 Drugs cause the brain to adapt, to change, because they sledge hammer the brain with signals that nothing natural does in the same way. And once the brain adapts, if you remove the drug from it, you can feel very uncomfortable, you can no longer feel normal, and you want another dose of the drug to get you back into that state that you were before. That adaptation is what drives addiction for most people, and that's one of the most critical things to recognize. In some cases it's irreversible, in some cases it's completely reversible, but above all, people who don't start never have to walk down that path. Welcome again to our seventh season of the John Seaman Had Buttons School Conversations Discussion Series. My name is Mark Sokol, I'm the president and CEO here at JCC Greater Boston. The series invites distinguished figures to engage in unique exchanges around controversial and sometimes very difficult topics. Our panelists are always led by expert moderators through respectful, thought-provoking discussions on issues of concern to the Jewish community, the general community and to our world. They offer insights into so many important and meaningful things. The hallmark of this series is civil, respectful dialogue and conversation. Tonight, we present another program that is both timely and touches nearly every corner of our community, America's Opioid Epidemic. The situation in Massachusetts is especially dire with the fatal overdose rate more than double the national average and among the highest in the country. While the extent of the crisis is easy to see, the cause is harder to pinpoint. Our panel tonight will examine the origins of the worst public health crisis of the 21st century and expose the role of pharmaceutical companies played in pushing addictive opioids into the American market. They will look ahead to what needs to be done to stem the crisis. Finally, two things. Jonathan Seiman, for whom this series is named, was a leader with a unique ability to get people from different sides of an issue to sit together and to listen to each other. In this spirit, we ask that our audience please be respectful of all thoughts and all opinions shared by our panelists. As I always say, this is not a Red Sox Yankees game, no cheering, no booing, and no popcorn. So once again, welcome to our panelists, welcome to our audience, and I'd like to turn things over to our moderator, Barry Mair. Thanks to Mark and to everyone at the JCC for making this possible, and thanks to all of you as well for coming out tonight. As a personal aside, I consider this evening a success already, since the last time I was at a JCC was right after I was bar mitzvahed. And so it's a kind of a return to my roots as well. So, you know, we're here to talk about the opioid crisis, and we are hearing that term virtually everywhere on television, radio, in newspapers. And it almost sounds simplistic when you hear the term opioid crisis, but it's a very complex situation. It's really kind of a hydroheaded one. It's a problem that involves not only prescription drugs, but illegal street drugs like fentanyl. These are these drugs are the drugs that are driving the current increase in overdose deaths. And because it is a complex problem, it's also a very complex, there are many complex issues involved with it. And those are some of the issues that I hope we're going to talk about tonight. And I hope there's going to be, there will be things that you'll take away from this discussion as well. I mean, we're going to talk a little bit about how the, with our experts are going to describe how this crisis began and where we are today, what addiction is, the science of addiction, what we can look for in our own homes and our family members to understand the signs of addiction and ways to prevent that. And also deal with other aspects of the opioid crisis, which is how do we deal with people who are in pain, who are suffering from legitimate pain and the types of treatments that are either available to them or that are being restricted and not available to them. So I'd like to, you know, also make the same point that Mark made, which is that I'm not a legislator, a regulator, a litigator. And I hope we can approach this conversation in that same spirit that we're here to learn about an issue and hopefully take something away from it. And so with that, I'd like to just turn to all of you. And maybe we can start with a simple question of how do we get here and where are we through your own particular lens? And since Rich, you were introduced first, why don't you take that on first? Thank you. And thank you all for having us. I think this is really important, particularly as a community. You know, I became addicted to heroin quite young. I was around 15 years old and, you know, it was new. It was just coming into, you know, the Boston area out by the suburbs and Brighton and what I call the suburbs. But and we didn't know. I mean, the thing that I think is the same today as it was then is that nobody knew what was about to happen. Opiates are much more dangerous than people can think. When I had taken my first bag of heroin, you know, that was it. It was utopia. I changed the way I felt and I never looked back. And it got worse and the losses came and the trouble came and the incarcerations. My parents had no idea what was going on, you know, but there was hope. There were people out there. There were people out there working, you know, making those connections, responsible connections to recovery. And, you know, there was a lot of slipping and sliding and falling. And, and, and Dr. Dr. Matters, maybe you can jump in here and talk to us about that same question, but from the perspective of a research scientist, someone who's been following this. Well, I've been following drugs since 1963 when I got my first collection of LSD from the CIA experiments. And I was asked to find out how they work. And the most important thing I took away from that experience, which carries me to this day, is that drugs cause the brain to adapt to change because they sledgehammer the brain with signals that nothing natural does in the same way. And once the brain adapts, if you remove the drug from it, you can feel very uncomfortable, you can no longer feel normal, and you want another dose of the drug to get you back into that state that you were before. That adaptation is what drives addiction for most people. And that's one of the most critical things to recognize. In some cases, it's irreversible. In some cases, it's completely reversible. But above all, people who don't start never have to walk down that path. And Andrew, you're sort of on the front lines dealing with people who are addicted to drugs, trying to help them get off of drugs. So how, in the terms of your professional work, has the picture changed over the past decade for you? You had also started by asking how did we get here. And to talk about how the picture changed and how we got here, I think it's important to talk for a moment about where we actually are and what the opioid crisis really is. Because as you mentioned, we can't open up a newspaper without hearing about the opioid crisis. It's on the radio, it's on television. And over and over again, we're hearing about the opioid crisis, but what is it? And I think it's important to understand that the opioid crisis is not a problem of drug abuse. This is not an epidemic of people