my name is Chris Johnson and I’m an
emergency physician and I’m going to
talk to you today about the opioid
epidemic I have been involved in
fighting this epidemic in this crisis
and watched evolve from my experience as
an ER physician for the last 15 years
I’ve sort of had a seat on the
frontlines if you will and unlike some
of the other talks or other
presentations you might have heard about
this epidemic I want to talk to you
about how it happened and more maybe
more importantly why it happened and I’m
gonna tell you right now it was not an
accident no one should leave this no one
should leave this lecture wondering I
guess no one saw that coming people saw
it coming and I’m gonna talk to you
about how that happened
I’m gonna begin with an apology on the
behalf of the medical industry we failed
you
those of us in charge of looking out for
your health and safety failed you and
I’m going to detail that failure in the
next 17 minutes my background I’m
originally from Virginia and I moved to
Minnesota to train emergency medicine at
Hennepin County Medical Center and I
trained there from 2000 and 2003 and
that was my introduction to the problem
of substance use and I’ll be honest when
you when you train and work in a County
Hospital it can be a little dismissive
of it because in a County Hospital
population you see lots of social
pathology broken families parents
incarcerated you know lack of
opportunities and education and you kind
of think well substance use goes along
with that
but then in 2003 I graduated my
residency and I began practicing here in
Methodist Hospital in st. Louis Park and
I was seeing the same thing I couldn’t
go a shift without seeing a patient
coming in with chronic pain exacerbation
or possibly an overdose on high doses of
opioids that they were taking every day
and this is why I began investigating
the cause of this problem and hopefully
come up with some solutions so the
problem what are opioids and why are we
talking about them well a little history
the use of opioids as a medicine for
pain goes back as far as written
civilization the Greeks the Assyrians
the Persians all documented use of this
medicinal plant for
the use and treatment of pain and the
traditional method of getting morphine
was this this is the seed pod of the
opium poppy Papaver somniferum and the
way you collected that medicine was you
made a slice in it and collected this
milky substance which contains morphine
now the reason it’s called somniferum
actually goes back to Roman mythology
somnus was the god of sleep and so when
we give patients or you’ve seen someone
receive these drugs they become tired or
sleepy
they are somnolent and as we all
remember somnus first appeared in our
literature with Ovid’s metamorphoses
which was the latin epic poem detailing
of the history of the world up until
julius caesar and 15 volumes i thought
the first nine volumes flew by by the
way but they’re like the last six is you
want to get to the Rubicon you know you
got an army and actually morphing comes
to us from mythology as well Morpheus
was the Greek god of dreams and opioids
help treat pain in two basic ways one is
that they actually block the strength of
the nerve the pain nerve signal from
periphery to your spinal cord and so
that inhibits the experience of pain but
the more important one for our purposes
is this hope you always make you feel
good and by altering your mood they
alter your perception of pain pain is an
emotional experience sort of like all of
life is and what opioids do is they
increase your mood by increasing
dopamine in your reward center and this
is a simplified version but if this is
this is your brain and your reward
center without opioids and you have a
little steady stream of dopamine in your
reward center and you your brain feels
okay and then what happens with opioids
heroin morphine whatever is that you
have this flood of dopamine and you
think my god that was awesome and that
is that is how it effects your
experience of pain the problems that
opioids carry risk on they also bind
receptors in your brain that control
your breathing and in high enough doses
can stop your breathing and once you
stop breathing you’ve got a few minutes
to restore oxygen to your brain or heart
or you die thereafter of association or
the problem is that the United States
has four and a half percent of the
world’s population but we consume 30% of
the world’s opioid pain relievers that
sounds crazy was it always like this it
was not from the years 1992 to 2012 the
number of prescriptions of opioids in
this country tripled and I don’t have to
tell you the population of this country
did not triple but the number of
prescriptions is actually only part of
the story here’s another part the size
of the prescriptions got bigger so it
wasn’t just the number of prescriptions
being written the amount of opioid in
every prescription massively increased
this graph here you can tell that these
are years at the bottom but this is
oxycodone consumption in the United
States and blue and Europe in red and so
