and nobody knows exactly what the concentration of the fentanyl in it, how strong it is, and how easily it could possibly cause an overdose, which is why we've seen the huge explosion in deaths take off, because as people, like Daniel mentioned, turn from treating their addiction over the counter with the typical opioids that they had been buying from these pill mills for years to having to be forced to purchase them on the streets, well, they have no ability to test the concentration. They have no ability to know what they're getting into. And that fentanyl is extremely potent, and unfortunately, in many cases, leads to overdose and can happen very quickly, as Lori experienced.

Daniel Forkner:

[19:10] But David, let's take a step back for a minute, because with the exception of cancer and end-of-life care, the number one reason that opioids are prescribed in the first place is for chronic pain. Chronic Pain

Lori:

[19:22] I was put into pain management due to a--I broke my jaw in three places when I was 13 years old, and it wasn't fixed properly, and so I have a malformed condyle on one side. I needed a bilateral joint replacement in my jaw as well as half of my mandible replaced. I'm not even supposed to chew anything harder than mashed potatoes. My jaw is just severely injured and causes a lot of pain. That's why I was originally put into pain management. Over the 13 years I've been in pain management, I've had new problems. I have cancer now. I was diagnosed with renal cell carcinoma four years ago, and I've been fighting that for four years. They also discovered that I had serious back issues--a herniated disc and spinal stenosis--and so I have a lot of reasons for pain, and so I haven't had as much trouble, you know, getting my medications as a lot of people have, but I've seen a lot of people get cut off on their medications, get them cut down to a point that's pretty much ridiculous. You know, I've seen a lot of that take place.

Daniel Forkner:

[20:34] Now, there is some debate about whether opioids are the most effective treatment for long-term chronic pain. One highly cited paper published in 2015 in the journal "Annals of Internal Medicine" examined adults with long-term chronic pain and concluded that there was little evidence to support that doses of opioids could effectively manage pain long-term, but that they did contribute to other health risks. But, as Lori pointed out, the way pharmaceutical companies have manipulated the game--well, there never really was any alternative for doctors faced with treating chronic pain patients, and at the same time, pain management, it really isn't covered in a comprehensive way in medical school, which leaves many physicians unprepared for these patients. Now, to be clear, that does not mean that opioids are not effective for some people. It just means we don't fully understand the long-term benefits, and it's clear that the risks, if we truly understood them, would rule out the treatment for many people. But regardless, David, of whether opioids are the best treatment for chronic pain, we should take a step back and ask, "Why do we have so many chronic pain cases in the first place?" The CDC found just last month, using data from 2016, that over 1/5 of the entire U.S. population has chronic pain. So where is it coming from?

David Torcivia:

[21:55] Well, Daniel, the highest rates are found in women, veterans, adults who are unemployed after previously working, and, of course, those living in poverty and rural areas, and if we look at the rates of overdose deaths, well, unsurprisingly, we find correlations in certain lines of work. Massachusetts Department of Health just published a study this August that found a link between opioid overdose related deaths and those who work in dangerous jobs like construction, roofing, carpentry, pipe-laying, and painting. In fact, in the state of Massachusetts, overdose deaths are occurring six times higher in construction-related fields than in the general workforce. Not only do these workers perform labor that can be tough on the body and cause frequent injuries, but they often have low job security, are denied sick leave, are paid low wages, and, yes, of course, lack health insurance. Given these factors, the only option for these workers when they are dealing with injuries and pain is to take opioids so they can keep working, so they can keep taking home a paycheck, so they can avoid being fired and do their best to avoid the pain instead of really treating the problems that cause it in the first place.

Daniel Forkner:

[23:04] And what's really sick about this situation is that pharmaceutical companies not only knew this but really capitalized on it. It's actually how Purdue Pharma got their drug Oxycontin off the ground in 1996. They chose small towns in Virginia and West Virginia to launch their brand, so to speak, because of the high number of manual labor jobs in logging, coal mining, and steel working in those areas. They marketed their drugs as way to treat injuries common to these types of jobs. The company even offered the first bottle of pills for free.