taking dangerous drugs because it feels good and they're accidentally harming themselves. I think the opioid crisis is best understood as an epidemic of opioid addiction. And as Dr. Madras mentioned, once somebody becomes addicted to a drug, they need to keep using that drug to feel normal or to avoid feeling awful. And while some people did become opioid addicted taking opioids because they like the effect, many people became opioid addicted, taking opioids as prescribed by doctors. And what we're really dealing with when we talk about the opioid crisis, the array of health and social problems that we define as the opioid crisis, I believe has been driven by a sharp increase in the number of people suffering from the condition of opioid addiction. And if you frame it that way as an epidemic of opioid addiction, then you'll understand that the reason we're experiencing record high levels of opioid overdose deaths, the reason we're seeing heroin and fentanyl flood into non-urban communities. The reason we're seeing a soaring increase in infants born opioid dependent, children winding up in the foster care system, outbreaks of injection related infectious diseases, the driver behind all of these problems has been the increase in opioid addiction. We've had addiction all along. There's a history of addiction in this country. It tends to travel from drug to drug. Certainly in this current crisis, the seeds were laid through what was probably the over-marketing and over-prescribing of prescription painkillers. But there are other factors that play into it. There's a recreational factor. A lot of people get into drugs recreationally rather than through prescriptions. So why don't we talk a little bit about, maybe start with Dr. Madras to expand a little bit on the process of addiction and then maybe, Rick, you can follow up on how it feels as a person becoming addicted. People become addicted to drugs because of a combination of themselves, who they are as a person, whether or not they have a psychiatric problem, whether or not they're stressed or anxious, whether or not they've suffered childhood abuse, whether or not they've had many setbacks in life. So the personal is a factor that's very important. The environment is another factor that's critical. Who your friends are, who your influencers are, whether or not drugs are easily accessible. When I was deputy drug czar of the country, kids were doing farming parties, P-H-A-R-M-I-N-G. They would go into their parents' cabinets, medicine cabinets, raid them and put out a large glass bowl, dump all the pills they could find and just pop them and figure out whether or not they like them or not. So access, the environment is a critical one and obviously the third is the drug itself. We know from a lot of studies, thousands of studies now that drugs can produce changes in the brain that compel using and using over and over again. Well, how was your brain change? But I think we're talking about addiction. And by definition, addiction means more. And, you know, I didn't wake up one morning and say, I can't wait to be a heroin addict and end up losing the love and affection of my family and being incarcerated. But what happened was I started out with other drugs. And I think that's really important for all of us as a community to know, I don't think people just wake up and become heroin addicts. You know, I think for me and for the friends and the people I hung around with, it was a slow process of, you know, drinking on the weekends. I played hockey, you know, I drank with the hockey team and, you know, and then we started smoking. Well, what was the first thing that when you made that change? Because we all drank, we all, I smoked when I was a kid, but you went the extra mile as it worked. And what did you do over into that? I drank the extra mile of Juana, even at that point, for a different reason. I think you did it maybe to socialize. I did it to change the way I felt. And so what happened was, and I didn't know this was happening to me, this is only in hindsight. And so anything that could do that was definitely for me. And heroin really ended up doing it to the point where, you know, it was like a euphoric marshmallow kind of really laid back. I mean, I could stand up on a corner, wait for my dealer and just nod out. Right. And Andrew, you see people coming in all the time and is the type of person changing or is the psychology of the person changing? Is there any change in the nature of the people that you've seen over these past 10 years? Yeah, so in my experience treating opioid addiction, I treated, I mean, if I could roughly break up the patients I've treated into two groups, an older group and a younger group. The younger patients that I treated became addicted to opioids, either through recreational use, mostly through non-medical recreational use, although some became addicted through medical use, they had serious medical problems, and that's how they got hooked. My older patients had become opioid addicted almost entirely through medical use. And when it comes to highly addictive drugs like nicotine or heroin or hydrocodone or oxycodone, just about anyone who repeatedly uses the drug is going to be at risk of getting addicted. Opioids are not like alcohol. Alcohol can be a very serious problem for a significant subset of our population, but most of the population can be repeatedly exposed to alcohol and doesn't get addicted to it. About 10% become addicted. A lot more than 10% have risky drinking and health problems, but addiction occurs in about 10% of alcohol users. With the highly addictive drugs, the individual's characteristics become less important, they're important, but less important. The drug's inherent addictive properties and the repeated exposure to the drug become more important. One of the things that, when I first started reporting on this back in 2001, that long ago, one of the things I was most struck by were calls I would get or people I'd meet who had lost a child, a son or a daughter, who had overdosed. Maybe they went to a farming party. Maybe they tried a drug like oxy for the first time. I was shocked when I would hear these stories. The problem is now we're hearing these virtually every day. We're hearing about a kid getting addicted. We're hearing about a kid overdosing. Perhaps many of the people who've come here tonight have had family members that have become addicted, who have overdosed. From your experiences, and again, we'll start with you, Dr. Rogers, what should one be looking for? You've got a son, you've got a daughter. What are the signs that someone might be drifting towards overusing or becoming addicted to a drug? Well, I think the most important thing for every parent to recognize is that the initiation of any drug is already a flag. If you're under 18 and you're using alcohol, you're smoking, you're using marijuana, that puts a child at tremendously high risk for progressing onto other drugs. We don't know why, but it seems as if drugs, they're very different. They have different effects on the brain, different targets. But most people who are addicted to opioids are polypharmacists. That means they use many drugs. And when people do postmortem studies, they study what they died of. They don't find only one drug in them. They find alcohol, they find marijuana, they find benzodiazepines, cocaine. So what we have to recognize is that the use of any