here we are
oxycodone as the pain reliever in
percocet so here we are a little bit
above Europe per person up until the mid
90s and then we did that so it wasn’t
just a number it was the size of the
pills we had this massive increase in
opioid exposure in this population
coming from the medical industry but
that’s only part of our problem now you
guys have all seen the stories about
heroin and fentanyl and I would
encourage you not to view these as
separate problems they are intimately
related and followed on the heels of the
increase in opioid prescribing these are
opioids they bind the same places of the
brain do not view them as dramatically
separate chemicals okay three out of
four users of heroin began with pills
and often what happens is that a patient
who became dependent on the pills over
years and found their supply getting a
more difficult to come by or too
expensive they would turn to heroin
which was often cheaper the result of
this massive increase in opioid
prescribing and now uses of heroin and
fentanyl has led to a massive increase
in overdose deaths in the year 1999 the
total number of opiate overdose deaths
in this country was 6,000 that was 4,000
from prescription opioids and then
another 2,000 from heroin in 2016 that
number had climbed to 50,000 if you want
to know what 50,000 looks like well that
would be 16 World Trade Centers and
you’re still 2,000 short
and all of you might remember we went to
war over just one of these the United
States has four and a half percent of
the world’s population but we have 27
almost 20% of the world’s drug overdose
deaths so how and why did this happen
this has been a problem that we’ve seen
in the inner cities but then it’s also
now moved out to the suburbs and the
affluent it has affected some of our
greatest artists but it doesn’t spare
the athletes so how and why did this
happen
I would like to tell you that it was
good intentions gone awry perfect storm
wrong place wrong time but that is
simply not true the medical industry has
changed dramatically in the last 20
years in particular the powered
influence of the pharmaceutical industry
and the ascendance in in my profession
again of meeting corporate imperatives
above all else so how did the opioid
manufacturers gain control of the
marketplace they did a number of tactics
that I’m going to talk you through
number one is this the recruit pain
specialists at academic centers to be
the sort of key opinion leaders and
thought leaders and their goal is to
convince the medical community workaday
Doc’s like people people like me that
aren’t reluctance to use opioids for
chronic pain conditions what was
misplaced that opioids were safer than
then we had thought they were and that
there was so much pain out there it was
we were negligent in how much pain we
were permitting to occur that pain was
an undertreated epidemic there was a
number of these doctors that they
recruited but probably possibly the most
important one was this gentleman here
dr. Russell Portnoy he was the subject
of the Wall Street Journal article pain
drug champion has second thoughts
published in 2012 he saw his job as
rehabilitating the medical community of
Opio phobics people with an irrational
fear of opiates he was president of the
American Pain Society in 1995 and was
the American Pain Society that came up
with this pain was a vital sign I
remember these buttons when I was a
resident my faculty had it I had it you
warm on your scrubs patients you know
pain was to be taken as seriously as
blood pressure heart rate temperature in
terms of predicting potential more
morbidity for a patient that’s how
seriously we were to take their reported
pain levels doctor Portnoy published an
article
a position statement in the clinical
Journal of pain in 1996 stating that the
risk of addiction from opiates when used
for pain was less than 1% less than 1%
for that sir sounds safer than I was led
to believe do you know where that less
than 1% statistic came from it came from
an article in the New England Journal of
Medicine it became no it was published
by 1980 by Jane Porter and Herschel Jick
and it demonstrated that opioids were
less than 1% became addicted to opiates
and I’m gonna use the balance of my time
to go through that study the statistic
I’m just kidding you can read the whole
thing in 90 seconds this is it it was a
five sentence letter to the editor this
is the study that supposedly proved that
opiates for use with pain
they weren’t addictive now all they did
was they didn’t actually intend this to
say that at all I mean remember this
this was written in 1980 and like 16
years later they’re now saying it proves
opiates aren’t addictive all they did
was they followed hospitalized patients
who had an acute injury about 12,000 of
them and then followed them afterwards
to see how many developed addiction they
were put on opiates indefinitely
these were acute injury patients who
just received a dose or two in the
hospital it said nothing about treating
chronic pain with obits and this was the