David Torcivia:

[23:38] Talk about taking a play directly out of the drug dealers' handbook.

Daniel Forkner:

[23:42] Exactly. And doctors who had never prescribed opiates for anything but the most serious illnesses were now being approached by people requesting them, and the representatives from Purdue were telling doctors that there were no serious risks to the drug. Well, Virginia continues to feel a disproportionate share of the burden of this national problem. More opioids are prescribed per person in the city of Martinsville, Virginia, than anywhere else in the country. The average doctor in that city and the surrounding county prescribe almost eight times as many opioids each year than the average doctor in most other U.S. counties. Physician Frustration

David Torcivia:

[24:19] Well, the astute listener will realize that, well, patients aren't the only ones struggling with these realities. Doctors, of course, are too. As we mentioned, the American approach to drug use is basically entirely unique, and rather than try and provide help and support for those who need it most, we'd rather just throw the users in jail and blame the doctors for prescribing the pills and then call it a day. Many doctors are now feeling pressured to stop prescribing opioids even for patients they believe truly need them for fear of being sanctioned or even criminalized as part of a new crackdown effort by the government to halt all this rampant over-prescribing.

Lori:

[24:58] I've seen my doctor--you know, my doctor has admitted to me how hard all of this is on him, you know, and how the, you know, DA, the government, the CDC, that, you know, they're all just really making it hard for physicians that are, you know, pain management physicians.

Daniel Forkner:

[25:17] We're seeing a general trend going on really across the healthcare system in which physicians are getting burned out, and they're really unhappy in their work. A paper published in August by the University of California School of Medicine found that physician burnout increased to 54% by 2014, which was a 9% increase over and above what other U.S. workers experienced. Now, burnout in this case is defined as lacking a sense of accomplishment, feelings of cynicism, and a lack of enthusiasm for work. David, I find it particularly sad if our doctors don't feel a sense of accomplishment, because, I mean, a lot of people that go into medical school, I think they go into it with this feeling that they're going to improve people's lives, that they're gonna help save people. I mean, yes, there's the stereotype of people going into medicine for the money, but a large percentage of people do it because they want to...

David Torcivia:

[26:12] Well, to make a difference.

Daniel Forkner:

[26:14] Yeah, exactly. But unfortunately, once they get into their actual practice, many of them don't get that sense of accomplishment. Now, this paper cites five major causes for these trends: the rising price of drugs, which we talked a little bit about in part two, as well as hospital ownership of healthcare systems, productivity standards, complexity imposed by the Affordable Care Act, and new electronic health records, which take up more and more of a physician's time without actually improving patient care.

David Torcivia:

[26:44] But most notably, continuity of care in American healthcare has been breaking down. Continuity of care, meaning a physician cares for the same patients over time and ultimately develops a relationship with them, has been a historical mainstay of healthcare, and what has for so long been a motivating force attracting people to the healthcare profession. From this study: "Continuity of care historically provided the necessary bonds that regenerated the early career feelings of scientifically based benevolence that attracted most doctors into the healing arts." [27:22] But this is rapidly breaking down, and the doctor-patient relationship is now more of an insurance company-client relationship. Not only are doctors like Lori stressed complying with government demands to cut back certain prescriptions, but insurance companies themselves often define what care a doctor is and is not allowed to administer because of those financial reasons that we discussed in part one, "Bill of Health." This all affects continuity of care. Patients change doctors more frequently than ever, in part because employers change insurance companies often, which means a physician a patient was seeing can suddenly become out-of-network, and they are forced to switch, and also because, since fewer physicians are going into private practice, patients are being assigned to various doctors based on the whims of a hospital-owned healthcare system.

Daniel Forkner:

[28:14] This is such a significant factor to me, David, and I know we're getting a little bit off topic here from the opioid situation, but when you think about what a doctor has been historically, it's someone that got to know you, someone that formed a relationship with you, maybe knew your family, and therefore could give you the care you needed because they understood your history, they understood how you might react to certain treatment, and I think most people want their care to be like that. But we find ourselves in a situation in America where people are not given the choice, necessarily, of the doctors they see, but yet we're given this illusion that we have this infinite choice. Again, the insurance complexity is presented to us as a free market in which we can choose anything we want, and our freedom is limitless here, but again, I think it's important to emphasize the point here, that what people truly want is not a faux market of five different payment options for insurance while having restricted care. I think what people truly want is the ability to go see any doctor they want in any facility they want without having to worry about whether or not it's contractually permissible.