drug by a child whose brain has not fully developed is one sign. They're friends. Who are their friends? Have they changed their friends? Are they becoming more secretive in the house? Do they tend to lock their doors more often? Stay behind closed doors? Is the relationship with you getting different? Are they less open with you? Are they sleeping less? Are they spending a lot more time away from home? Are they on social networking sites more? There's a whole list of flags that every parent should be aware of. And Rick, you should be an expert on this, right? What do you know to look for? Not on my own experience, but I have six children and I have three children in recovery, responsible recovery. And I went through this with them and I was an exempt from those signposts. And I also was an exempt from the denial that comes with this. I didn't want to believe that my son was doing something or my daughter was doing something. And I'm on the front line with this stuff every day. But it was the door, you know, not coming out of your room sleeping. Sleeping to two o'clock. You know, the friends sneaking out at night. They're coming in and not wanting to talk. You know, there's a lot of signposts and a lot of this stuff you can get online. You know, I know the Massachusetts organization of addiction recovery more has a number of links to sites like this that you can actually go on. Because I think it's important in how to confront a son or a daughter and when to do that and how to do it professionally. There was a character in the book. I wrote an actual person, a mother. Now her daughter became a stone cold oxy addict. She was stealing from the family. She was falling apart. And the mother, as many mothers are or parents are, was in total denial. So Andrew, when you're dealing with families, which I take if you are in your practice as well, how do you deal with that aspect of things? Having to have them confront what a relative may be going through. I'm not sure I totally understand your question, but an important point here is that because I think when you're asking this question and the answers you got, which I agree with and I thought they were very good answers. It sounds like this question about how do you recognize when there's a problem and what should you do about it and how do you confront that individual. Typically that discussion is focused on parents and what to do about their kids. And it's really important to recognize that this is not just parents worrying about their kids, but seniors are another group that have been hit very hard. There are a lot of adults who need to be concerned about their parents. And how do you deal with that? It can be very difficult. It's easier when it's a young person and it's illicit drugs. It's much harder if it's an older person and they're receiving prescriptions from a physician. Often the individual who may be addicted to the prescription will have a harder time accepting that they're suffering from addiction because they're receiving a legitimate prescription from a doctor. And they may even be taking it as prescribed. We might still consider them addicted because they actually look in many ways like the people who we've just heard about. They're having a decrease in the quality of their life. They're no longer engaged in family. They're on the sofa all day long. And so it can be very challenging in trying to help people. And the other messages I would just have are that if you suspect that there's a problem and that there probably is a problem and you should act on that concern, what do you do? I'd say my advice to answer your question would be to try and engage that person as empathically as you possibly can. You let them know that you love them. They're going to very likely feel ashamed about having this problem because of the stigma of addiction and to let them know that you want to help them and support them and that you're there for them, I think is probably the most critical thing. So you're all very empathetic and I think compassion in both the treatment of addiction and the treatment of pain are sort of important guideposts going forward. So again, for each of you, we're here at this moment. We're confronted with an epidemic. What would each of you like to start see happening? How do we start working our way out of this? You mean at a national or local level? Either one because I think it has to happen on both levels and sometimes I think it has to happen on the local level. What does a community like this need to do? Let's not wait for Washington to act. What do people on the local level do? So there are three areas that absolutely need help in this country. One is prevention and prevention has many, many, many faceted solutions. One is reducing unnecessary prescriptions. One is preventing children from initiating drugs because you can never predict no parent has a crystal ball that will predict whether or not that child is going to start with marijuana or alcohol and then progress straight mainline either to heroin or to prescription opioids or to cocaine. Prevention is critical. We also have to educate in our communities the most simple fundamental things. I've given last year I gave 70 presentations on the Opioid Commission. Many of them to audiences that were not in the field. And I would say here is a list of drugs. How many of you know these are opioids? And half the audience didn't know that every single drug I listed there were over 25 were opioids. I said every single one of those goes to the same target in the brain that promotes addiction and that can kill you and you should be aware of that information. And someone should be telling you this. Somebody should also be telling the community that a pill that is not bought in a drug store could be a fake pill. There are pill presses being made in China. They are imported here. The logos for the pills are very well known and easy to reproduce and these pills have fentanyl. Somebody I know, Eric Bowling's son, got one on the campus of the University of Colorado because he was anxious and his friend said, here's a little tranquilizer that will help you sleep in your first week in college. It had fentanyl and he died within an hour. There are so many ways in which prevention is critical. I won't take up all the time, but I'll get to intervention and treatment later. Alright, so Eric, your turn. What would you like to see? I'm going to pick up where she left off is intervention and prevention. There are ways today to intervene. Describe what those terms mean. Intervention is whether you're a parent or in the community we have now, diversion programs, we have set up prevention programs to be in the schools, in the high schools, and we're trying to get down into the middle schools just to educate and to raise the level of awareness as to actually what we're dealing with and where we're going with this. Whether you become addicted to opiates and the end run are immediately, there's a lot of other things that happen to particularly children before that. My whole thing is addiction is whether it's opiates, whether it's marijuana or alcohol, you know, does it make your life unmanageable? Does it take away from you the opportunity to be all you can be? And that's where intervention has to come in. And you can do it on a family level and there's plenty of people out there that do it. We have, and our recovery coaches in the law office, they