great failure of medical ethics this is
where we truly let the population down
because that sort of paragraph is in
scientific terms is called an
observational study you look after the
fact and you observed that’s interesting
okay that’s the beginning of the process
that’s not the end what you should do
after you observe this is like how do we
prove this do we think that more people
can take these safely indefinitely let’s
do an experiment the experiment was
never done the longest experiment done
for opiates for use with chronic pain
was 12 weeks most were just six it is on
the bat basis that we started
prescribing opioids on an indefinite
basis to patients now what does dr. port
and I say now about opiates well in a
taped interview I gave innumerable
lectures about addiction in the 80s and
90s that
weren’t true if I had an inkling of what
I know now then I wouldn’t have spoken
the way I spoke by the way the Wall
Street Journal also identified millions
in donations to his pain clinic which
pays him from opioid manufacturers
tactic to market to the primary care
doctors this was not done until 1996 and
one product changed all that
oxycontin released by Purdue Pharma in
1996 as a continuous release preparation
of oxycodone which again is the pain
reliever in percocet prior to 1996 and
oxycontin extended release opioids or
ongoing use of opioids was reserved for
hospice patients it was it was
prescribed typically by pain specialists
and cancer doctors for people at sort of
end-of-life care but here’s the thing
you can’t make billions on hospice
patients first there aren’t that many
and then number two they expire you can
make billions on back pain and that’s
exactly what they set out to do and the
way you get to back pain and treat
people for a long time and the most
people as you get to primary care and
that’s exactly what happened in
unprecedented numbers drug
representatives flooded the the primary
care clinics often making you know a
visit every week they would have gifts
and food and flattery there’s multiple
like this forty conferences in five
years that’s like one more than every
two months and they invited the doctors
the nurses the pharmacist everyone
involved in the opiate delivery food
chain was included and they didn’t
forget the patients for patients you got
free drugs oxycotin had a starter coupon
program where your first prescription
was free now tell me that isn’t like the
creepy guy outside the high school with
a little bag because I’m your friend you
just try this tactic 3 influence
government and regulatory bodies to
favor increase prescribing you needed to
do this for a couple reasons one is you
still have to get approval for your
product to make sure you could you know
it was indicated in market to market it
and the other reason is that while the
the pain specialist sort of gave us
permission to prescribe if you really
want to increase prescribing have a
stick not just a carrot but a stick and
in 1992 the primary client of the FDA
since 1992 is basically the
pharmaceutical industry and this was a
direct consequence of something called
the Prescription Drug User Fee Act
half of the FDA’s budget is now provided
by the industry and that actually that
that came out of the AIDS crisis
actually it wasn’t some malevolent thing
back then in the 1980s we had all these
people with HIV and they’re expiring and
there’s this clamor like what are we
gonna do for all these patients and the
FDA was overwhelmed and said look we’d
like to do these trials to get you
helpful for medicines but we don’t have
the budget to do it and so the industry
stepped in but ever since then they’ve
been dependent on the industry for their
funding and it is very difficult for a
regulatory body to regulate an industry
when it depends on the industry for
money and in the 1990s they approved
opiates for chronic pain again based on
no studies longer than 12 weeks and
here’s the stick part get those pain
scores down the the pharmaceutical
industry influence the Joint Commission
which is responsible for evaluating and
accrediting hospitals this was on the
wall of every emergency department room
I worked in you know zero to ten what’s
your pain level at nurses were compelled
to recheck on the patient’s our what’s
your pain level we got to get that down
the Joint Commission published a guide
in 2001 about pain management and that
was funded by Purdue Pharma and told us
that the risks of opiate use had been
exaggerated tactic for they blur the
lines between patient advocacy and
academic groups and marketing take a
look at this group partners against pain
pain it’s not something you need to you
you can have to manage alone you have a
partner and look at they’re holding
hands
like who would argue against that
they’re fighting pain and loneliness but
if you scroll down to the bottom of the
screen this was purely a creation of
Purdue Pharma what they call unbranded
outreach that was 1993
and take a close look at these academic
societies it’s the American Academy of