Juanne:

[29:24] The doctor said, "Oh, she needs this test," and I had the test, you know? So there's that. And the other thing I'd like to mention, and this is another lie that is perpetuated: we have total freedom when it comes to choosing doctors here, okay? I lived in Toronto for most of my working life, and I changed jobs pretty regularly, because I switched career courses a couple of times. I went to a clinic, and I had one doctor there until he retired, and then another doctor took over his practice, and I switched jobs--oh, God, I can't tell you the number of times I switched jobs--and I kept going to that clinic. I never had anybody tell me who I could go and see in terms of my family doctor. The government wouldn't dare tell me who I can go and see.

Daniel Forkner:

[30:13] That was Juanne from part one of the series. So David, we're coming to the end of this episode, and it's not a very long episode relative to some of our other shows, but... Making Sense [30:23] I think as a part three, this really ties together many of the issues we discussed in part one and part two, and, of course, like you mentioned, so many of the other topics we illustrate, and I think it's important to simplify this down to what perhaps is really going on, and it seems very clear that after pharmaceutical companies flooded the market with these highly addictive and very potent drugs, we realized that there was a problem, but our response was the usual American one: crack down on the users, throw them in jail, restrict access, punish doctors for over-prescribing, and see if we can just prohibit our way out of the problem, which in turn made things infinitely worse. People who relied on these drugs were now turned to the streets, where dealers could supply them with very expensive and highly concentrated drugs like fentanyl and heroin, with varying doses so the people didn't necessarily know what they were going to get, and for those who recognized that they have a dependency and wanted a way out, well, were we there to offer treatment? Were we there to offer support? Were we there to say, "It's okay"? Or were we there blaming them, pointing the finger at them, telling them to get their life together, calling them pill heads? [31:37] In fact, I think one senator even said at one point that those who OD are part of natural selection doing its work. The American approach to this is not one of understanding and certainly not one of compassion.

David Torcivia:

[31:50] But how much of this problem is because of the American approach in the first place? As we've talked about for hours at this point, the way the American health system is structured, that problems like our opioid crisis are not only caused by the system, but they're inevitable because of it. The way that we incentivize doctors to benefit pharmaceutical companies and insurance companies and hospitals over the patients that they are oath sworn to protect first and foremost has broken our system fundamentally. It should be no surprise, then, that the pharmaceutical industry exists mostly to exploit the misery and suffering of others. As much as they may claim to be out there researching, looking for new drugs to improve our health, so much of this is really just about, "How can we create an ongoing stream of revenue?" and opioids in particular are one such perfect example of this. [32:41] You hawk these pills to doctors, force them to prescribe it by tricking them into thinking they're much more benign than they actually are; that they're healthy, even; they're good for teenagers; they're perfect for children; that we need to start prescribing people on pain in a way that we've never even talked about or thought about before. And take into account the way that our economy is structured, the way that we force people to work when they should be at home resting, when they should be getting treatment in responsible ways and physical therapy and things that actually treat the problems that cause these pains in the first place; that force them to work through the pain and offer them only one alternative. "We're gonna hurt you, we're gonna get you addicted, but you won't feel the pain, at least for a little bit. Yes, you'll have a new problem. Yes, you'll have to pay for this. But your insurance, at least for now, will cover this." If you lose it later, well, you know, you can always turn to the streets, where the pills are available, and they're still, in part, supplied by these same pharmaceutical companies, made available through pill mills and irresponsible doctors. But wait. Legislators have caught on to what is happening, and instead of punishing the companies that pushed this, that created this problem in the first place, we've turned instead to making it even harder for doctors to fix this problem, to give patients once more what they believe they truly need, and instead make them fear the repercussions of being perceived of overprescribing. [33:59] We tightened the faucet, and in the process, denied people this drug that we had gotten them addicted to by our gross incentives in the first place, and now our morgues are filling up. [34:10] There are many counties who have never had this many dead bodies before. They literally don't have room for them. They're building additions to this, passing bills and bonds for taxpayers in order to hold more bodies of their constituents that they are supposed to be protecting in the first place. This is a system that is out of control, and ends up causing the direct loss of tens of thousands of American lives, and that number's gonna climb over the next decade to be over 100,000 people dying to these overdoses annually under optimistic projections, and that's because, while we've acknowledged we had a problem and we are attempting to find solutions, we've done so little to actually make a difference. Now, I've been fortunate enough actually to work on some of these CDC campaigns to raise awareness of what is going on with the oxy crisis, with the opioid crisis, and the focus of these campaigns are mostly on education--the fact that these pills are addictive in the first place. But that's not the problem. We understand the addiction inherent in these things. But people feel like they're forced to take them, to turn to them, and this drug crisis is unlike all the other ones we've seen so far, and yes, this country has constructed most of its drug crises through irresponsible legislation and the action of the government in treating them or persecuting them or creating the problem in order to drive votes. It's true. But for the most part, those were focused on minorities, and the media never responded well to that. [35:34] But now, the opioid crisis, by and large, is affecting, yes, still those in poverty, but many, many more white people than the other drug crises had before, and that's caught people's attention. As gross as that is, the media's trumpeting this opioid crisis, talking about the problem. Type it into Google. You'll see, "opioid crisis," how many articles are written about this, and for good reason. Again this is double the amount of people who are killed by guns every year in the United States. This is more people than were lost in the Vietnam and Iraq War combined annually. It is a crisis, absolutely, but the fact that we only pay attention to what it is because of people, the color of their skin, who are dying, is part of the problem that we have in the first place. [36:17] This is wholly different, because the people in this crisis so often feel like they can't reach out because of the way that we've treated drug users in the media before. They hide their addictions. This is your piano teacher. This is your plumber. This is the person who serves you food every day and has aching feet and was forced to take opioids to stay working and finds themselves addicted and buying them off the street afterwards when they can find their pills no longer. This is something that affects families, the middle class--even the rich find their numbers slowly falling because of these overdoses. These are your neighbors, and if we remember that, and we remember that's how we need to perceive all drug users--as people within our community who are desperately out there looking for help--and not treat them as an other, then we can actually start working towards a solution. These are victims of a healthcare system, of a pharmaceutical system, of an economic system that is out of control and more than happy to chew people up, spit them out, leave them lying without a spot in the morgue because there is a profit to be extracted from that individual's life.

Daniel Forkner:

[37:26] And David, you mentioned the addictiveness of these drugs, and I think addiction is a topic that really deserves its own episode. There's a lot that goes into it, and it's perhaps out of the scope of this three-part series, but I do want to mention that when we focus purely on the amount of drugs or accessibility of drugs within a community, we're not seeing the underlying causes of addiction. We have to look at the wellbeing of people in those communities to really understand what's going on, and Johann Hari, who has written a couple books on depression and addiction specifically, he's provided some clues as to how we have misunderstood addiction, not just in America, but around the world. [38:07] Beginning in the '80s, there were a series of studies carried out to measure the addictiveness of cocaine and other drugs in rats. Now, researchers put rats in cages, and inside those cages were water bottles laced with cocaine, and what they found is that once the rats got a little taste of the cocaine, they would drink from that bottle over and over until they died. This happened time and time again, and it helped inform us of the dangers of addictive drugs. However, there was one researcher--his name was Bruce Alexander--and he thought that the environment in which the rats lived, which, at the time, was an isolated and small cage with nothing in it but drugs, might have been playing an important role, and so he designed a new experiment, and they called it "Rat Park." Now, in this experiment, rats still had unlimited 24-hour access to drugs--morphine in this case, a powerful opiate--but instead of being stuck in a cage, the rats were free to roam around, play with toys, and most importantly, interact with each other, have sex, and do all the things a social creature likes to do. In this environment, the rate of morphine consumption among rats dropped dramatically--almost 25 times less than the caged rats--and there were no overdose fatalities that occurred. [39:27] Now, this experiment and others like it have led researchers to conclude that it was not the drug itself that was dangerous for the rats, but it was isolation and the breakdown of all the things that make up a quality of life for a rat. And are we so different? I think there are a lot of clues in the life circumstances of the people this opioid issue impacts the most. Just look at how Purdue Pharma got its signature drug off the ground by targeting people in low-income, injury-prone industries that have low job security. These are people who, by definition, lack support. [40:04] And that, I think, is really what this comes down to. Look, every individual has a unique circumstance in life with unique needs. Not everyone needs the same support, but we have a society intent on dismantling every form of support, every form of solidarity, every form of community. When almost half the country has nothing in savings, has experienced declining financial stability for decades, and struggles to maintain a roof over their heads and food on the table, when people everywhere are stuck in the so-called "gig economy," where there is no such thing as sick leave or workers' compensation, where your boss is an iPhone app, and your only colleagues are people you've never met who are all being rated against you, and when, under these types of conditions, the door is flung open for large profiteering companies to target our most pressing vulnerabilities and weaknesses, is it any wonder we have mental health and dependency problems? Is it any wonder people turn to the only thing available to them to help manage their pain? [41:05] This issue goes beyond unscrupulous doctors. This issue will not be solved by throwing poor and vulnerable Americans in prison. This issue can only begin to turn around when we halt the systemic violent assault on the mental, physical, emotional, and communal health of every American. And if we do that, maybe we can stop the assault on the rest of the world as well. And David, you mentioned that the victims of this broken system are hiding. They're ashamed to have their dependency found out. Well, when I talked to Lori, I asked her. I asked her if her friends and her family and her community support her in this time of struggling, this time where she's facing cancer, chronic pain from a surgery gone wrong, and other health issues in her life, and this is what she said:

Lori:

[41:55] I don't even talk about it with a lot of people in my life. Most people in my life don't even know to what extent I seek out pain management or am involved in pain management, because I'd be afraid to tell them, because there's a stigma. You know, I think a lot of people, you know, they see anyone that takes these pills [indistinct]--I've heard "pill heads." You know, I've heard lots of just really derogatory things said about people that are even in pain management--people that are doing it the right way, the way you're supposed to do it. You know, I've been in pain management for 13 years. I've never gotten in trouble by my doctor or been fired from a physician. You know, I've tried to do things the right way, but I don't talk about it with people, 'cause I know I'll be judged.

Daniel Forkner:

[42:41] Next, we asked Lori, "How would you want someone to support you? How would you want your friends and family to approach you?"

Lori:

[42:49] I mainly wish that they would come to me with at least an understanding that I'm in pain that they can't fathom--you know, pain that they don't understand--and I would like for them to be supportive of that, and that would open the door for me being able to talk to them about other things, including how I manage that pain.

Daniel Forkner:

[43:12] If we can stop stigmatizing people, then maybe we can expand awareness and education for how to save them. What Can We Do?

David Torcivia:

[43:22] It's a heavy episode, Daniel, but let's talk about one or two just really small, practical things that we can really make that possible and genuinely start to save people. In other nations around the world, we've seen a huge expansion of methadone clinics and methadone treatment, and this is actually something that's sort of a controversial topic in the opioid community. Methadone itself is an opioid. It has the same effects as oxy or something similar. It is a--you can overdose on it, but it is controlled and deployed in very safe amounts, and they were places this unsafe addiction of who knows what people are getting off the street, and instead make sure that they're getting something clean and pure and have a safe way to do it, while also receiving clinical support, community counseling, therapy, and other treatments that extend beyond solely this drug that is being deployed. Of course, this could also be seen as another way that these pharmaceutical companies have created a pipeline of addiction, of people who consistently, daily, consume another one of the drugs that they produce in order to profit off, once again, these addictions. And, in fact, pharmaceutical companies have recognized the profit potential in these methadone clinics and have devised a way that they can carry this profit pipeline straight to the home. Purdue Pharmaceuticals, that same company that first brought us Oxycontin and kicked off a lot of this problem, well, they recently patented a brand new drug, a drug called buprenorphine. [44:48] This drug is very similar to methadone. It's another opioid. You can take it home, though. Your doctor prescribes, you take it every other day, and it prevents you from going into opioid withdrawals, prevents you from looking for other drugs that might not be as safe to take, but it is still an opioid. You're still addicted, you're still feeling the euphoria--just maybe less so--and it's very difficult to overdose on it. [45:09] This is another pipeline of profit that Purdue has built in order to keep people addicted so they can keep squeezing them for money, and without the community support that occurs in these clinics, well, methadone doesn't make you get any better. You're just addicted to something else, and something that, since it's provided by the pharmaceutical industry, is arguably considered safe, and done in very specific ways to prevent you from overdosing, but the addiction is still there. It's not treated. It's the community support that comes together that actually makes a difference, and that's the thing that's lacking in so many places, especially here in the United States, and that's why the stigmatization is so important. If we can get past the idea that these are drug addicts, that these are people who are doing something that is harming them, and whether or not that's true--I mean, absolutely, taking these drugs, overdosing on them, is not good for you. But we need to remember that something pushed them to do that. They felt like they had no choice, and they ended up down this path, and just because they made a wrong decision, even if that was the only decision left to them, doesn't mean that we cut them off. It means that we need to come to them and support them even more, because if we were in that situation, that's what we would want, that's what we would need, and that's what Lori is sitting here telling us. She says, "This is what I need as somebody who is suffering from this, who has been suffering this for so long, who has lived this life," and if we can't listen to that, then we haven't learned anything at all over the course of all these episodes. [46:34] Beyond that, there are things you can do very specifically within your community itself. These overdoses are happening constantly. Over the course of this show, almost eight people will have died in the United States alone. Those deaths, though, they're all preventable. There's a simple drug that can be given to somebody who is overdosing that can save their life, give them enough time to be brought to hospital, where they can be treated and prevented from dying from this overdose. This drug called naloxone, or the brand name Narcan, is available all across this country. You can buy it over the counter in many places like CVS, and almost every single state, there are places where you can be trained in order how to use this, deploy it, and even receive training to give to other people. This is something that's very simple to do. I've done it. And once you are trained in this, you can help other people learn too. Some of these trainers, you can even get free Narcan yourself to distribute to places where people will be in the most need for it. You know a junkie? Teach them how to use this. Give them a prescription. It might save their life or the life of somebody they know. You know a hardcore bar. You know a public library--someplace that people might go and overdose in a bathroom. Make sure that the people who work there are trained in this and have this drug available to them so that they can save a life. This is a simple thing. It's easy to do. We can save so many lives every year with this if we collectively, as a community, come together and realize that we need to take our health and the health of those around us into our own hands. [47:59] It's not enough to turn and look the other way because these people are drug addicts. That time is done. These are not the other. These are our friends, our neighbors, even our doctors, and we need to be collectively responsible for all of us together. As always, that's a lot to think about, but think about it we hope you will. You can read so much more about all of this on our website, as well as a full transcript of this episode, at ashesashes.org.

Daniel Forkner:

[48:26] A lot of time and research goes into making these episodes possible, and we will never use ads to support this show, so if you like it and would like us to keep going, you, our listener, can support us by giving us a review, sharing us with a friend, or hitting that five star button on the iTunes podcast app. Also, we do have an email address. It's contact@ashesashes.org. Send us your thoughts. We'll read them--every one of them. Even if sometimes we don't get back in a timely fashion, we will eventually.

David Torcivia:

[48:57] I'm feeling personally called out right there.

Daniel Forkner:

[49:00] But we do appreciate it. We love hearing from you.

David Torcivia:

[49:04] You can also find us on all your favorite social media networks at AshesAshesCast. Next week, we've got a timely episode as all us Americans turn to the polls. We hope you'll tune in, but until then, this is Ashes Ashes.

Daniel Forkner:

[49:18] Bye.

David Torcivia:

[49:19] Bye-bye.