are interventionists too. And they'll educate, they'll sit with the parents before they'll intervene with the individual. And then they put a plan together to do that. And what should we do about the opioid crisis? Try to keep it simple. No, I can because I really do think there is a simple answer to that question. The solutions are complex. It's a difficult problem to tackle, but the big picture strategies for dealing with the opioid crisis I think are very straightforward. And you know, if you understand that the opioid crisis is an epidemic of opioid addiction, what we need to do about this epidemic of opioid addiction is similar to what we would need to do about any disease epidemic. Think even about an Ebola outbreak. What would you do about an Ebola outbreak? The strategies would be to contain it, meaning prevent new people from getting the Ebola infection. And to see that the people who have the Ebola infection, the people who have the Ebola infection are receiving life-saving treatment so it doesn't kill them. What we need to do about the opioid crisis is really the same. We have to prevent more Americans from becoming opioid addicted, really reduce the incidence of opioid addiction. But how do you do that? More than anything else, to prevent people from becoming opioid addicted, I agree with what's been said, but I think the single most important strategy for preventing opioid addiction is to promote much more cautious prescribing so that doctors don't directly cause addiction in our patients and so that we don't indirectly cause addiction to another area that I wanted to touch on with all of you. And that is the treatment of pain. Pain is a significant problem. There are people that suffer from severe long-lasting pain. Many of them say that they are, in some ways, the victim of the crackdown on painkiller prescribing. So how do we sort of balance those problems, address those problems? Well, I think the most important thing is to, as Andrew said, to prescribe very cautiously because, for example, in the past and still in the present, Governor Baker was with me and complaining to me a little while ago that somebody told him a dentist was still prescribing 60 or 90 percocets for a tooth extraction which takes one or two days for the pain to disappear. There is still too much prescribing of opioids and I think that that is a major problem. I think the, so we have to be very judicious on whether or not the pain merits the opioid because there are so many alternatives to opioids in terms of dealing with pain. For example, a study was just done showing that ibuprofen or non-steroidal anti-inflammatories are just as effective as opioids in relieving knee pain, lower back pain, joint pain. The most common causes of pain that, and until very recently, someone just wrote a script for opioids, it obviously was completely unnecessary. We have to find alternatives. There's research now at the NIH, the National Institutes of Health, that is trying to find alternatives to opioids, but we already have many alternatives to opioids for pain relief unless it's severe, intractable, end stage. There are many caveats to that. There's sometimes when only opioids will do. I agree and thank you for your efforts in trying to reduce the number of opiates in the marketplace and there are alternatives. I know there are alternatives. Personally, I cannot take opiates. Well, you're ruled out at this point. I mean, I just would never do it because I never would want to trigger my addiction. So I have to look for alternative pain medication and I do when it's available. My son had major surgery and he was recovered from opiates from oxycodone and he had blockers. But it was interesting to me because for him to get that prescription to Beth Israel Hospital, they didn't have it and they had a wait for permission to use it. I think there's a lot more stuff available that we're not really, that they're not using, that they could use. And Andrew, you were mentioning about older patients who have become dependent, addicted on opioids through long-term medical use. Is there a point or is there some argument to be made that if that person is doing okay, let's just let them and that drug is helping them with their pain, let's just leave it be or where does the intervention start when you're dealing with an older patient? Well, older patient or middle-aged people, the fact that they may be doing okay on opioids, there are many people who are put on opioids, they're taking them around the clock and they're not doing well. And there's really good reason to believe that opioids are not going to be effective for long-term use because of tolerance to the pain-relieving effect which would mean that in order to continue getting pain relief you need higher and higher doses. The fact that there are people who could be on opioids long-term and seem to do okay is not surprising because that's the basis for treating opioid addiction with opioids. There are people who can take opioids and do okay. That's very different from saying that they're continuing to get pain relief. There are many people on long-term around the clock opioids who are convinced they're getting pain relief. They will tell you that they're getting pain relief and they're not lying. But what they're probably experiencing when they take the opioid is the relief of the withdrawal pain or the relief of pain hypersensitivity because when opioids are wearing off or when you're going into withdrawal, everything hurts but especially if you have a reason, a chronic medical problem, that pain problem is going to be much worse. So these individuals take the opioid, that pain is relieved and they can be convinced that the opioid is helping them as far as how to handle this population. And you could take people with conditions like fibromyalgia or low back pain with a normal spine or chronic headache. Three of the most common reasons are people are on long-term opioids. The medical community is now recognizing that we shouldn't have put so many people on long-term opioids for these conditions. It's more likely to harm the patient than help them. That doesn't mean, though, that we should force these people off rapidly. Many of these people may not be able to come off of opioids. Some of them, if they're on dangerously high doses, I think even if it's a really dangerous dose, a doctor is not going to want to keep giving it to them. So I think some of these people we can maybe manage on the opioids that they're on. Some of them we can help come off. It's a lot of work. If you can get them completely off of their opioids, often they have a significant... I know you're aware of this because you wrote a book on the topic, they often have a significant improvement if you can get them completely off of their opioids. But many can't do that so we have to really work with them. And yes, some of them, even though I think they may be doing well, despite being on an opioid, not because of the opioid, I think some of them maybe we really should leave them on that opioid if it's a modest dose. When we talk about alternatives, and I'm going to veer off a little bit here, something we were talking about over dinner, medical marijuana has often been raised as an alternative pain treatment to opioids. It's also being raised as a drug that should be legalized. And there are some people that claim that if we legalize marijuana, we're going to reduce