pain management that’s the forum
president dr. Lynn Webster we have an
epidemic on our hands and the status quo
is failing us curious thing about that
Academy they’ve got a corporate counsel
and look who’s on it Purdue Pharma endow
Pfizer jell-o makers of opiates so is
farmer the one to blame well they are
they certainly a part of it I mean they
they these were there this was their
marketing strategy but I want to caution
you that it’s too easy to just blame the
pharmaceutical industry the
pharmaceutical industry sells all over
the world this crisis didn’t happen in
Japan
it didn’t happen in Germany happen here
so what is it why did it happen here as
opposed to these other countries that
they have patients who have chronic pain
pharmaceuticals do they they sell them
there too well this is from my
performance of review in the year 2012
those are my arms I’m very proud Chris
we are also proud of you for the work
you are doing with chronic pain but it’s
such a fine line between increasing risk
of open addiction and hCAP scores what
age cap scores are those are your
patient satisfaction surveys they do not
exist for your health they exist for you
as a customer to get you coming back
medicine in America unlike other
countries is first and foremost a
business enterprise and every business
enterprise has as his primary obligation
is to make money for the owners and
investors and in the process enrich the
participants even not-for-profits have
investors their bondholders in fact
fiduciary responsibilities which all
these executives undertake compels them
to do this for this reason American
medicine is not incentivized for your
long term health is incentivized to sell
you health care services but this leads
to an unavoidable conflict in health
care healthy patients don’t need to buy
health care now why would this pose a
risk for opioid crisis because a system
driven to sell services thrives and
patients are in a state of chronic
disease and that is precisely the model
that opiates employ it checked off a lot
of boxes for us it allowed us to expand
the customer base pain is a vital sign
pain is an epidemic pills solve the
problem visit or quit you can see tons
of patients and turn them over
pills are by prescription only we corner
the market you know tylenol doesn’t
solve this opioids do and treatment is
lifelong and indefinite patients become
dependent on these opioids and keep
coming back so what do we do about this
to pass forward a short term in a long
term in the short term we need to
prevent creating new opiate dependent
patients in the long term reform a
system that created this studies do not
support the use of these medicines for
management of chronic pain if you have
back joint neck pain do not start these
medicines they don’t work in the long
term medical assisted therapy helps
patients who who have developed opiate
use disorder but is a very imperfect
solution it cuts your rate of overdose
in about half but your risk of death is
still three to five times higher if
you’re on medical assistant therapy that
if you never developed a problem at all
bottom line is this the American system
is a failure in addition to overcharging
you we are not getting you good medicine
good therapy that is well driven by
science and it’s not because doctors
want to cause harm our incentives are
broken we need a different type of
system one that rewards outcomes or at
least stops rewarding just the sales of
services this would be more in line with
the Hippocratic oath and what other
countries do so what can you do going
forward well we can at least acknowledge
that opioids don’t work for chronic pain
as far as I’m aware the American Medical
Association American Heart Association
none of them have acknowledged this we
need to interrupt the financial
relationship between doctors and the
industry we need to make research more
scientific and make the FDA independent
and we can need to stop volume-based
revenue for doctors and Clinics oh and
let’s stop this whole talk about
morality and this is a challenge I would
even say to the traditional recovery
industry we have created addiction in
mice in chimpanzees insects pigeons we
don’t talk to them about their character
defects so this is my final slide I
conclude here this is a painting by
Edward Munk it’s called despair it is
derived from the Latin verbs better
which means to hope so despair literally
means without hope I got involved in
this problem because I was initially
very frustrated with trying to manage
these patients in the emergency
department but the more you learn about
these patients and what they’re going
through what their families are going
through it is a world of suck you do not
want to wish that on anyone
and so I argue for reducing opioids
because I don’t not because I want them
to suffer pain but because I don’t want
them to enter this life of misery and I
want a healthier system from my
colleagues who many of our great people
that want to practice effective
compassionate medicine because we all
you [Music]
emergency physician and I’m going to
talk to you today about the opioid
epidemic I have been involved in
fighting this epidemic in this crisis
and watched evolve from my experience as
an ER physician for the last 15 years
I’ve sort of had a seat on the
frontlines if you will and unlike some
of the other talks or other
presentations you might have heard about
this epidemic I want to talk to you
about how it happened and more maybe
more importantly why it happened and I’m
gonna tell you right now it was not an
accident no one should leave this no one
should leave this lecture wondering I
guess no one saw that coming people saw
it coming and I’m gonna talk to you
about how that happened
I’m gonna begin with an apology on the
behalf of the medical industry we failed
you
those of us in charge of looking out for
your health and safety failed you and
I’m going to detail that failure in the
next 17 minutes my background I’m
originally from Virginia and I moved to
Minnesota to train emergency medicine at
Hennepin County Medical Center and I
trained there from 2000 and 2003 and
that was my introduction to the problem
of substance use and I’ll be honest when
you when you train and work in a County
Hospital it can be a little dismissive
of it because in a County Hospital
population you see lots of social
pathology broken families parents
incarcerated you know lack of
opportunities and education and you kind
of think well substance use goes along
with that
but then in 2003 I graduated my
residency and I began practicing here in
Methodist Hospital in st. Louis Park and
I was seeing the same thing I couldn’t
go a shift without seeing a patient
coming in with chronic pain exacerbation
or possibly an overdose on high doses of
opioids that they were taking every day
and this is why I began investigating
the cause of this problem and hopefully
come up with some solutions so the
problem what are opioids and why are we
talking about them well a little history
the use of opioids as a medicine for
pain goes back as far as written
civilization the Greeks the Assyrians
the Persians all documented use of this
medicinal plant for
the use and treatment of pain and the
traditional method of getting morphine
was this this is the seed pod of the
opium poppy Papaver somniferum and the
way you collected that medicine was you
made a slice in it and collected this
milky substance which contains morphine
now the reason it’s called somniferum
actually goes back to Roman mythology
somnus was the god of sleep and so when
we give patients or you’ve seen someone
receive these drugs they become tired or
sleepy
they are somnolent and as we all
remember somnus first appeared in our
literature with Ovid’s metamorphoses
which was the latin epic poem detailing
of the history of the world up until
julius caesar and 15 volumes i thought
the first nine volumes flew by by the
way but they’re like the last six is you
want to get to the Rubicon you know you
got an army and actually morphing comes
to us from mythology as well Morpheus
was the Greek god of dreams and opioids
help treat pain in two basic ways one is
that they actually block the strength of
the nerve the pain nerve signal from
periphery to your spinal cord and so
that inhibits the experience of pain but
the more important one for our purposes
is this hope you always make you feel
good and by altering your mood they
alter your perception of pain pain is an
emotional experience sort of like all of
life is and what opioids do is they
increase your mood by increasing
dopamine in your reward center and this
is a simplified version but if this is
this is your brain and your reward
center without opioids and you have a
little steady stream of dopamine in your
reward center and you your brain feels
okay and then what happens with opioids
heroin morphine whatever is that you
have this flood of dopamine and you
think my god that was awesome and that
is that is how it effects your
experience of pain the problems that
opioids carry risk on they also bind
receptors in your brain that control
your breathing and in high enough doses
can stop your breathing and once you
stop breathing you’ve got a few minutes
to restore oxygen to your brain or heart
or you die thereafter of association or
the problem is that the United States
has four and a half percent of the
world’s population but we consume 30% of
the world’s opioid pain relievers that
sounds crazy was it always like this it
was not from the years 1992 to 2012 the
number of prescriptions of opioids in
this country tripled and I don’t have to
tell you the population of this country
did not triple but the number of
prescriptions is actually only part of
the story here’s another part the size
of the prescriptions got bigger so it
wasn’t just the number of prescriptions
being written the amount of opioid in
every prescription massively increased
this graph here you can tell that these
are years at the bottom but this is
oxycodone consumption in the United
States and blue and Europe in red and so
here we are