the opioid problem because people start smoking pot instead of taking opioids. But what do we know right now pros and cons about marijuana? Its benefits, its risks, or we are trying to solve one problem, are we about to open another Pandora's box? Well, the most recent data says that people, there's a few longitudinal studies. What that means is you follow people for one to four years rather than just interviewing them and saying, does marijuana help you? And they'll say, oh yes, I've stopped using opioids. A longitudinal study means you follow that same person over a number of years, and in these cases, there are a few very good studies that have been done that have shown that people do not reduce their opioids and their pain does not get better if they top off the tank with marijuana and they are more likely to develop a marijuana use disorder. They are more likely to have an opioid use disorder and they're less likely to stay in treatment for opioid use disorder. So, at this point, there's one study that came out a few years ago that said states where marijuana has been legalized as a so-called medicine, those states have lower overdoses, but that is a completely, from the point of view of statistics and scholarly look, that is just not the way you do it. You have to follow the individual, not the state level, and since that study came out, another one came out in probably the most prestigious science magazine saying that the states that have legal marijuana, the opioid overdoses in fact, have increased. So, at this point, one has to say that the evidence is not in favor of, and when you say medical marijuana, I don't know what that means. Is it 90%? Is it 10%? Is it THC? Is it Hindu Kush? Is it blue-purple smoke? You know what it means. No, there's no standard. This is not an approved drug. There are no randomized controlled trials. This, it does not come close to what FDA standards would require for putting the signature of a large body of professionals in endorsing. Rick, are you seeing sort of with the marijuana that's out here today is much more powerful than the marijuana I remember encountering? And what impact is that having? It's having a big impact. First of all, my question always is we have legalized tobacco, we have legalized gambling, we have legalized alcohol, we have legalized pornography. How's that working out for us? I mean, this is just another drug in the treasure chest of things to use, abuse, and become addicted to. My wife is 15 years in recovery from marijuana. And, you know, her stories are no different than the stories of my son who was addicted to oxycodone and people addicted to alcohol. Addiction takes away, it robs you of the opportunity to be who you can, to be a good son, a good brother, a good parent. And that's what it's really about. Whether you're addicted to marijuana or oxycodone, I mean, if it takes away from your life, this is something that needs to be prevented. And it's best prevented early on. I mean, that's what we're finding out. You know, raise your hand, tell us. Right. And Andrew, in your treatment, how is it playing out? Well, you know, it's interesting because both sides of the marijuana debate are trying to use the opioid crisis. So the pro-marijuana folks are saying that marijuana is the answer to the opioid crisis. And folks opposed to marijuana are saying that it would make the opioid crisis worse because the argument is that it would be a gateway drug and more people would wind up ultimately on heroin. My own view is that I don't believe it would make the opioid crisis better or worse. I see it as its own separate problem. I have serious concerns that with an industry promoting use because of a financial incentive through legalization, we would see, and I think there's evidence we're already seeing, a sharp increase in use. And marijuana is less addictive than opioids, but as more people use it... You're basically creating another drug industry. More people would get addicted to it. And although marijuana addiction doesn't kill people the way opioid addiction kills people, it can really mess people up. So I don't see it as helping or hurting the opioid crisis. I see it as its own separate problem. One thing I would say, though, is if I was treating a patient with severe chronic intractable pain who was really suffering and had tried everything, I would sooner consider marijuana for that patient than heroin. And when we prescribe opioids, we're basically trying heroin on that patient because the effects produced by oxycodone and hydrocodone are really indistinguishable from the effects produced by heroin. I was out in Ohio a couple of... maybe six months ago giving a talk at a university and for all of you who are not aware of this, Ohio really is the epicenter of the opioid crisis in our country. I believe one out of every six deaths nationwide takes place in Ohio. And they're just being brutalized by the... It's at the point where when people have overdoses, they can be rescued from that overdose with a drug called Narcan and the cops carry it, and EMTs carry it, and firefighters carry it. And they've gotten to the point where they don't even want to revive people anymore because they keep coming back and reviving the same person four times a week. And they were very interested in knowing what they could do in their community. Like basic grassroots efforts that people there and people here can take. I have some ideas, but I'm going to turn it over to you guys first to see what your ideas are. Well, the police station and Gloucester that is an open house for people who want to get treatment is, I think, one of the most interesting models for what people can do with the grassroots movement. There is a fellow at Boston University professor who is beginning to copy the model in about 300 places throughout the country where people go to police stations and say, I've got a problem with opioids and can you help me? And they immediately try to get them on to medications that is going to get them off the dangerous drugs of unknown quantities, whether or not they're laced with fentanyl, and also get them into treatment. I think that we have to do a lot more. We have to revolutionize our entire system of treatment for opioids. I think every single hospital in the nation should have an addiction center that deals with substance abuse, substance use disorders, and they should have specialists that include psychiatrists, addiction medicine, people who are behavioral health specialists, recovery coaches, and so on. There should be a safe place where people can go and begin to get help on demand. If you go to an emergency room, you'll be treated. If you have an addiction and you show up somewhere and say, I need help, there's not anywhere in the country where it's automatic that you will have help on the spot, except in a few places in Massachusetts and a few other states. And I think we have to revolutionize the entire system of addiction treatment using that kind of model, of an integrated model that every single community hospital, health centers has a place, a safe place for someone to go. What would you like to see happen here? In this town? Yeah, well, I don't differ with the doctor, but I'm an abstinent-based person in recovery. And I'm not alone. I mean, there's tons of people that I know I could fill Fenway Park up with the people, because we had no choice back then, too. There wasn't a lot of other pathways to recovery. And I really push that even if it is under medication-assisted treatment and people are on medication-assisted treatment because I really want them to have what I have. You know, I woke up and there was the gift, the greatest gift of all, which was life. And Andrew, what steps here in this town, Newtom or in Altam or in wherever, small community, what could people at this grassroots level be doing? Well, actually, there's a lot being done at the local level across the country. Many counties across the United States have a task force to address the opioid crisis with membership on that task force from the medical community, from law enforcement, from policymakers. And I'm seeing across the country places where I visited really good work being done. I think the bigger problem is that we haven't really seen the help needed from the federal government. And I don't think local communities can do this on their own. They need help from the federal government, the resources, maybe money from a settlement against Purdue Pharma and other drug companies could be used. But this is a very expensive problem to create the kind of system that Bertha was just describing. And I can tell you that under the Obama administration, there was almost total neglect of the opioid crisis until very late in President Obama's term. Under the Trump administration, there's been a lot more attention paid to the problem. But we still aren't seeing what I think we really need, which is a commitment to long-term funding and the resources we need to build out the treatment system that Bertha just described. Now, before I get to a final question, I'm going to ask me, Barry, what would you like to see? If it sounds like this, communities like this, I think that people, the type of people, people like you who have come here tonight can play a tremendous role in reshaping this crisis. And it can be very simple. It can be from the standpoint of going to your employer, or if you are an employer, making sure that the insurer, the person that's providing you or your employees with healthcare provides them the best possible pain treatment, provides them an array of pain treatment. And walking away from that insurer, part of this problem was caused by the insurance industry, by their realization that they could make the biggest profits by simply just approving the prescription pills, not approving any kinds of other treatments for patients. So that would be a major step that businesses and employers and just individual employees could make in trying to kind of turn this ship around so as we move into the future, we're doing it on the basis of better, more scientifically sound treatments than the types of treatments that got us here into the dilemma that we now face. So I've said my bit. Now, we'll let you all play king or and queen for a day. There's all this litigation going on. Purdue Pharma has already paid up or agreed to pay $270 million to Oklahoma. There may be billions that come out of these lawsuits. A certain chunk of it obviously is going to go into the pocket of lawyers, but presuming that there's something left over, how would you like to see that money spent? I'd like to see it spend three ways. Number one, as Dr. Kaladney said, we have to help the people who currently have a problem. And I'd like to see a much, much better, much better treatment center services than we have. We have 14,000 treatment centers in the country. About a third of them offer help with regard to medications for opioids. Very few of them offer psychiatric services. Very few of them offer anything close to what are called principles of evidence-based treatment. And I think either the federal government which subsidizes many of them just literally closes them down and starts all over again. The model that I really like which is completely integrated within a safe medical healthcare system. We've got to do that. We have to work on prevention. Prevention of young people. We have to work on prevention and supply. Those of you who are here who haven't really heard the word fentanyl, be aware that fentanyl is now the number one reason why people are dying in the country. And this fentanyl is not prescription opioids. We haven't even touched on this. The vast majority of fentanyl is being made in China. It is being shipped to Canada and to Mexico and from there or directly to the United States and that's what's killing most of the people in Massachusetts right now over 80%. When I served in office we had a fentanyl crisis in 2006 and we developed a rapid response team to figure out what was happening. What we found out was that there's one lab in Mexico, in Toluca, Mexico that was producing all the fentanyl and then when that lab was taken out the overdose deaths went to near zero due to fentanyl. We still have the prescription. So there were many many problems that we face but prevention, intervention, treatment, evidence based, rigorous decent quality treatment all of these are essential. Ditto. What Bertha is talking about is really a hope that we all have and I think with this type of advocacy too we will see the day when that happens but it also takes a community like us to be able to do that. When people are reintegrating themselves back into a community especially from addiction issues or abuse issues or something it really is on us to accept those people and to be able to work with them in jobs and housing and education. So we can do this as I say, addiction may not be a choice but recovery is in that we do recover better together as a community. I know that for a fact as I said here today but I really believe in the holistic approach and I believe we are going to see that in the future with this kind of push. Andrew you have a billion dollars excuse me how would you spend that money? I think that we need to tackle the opioid crisis by preventing opioid addiction and treating people who are already addicted. We've talked about the need for a new system we want to make sure that people who are opioid addicted more easily access the most effective treatment for their addiction more easily access treatment than heroin, fentanyl or prescription opioids. Someone who's opioid addicted when they wake up in the morning they're going to be feeling pretty sick and they know they're going to need to use and if they've got 10 bucks in their pocket and they know where they can buy a bag of dope that's what they're going to do and if finding a doctor or getting treatment for their addiction is expensive and difficult they're just going to keep using. But really the other thing I would do with this money is I think this money settlement money or judgment money if any of these cases go all the way in front of a jury I think that a significant portion of that money needs to be used to correct the record. So you know you mentioned insurance companies and I think they were part of the problem it was too easy to write an opioid prescription but really the reason we're in the midst of a severe epidemic of opioid addiction is because of massive over prescribing. As the prescribing went up millions of Americans became opioid addicted and the reason the prescribing took off is because the medical community was responding to a brilliant multifaceted campaign that minimized the risks of opioids especially the risk of addiction exaggerated the benefits of long term use and it wasn't just