oxycodone as the pain reliever in
percocet so here we are a little bit
above Europe per person up until the mid
90s and then we did that so it wasn’t
just a number it was the size of the
pills we had this massive increase in
opioid exposure in this population
coming from the medical industry but
that’s only part of our problem now you
guys have all seen the stories about
heroin and fentanyl and I would
encourage you not to view these as
separate problems they are intimately
related and followed on the heels of the
increase in opioid prescribing these are
opioids they bind the same places of the
brain do not view them as dramatically
separate chemicals okay three out of
four users of heroin began with pills
and often what happens is that a patient
who became dependent on the pills over
years and found their supply getting a
more difficult to come by or too
expensive they would turn to heroin
which was often cheaper the result of
this massive increase in opioid
prescribing and now uses of heroin and
fentanyl has led to a massive increase
in overdose deaths in the year 1999 the
total number of opiate overdose deaths
in this country was 6,000 that was 4,000
from prescription opioids and then
another 2,000 from heroin in 2016 that
number had climbed to 50,000 if you want
to know what 50,000 looks like well that
would be 16 World Trade Centers and
you’re still 2,000 short
and all of you might remember we went to
war over just one of these the United
States has four and a half percent of
the world’s population but we have 27
almost 20% of the world’s drug overdose
deaths so how and why did this happen
this has been a problem that we’ve seen
in the inner cities but then it’s also
now moved out to the suburbs and the
affluent it has affected some of our
greatest artists but it doesn’t spare
the athletes so how and why did this
happen
I would like to tell you that it was
good intentions gone awry perfect storm
wrong place wrong time but that is
simply not true the medical industry has
changed dramatically in the last 20
years in particular the powered
influence of the pharmaceutical industry
and the ascendance in in my profession
again of meeting corporate imperatives
above all else so how did the opioid
manufacturers gain control of the
marketplace they did a number of tactics
that I’m going to talk you through
number one is this the recruit pain
specialists at academic centers to be
the sort of key opinion leaders and
thought leaders and their goal is to
convince the medical community workaday
Doc’s like people people like me that
aren’t reluctance to use opioids for
chronic pain conditions what was
misplaced that opioids were safer than
then we had thought they were and that
there was so much pain out there it was
we were negligent in how much pain we
were permitting to occur that pain was
an undertreated epidemic there was a
number of these doctors that they
recruited but probably possibly the most
important one was this gentleman here
dr. Russell Portnoy he was the subject
of the Wall Street Journal article pain
drug champion has second thoughts
published in 2012 he saw his job as
rehabilitating the medical community of
Opio phobics people with an irrational
fear of opiates he was president of the
American Pain Society in 1995 and was
the American Pain Society that came up
with this pain was a vital sign I
remember these buttons when I was a
resident my faculty had it I had it you
warm on your scrubs patients you know
pain was to be taken as seriously as
blood pressure heart rate temperature in
terms of predicting potential more
morbidity for a patient that’s how
seriously we were to take their reported
pain levels doctor Portnoy published an
article
a position statement in the clinical
Journal of pain in 1996 stating that the
risk of addiction from opiates when used
for pain was less than 1% less than 1%
for that sir sounds safer than I was led
to believe do you know where that less
than 1% statistic came from it came from
an article in the New England Journal of
Medicine it became no it was published
by 1980 by Jane Porter and Herschel Jick
and it demonstrated that opioids were
less than 1% became addicted to opiates
and I’m gonna use the balance of my time
to go through that study the statistic
I’m just kidding you can read the whole
thing in 90 seconds this is it it was a
five sentence letter to the editor this
is the study that supposedly proved that
opiates for use with pain
they weren’t addictive now all they did
was they didn’t actually intend this to
say that at all I mean remember this
this was written in 1980 and like 16
years later they’re now saying it proves
opiates aren’t addictive all they did
was they followed hospitalized patients
who had an acute injury about 12,000 of
them and then followed them afterwards
to see how many developed addiction they
were put on opiates indefinitely
these were acute injury patients who
just received a dose or two in the
hospital it said nothing about treating
chronic pain with obits and this was the
great failure of medical ethics this is