doctors hearing these messages from attractive sales reps working for Purdue Pharma if it was just the sales reps we would have been less gullible we were hearing these messages from pain specialists eminent in the field of pain medicine from professional societies So you're thinking about spending some money on an educational campaign or how would you address that? We've got to get to a medical community that has been very seriously misinformed and that continues to over prescribe we have to get them accurate information about the risks and benefits of these medications. So in the opioid commission there were 56 recommendations and because I wrote a significant piece of it I'm quite familiar with it 26 of them were to reverse engineer the mistakes of the past which includes pain as a fifth vital sign press gainy scores value based purchasing all of the things mental health parity medical education pain management education and so on. So many of what you've recommended were in that commission report This is an interesting question that let you all take a crack at because it's not opioid per se but it's about drug abuse it's about a story that I've read a couple of stories about which is there's a drug called gabapentin and a gabapentin I believe is an anti-seizure medication it's been approved for anti-seizure use but also was prescribed off label if I'm correct as a tranquilizer it's very good if you have fear of flying I can tell you that from personal experience but it's also become quite a big recreational drug on college campuses and so the question is how did gabapentin become such a widely prescribed drug of abuse or a drug that's being abused outside the medical setting and what can be done to address this the reason I think it's pretty clear why it was so prescribed Pfizer illegally marketed Neuront and Gabapentin and was even found guilty of criminal charges for the off label marketing of Neuront and paid an enormous settlement in the hundreds of millions of dollars for promoting an anti-convulsant drug that was really indicated for treating seizure disorder for promoting it for sleep anxiety and every possible condition and even though they paid that fine, I believe they probably still did better financially for having promoted the drug improperly and so the drug does have some abuse potential, significant abuse potential people who take it they feel a set of effect from it and so yes it is it does have street value and is particularly popular among people who might be struggling with opioid addiction because it may relieve some of the anxiety that you experience when you're before your next dose of an opioid. Okay you know one of the areas that I always struggled with when I was reporting about opioids is that there's very little scientific data in fact most people aren't familiar with it but the fact that when the drug OxyContin was approved by the FDA there were no long term studies about whether this drug was effective over the long term or what the consequences of using it over the long term might be and this is a problem that is not simply limited to OxyContin it affects a lot of a lot of opioid information so the question is what are the data gaps concerning epidemiology evidence based interventions that is how does one type of treatment say for back pain and opioid care to acupuncture or biofeedback or exercise how do we weigh these various competing treatments and what evidence is there to support those measurements first I'll begin with an indirect answer the indirect answer is that Governor Baker today sent a letter to the Food and Drug Administration telling them that they have to relabel opioids in the packet insert to say that the evidence for long term use doesn't exist and these really have been approved only for short term use so kudos to our Governor for doing that absolutely the evidence is so thin on long term use and it remains that way and one of the worst things that we did I think with the Food and Drug Administration was for something as powerful as opioids which we've known about that they're addictive and they can kill you we've known about it for 200 years was not imposing side by side comparisons with alternatives before approval so we now are beginning to see side by side comparisons with alternatives there are some alternatives where the evidence is pretty good like physiotherapy exercise therapy non-steroidal anti-inflammatories like ibuprofen but there still has to be in terms of long term use we need much better data with regard to this class of drugs anyone else want to weigh in on that not me so you're asking about different treatments and I think the critical point is that when you're talking about a dangerous treatment you really want evidence that it's going to help people treatment decisions are based on weighing risk versus benefit and when it comes to opioids as Bertha just mentioned we're lacking evidence that this is helpful when taken long term but we have overwhelming evidence that it's dangerous and the higher the dose the more dangerous it is and if you think about any medical intervention whether it's a surgical intervention or medicine if you don't have good evidence that that treatment is going to help a patient but you have very good evidence that it's dangerous those are treatments we should prescribe rarely unfortunately opioids continue to be routinely prescribed for conditions where we're lacking that evidence of effectiveness so you know along with the opioid prescription opioid problem the rest of you have mentioned the other face of the opioid crisis which is the traffic and growing traffic in a legal way. There's a lot of things like opioids counterfeit opioids like fentanyl that are coming in from places like China and Mexico and they as we know unfortunately are now the biggest driver in the growing numbers of overdose deaths and so questioner wants to know what is the government doing to control how the Mexican lab in Toluca Mexico was taken out that was simple because that was there were some sources in California but the Mexican lab was the major source currently there are multiple sources from China that are coming in through multiple venues the U.S. Postal Service does not have a tracking system like FedEx does or UPS so the Postal Service has been commissioned to develop a tracking system so that packages that come from China have to have a point of origin there are many many pressure points today one of the ministers in China just agreed to schedule meaning put into a restrictive schedule all fentanyls many people are unaware that fentanyl can be made into a thousand different variants and the when fentanyl is scheduled you can make a car fentanyl or a furanel fentanyl, butyral fentanyl and so on so the Chinese today and I believe this is pressure from the U.S. government the State Department and from the White House itself to for the Chinese to put a restriction on every possible variant of fentanyl now that's a first step we've tried to extradite the five major chemical manufacturers in China the Chinese refuse to let them come to the U.S. to face trial but the fact that they have restricted fentanyl is a first step I wait with baited breath to see whether or not they're actually going to oppose the law on their own chemists and it's basically a law enforcement problem I mean it's not a problem I can be dealt with in the medical setting this is basically having