where we truly let the population down
because that sort of paragraph is in
scientific terms is called an
observational study you look after the
fact and you observed that’s interesting
okay that’s the beginning of the process
that’s not the end what you should do
after you observe this is like how do we
prove this do we think that more people
can take these safely indefinitely let’s
do an experiment the experiment was
never done the longest experiment done
for opiates for use with chronic pain
was 12 weeks most were just six it is on
the bat basis that we started
prescribing opioids on an indefinite
basis to patients now what does dr. port
and I say now about opiates well in a
taped interview I gave innumerable
lectures about addiction in the 80s and
90s that
weren’t true if I had an inkling of what
I know now then I wouldn’t have spoken
the way I spoke by the way the Wall
Street Journal also identified millions
in donations to his pain clinic which
pays him from opioid manufacturers
tactic to market to the primary care
doctors this was not done until 1996 and
one product changed all that
oxycontin released by Purdue Pharma in
1996 as a continuous release preparation
of oxycodone which again is the pain
reliever in percocet prior to 1996 and
oxycontin extended release opioids or
ongoing use of opioids was reserved for
hospice patients it was it was
prescribed typically by pain specialists
and cancer doctors for people at sort of
end-of-life care but here’s the thing
you can’t make billions on hospice
patients first there aren’t that many
and then number two they expire you can
make billions on back pain and that’s
exactly what they set out to do and the
way you get to back pain and treat
people for a long time and the most
people as you get to primary care and
that’s exactly what happened in
unprecedented numbers drug
representatives flooded the the primary
care clinics often making you know a
visit every week they would have gifts
and food and flattery there’s multiple
like this forty conferences in five
years that’s like one more than every
two months and they invited the doctors
the nurses the pharmacist everyone
involved in the opiate delivery food
chain was included and they didn’t
forget the patients for patients you got
free drugs oxycotin had a starter coupon
program where your first prescription
was free now tell me that isn’t like the
creepy guy outside the high school with
a little bag because I’m your friend you
just try this tactic 3 influence
government and regulatory bodies to
favor increase prescribing you needed to
do this for a couple reasons one is you
still have to get approval for your
product to make sure you could you know
it was indicated in market to market it
and the other reason is that while the
the pain specialist sort of gave us
permission to prescribe if you really
want to increase prescribing have a
stick not just a carrot but a stick and
in 1992 the primary client of the FDA
since 1992 is basically the
pharmaceutical industry and this was a
direct consequence of something called
the Prescription Drug User Fee Act
half of the FDA’s budget is now provided
by the industry and that actually that
that came out of the AIDS crisis
actually it wasn’t some malevolent thing
back then in the 1980s we had all these
people with HIV and they’re expiring and
there’s this clamor like what are we
gonna do for all these patients and the
FDA was overwhelmed and said look we’d
like to do these trials to get you
helpful for medicines but we don’t have
the budget to do it and so the industry
stepped in but ever since then they’ve
been dependent on the industry for their
funding and it is very difficult for a
regulatory body to regulate an industry
when it depends on the industry for
money and in the 1990s they approved
opiates for chronic pain again based on
no studies longer than 12 weeks and
here’s the stick part get those pain
scores down the the pharmaceutical
industry influence the Joint Commission
which is responsible for evaluating and
accrediting hospitals this was on the
wall of every emergency department room
I worked in you know zero to ten what’s
your pain level at nurses were compelled
to recheck on the patient’s our what’s
your pain level we got to get that down
the Joint Commission published a guide
in 2001 about pain management and that
was funded by Purdue Pharma and told us
that the risks of opiate use had been
exaggerated tactic for they blur the
lines between patient advocacy and
academic groups and marketing take a
look at this group partners against pain
pain it’s not something you need to you
you can have to manage alone you have a
partner and look at they’re holding
hands
like who would argue against that
they’re fighting pain and loneliness but
if you scroll down to the bottom of the
screen this was purely a creation of
Purdue Pharma what they call unbranded
outreach that was 1993
and take a close look at these academic
societies it’s the American Academy of
pain management that’s the forum