you know, interdicting these drugs or these starting materials starting chemicals for the drugs in before they get yeah Charlie Baker under the new criminal justice law on bill I had strengthened the penalties on fentanyl and the distribution of fentanyl in one month I do court appointed work in one month I had two cases tolling eight kilos of fentanyl in the mass turnpike eight four and four wow and I stood at the cases for only eight because they were also illegal and they were going to probably be deported at some point but the number the amount of fentanyl that's still coming into this country has to be stopped it does make a difference as you were saying that you know every time I saw one of these guys and I have to represent him I'm a defense lawyer and I do it but also my advocacy is with the street addict and the person looking to connect to recovery and I'm looking at this and I'm saying you know this is going to kill so many people so one kilo will kill a half a million people so eight kilos do the math four million a month just in the one month that I was in that court so there are there are some people who believe and you know there are questions about an issue related to pain patients who are you know not being given alternative therapies it's not available to them either they live in places where it's not available not accessible or they can't find doctors who provide it there are people out there who feel that they've been abandoned much in the way that addicts feel they've been abandoned so how do we address those people you know there's a problem with the way you've just framed that question well I don't think it's a problem where I've framed it it's a problem the way you might want to answer it well I mean I've been treating opioid addiction for more than 15 years and I've never once met an addict I've met people who refer to themselves as addicts but I've never met an addict if by addict we're talking about people who are continuing to use and don't care who they hurt because they're having so much pleasure using opioids what I've treated are people suffering from opioid addiction some who became addicted because they it was pleasurable and that's how they got hooked some who became addicted through medical treatment and when we when you use the term addict to me it's not just stigmatizing because you're defining somebody with this disease like calling somebody with Schizophrenia Schizophrenic I think it is I don't like that either but with calling someone with addiction an addict in my opinion it's even worse because I think it's very misleading and so to ask your question about well there are the addicts who feel abandoned and the pain patients who feel abandoned is already accepting really what the sacros were trying to promote and their framework of the opioid crisis you know I think with all due respect that's ridiculous well let me finish my you know you agree with me I mean addiction and substance abuse and opiates is is not doesn't have a monopoly on addiction right you know people are addicted you know by nature through a obsessive compulsive behavior whatever it is and we don't know the answers to all of those and those are challenges and I understand the opiate crisis but I've never met an opiate addict that didn't use heroin Suboxon methadone Gabapentin these guys every day in the courthouse and it's an array of you didn't meet my patients I've always believed that people who have the disease of addiction and people who have pain need to be treated compassionately I've always approached that as a reporter I've always believed that as a person I believe there let me finish there should be a compassionate treatment for people who struggle with substance abuse and there should be compassionate treatment for people who have pain and the only question I'm asking is and you cannot choose to answer it if you want how do you deal with people who are not getting the pain treatment they need the problem with your question you're continuing to do this is you're acting as if it's not possible for someone to have both addiction and pain many of the people I'm not acting that way at all you're saying there are the addicts and the pain patients you're asking the question is if we have these distinct groups and we don't necessarily have distinct groups there are many people who have become opioid addicted some because they took it because they like the effect some because they were suffering from chronic pain and so of course of course people who are opioid dependent whether they wound up stuck on opioids because they did it because they like the effect or they wound up stuck on opioids because the doctor prescribed it to them we need to help that population we need to I'm not going to litigate this with you I'm going to ask Bertha to answer the question in any way she wants in terms of like how do you know you're I'm trying to pose a question one of the audience members is asking I think one of the most important things we have to remember is about 90 million people in the country currently are prescribed opioids and probably 10% of those have trouble in terms of compulsive use and so on and so forth so the vast majority of people who are prescribed opioids for acute pain post-surgical pain are not in trouble what we are worried about are the people who got the opioids either through legitimate prescriptions or through diversion taking the 50% of the people in the country who are misusing them take them free from friends and family or buy them it's that population that we have to worry about and my feeling is that that population is susceptible for a number of reasons that have to be dealt with they are susceptible because people who have opioid use disorder there's a much higher incidence of pain in them they have much higher incidence of anxiety much higher incidence of stress much higher incidence of psychiatric comorbidity so there is some people get addicted I think you're a poster child because the drug literally changed your brain but there are some people who have so many confounds and I think that those people have to be treated with much much more subtlety and much more integrated approaches to all the problems they have rather than just pain or illness that I think would be my answer good so I thought we'd end on a kumbaya moment we didn't but nonetheless thank you all very much for coming tonight I hope that it was time well spent and that you'll take something back and factor it into your lives going forward for our panelists I want to formally thank all of you for giving us education and giving us information and giving us stimulating questions and issues to think about but most of all we are at a Jewish community center and I'd like to end on my thoughts and Bertha you said this to Rick when we were having dinner you put your hand on his arm and said you give us hope and I think if there's a thought that I want to end on we have a country that we're connected to that's over there about 6,000 miles away it's called Israel and when Israel was deciding what they should choose for a national anthem they chose something called hattikva which means hope so after all we went through for 2,000 years let's always sing about hope for how many years or how many moments tonight how many tough questions in conversation we end on this notion of hope thank you for bringing us hope this evening and thank you all for being here