president dr. Lynn Webster we have an
epidemic on our hands and the status quo
is failing us curious thing about that
Academy they’ve got a corporate counsel
and look who’s on it Purdue Pharma endow
Pfizer jell-o makers of opiates so is
farmer the one to blame well they are
they certainly a part of it I mean they
they these were there this was their
marketing strategy but I want to caution
you that it’s too easy to just blame the
pharmaceutical industry the
pharmaceutical industry sells all over
the world this crisis didn’t happen in
Japan
it didn’t happen in Germany happen here
so what is it why did it happen here as
opposed to these other countries that
they have patients who have chronic pain
pharmaceuticals do they they sell them
there too well this is from my
performance of review in the year 2012
those are my arms I’m very proud Chris
we are also proud of you for the work
you are doing with chronic pain but it’s
such a fine line between increasing risk
of open addiction and hCAP scores what
age cap scores are those are your
patient satisfaction surveys they do not
exist for your health they exist for you
as a customer to get you coming back
medicine in America unlike other
countries is first and foremost a
business enterprise and every business
enterprise has as his primary obligation
is to make money for the owners and
investors and in the process enrich the
participants even not-for-profits have
investors their bondholders in fact
fiduciary responsibilities which all
these executives undertake compels them
to do this for this reason American
medicine is not incentivized for your
long term health is incentivized to sell
you health care services but this leads
to an unavoidable conflict in health
care healthy patients don’t need to buy
health care now why would this pose a
risk for opioid crisis because a system
driven to sell services thrives and
patients are in a state of chronic
disease and that is precisely the model
that opiates employ it checked off a lot
of boxes for us it allowed us to expand
the customer base pain is a vital sign
pain is an epidemic pills solve the
problem visit or quit you can see tons
of patients and turn them over
pills are by prescription only we corner
the market you know tylenol doesn’t
solve this opioids do and treatment is
lifelong and indefinite patients become
dependent on these opioids and keep
coming back so what do we do about this
to pass forward a short term in a long
term in the short term we need to
prevent creating new opiate dependent
patients in the long term reform a
system that created this studies do not
support the use of these medicines for
management of chronic pain if you have
back joint neck pain do not start these
medicines they don’t work in the long
term medical assisted therapy helps
patients who who have developed opiate
use disorder but is a very imperfect
solution it cuts your rate of overdose
in about half but your risk of death is
still three to five times higher if
you’re on medical assistant therapy that
if you never developed a problem at all
bottom line is this the American system
is a failure in addition to overcharging
you we are not getting you good medicine
good therapy that is well driven by
science and it’s not because doctors
want to cause harm our incentives are
broken we need a different type of
system one that rewards outcomes or at
least stops rewarding just the sales of
services this would be more in line with
the Hippocratic oath and what other
countries do so what can you do going
forward well we can at least acknowledge
that opioids don’t work for chronic pain
as far as I’m aware the American Medical
Association American Heart Association
none of them have acknowledged this we
need to interrupt the financial
relationship between doctors and the
industry we need to make research more
scientific and make the FDA independent
and we can need to stop volume-based
revenue for doctors and Clinics oh and
let’s stop this whole talk about
morality and this is a challenge I would
even say to the traditional recovery
industry we have created addiction in
mice in chimpanzees insects pigeons we
don’t talk to them about their character
defects so this is my final slide I
conclude here this is a painting by
Edward Munk it’s called despair it is
derived from the Latin verbs better
which means to hope so despair literally
means without hope I got involved in
this problem because I was initially
very frustrated with trying to manage
these patients in the emergency
department but the more you learn about
these patients and what they’re going
through what their families are going
through it is a world of suck you do not
want to wish that on anyone
and so I argue for reducing opioids
because I don’t not because I want them
to suffer pain but because I don’t want
them to enter this life of misery and I
want a healthier system from my
colleagues who many of our great people
that want to practice effective
compassionate medicine because we all
you [Music]
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