Speaker 1: Hi, I'm Ethan Nadalman, and this is Psychoactive, a production
Speaker 1: of I Heart Radio and Protozoa Pictures. Psychoactive is the
Speaker 1: show where we talk about all things drugs. But any
Speaker 1: views expressed here do not represent those of iHeart Media,
Speaker 1: Protozoa Pictures, or their executives and employees. Indeed, heed, as
Speaker 1: an inveterate contrarian, I can tell you they may not
Speaker 1: even represent my own. And nothing contained in this show
Speaker 1: should be used as medical advice or encouragement to use
Speaker 1: any type of drug. Hello, Psychoactive listeners. Um, Today We're
Speaker 1: gonna talk about an issue, uh that I've long been
Speaker 1: fascinated by, but it's becoming ever more important, and it's
Speaker 1: the issue that has to deal with the under treatment
Speaker 1: of pain, and especially chronic pain, and especially in Amerror Ka.
Speaker 1: I mean, we've all familiar with the overdose crisis and
Speaker 1: the over pushing and prescribing of opiois by the pharmaceutical
Speaker 1: companies and now the problems with overdose connected with fentinel
Speaker 1: and other drugs like that. But there's been a flip
Speaker 1: side to this thing, which is that opiois have been
Speaker 1: around for a very long time, thousands of years in fact,
Speaker 1: for treating pain and the medication of pain is one
Speaker 1: that has gone through all sorts of changes and waves
Speaker 1: over the past years and decades and even centuries. Now
Speaker 1: my guest today is Kate Nicholson. Kate is I mean,
Speaker 1: a brilliant lawyer, graduated Harvard Law School many years ago,
Speaker 1: worked in the Justice Department Civil Rights Division for a
Speaker 1: couple of decades. But the reason I'm having her on
Speaker 1: now is because she recently started an organization called the
Speaker 1: National Pain Advocacy Center, specifically devoted to advancing the healthy
Speaker 1: human rights of people in pain. So, Kate, thank you
Speaker 1: so much for being my guest today. I'm delighted to
Speaker 1: have you on, and uh, let's get started. Delighted to
Speaker 1: be here. Your work dealing with people with disabilities influenced
Speaker 1: some of your thinking on this, but perhaps even more
Speaker 1: so was your own personal experience with really terrible pain
Speaker 1: for really long period of time. So just tell me
Speaker 1: a little more about what that was like and what
Speaker 1: you learned through the process. When my pain began, I
Speaker 1: was already working as a civil rights attorney in the U.
Speaker 1: S Department of Justice, doing primarily health related civil rights law.
Speaker 1: So Sunday afternoon in August, I sat down to get
Speaker 1: to work like I always did, and after about thirty minutes,
Speaker 1: my back started to burn really badly. I felt a
Speaker 1: little like acid was eating my spine, and pretty quickly
Speaker 1: the pain intensified and a lot of the muscles in
Speaker 1: my body seized up on me and I ended up
Speaker 1: in a face plan on the floor of my office.
Speaker 1: It turned out that I had had a surgery and
Speaker 1: a doctor had severed a part of the nerve plexus
Speaker 1: leading into my spinal cord, and the consequences only appeared
Speaker 1: when the nerves began to regenerate, scarring it adhesouldn't sort
Speaker 1: of embedded informed and caused a lot of problems for me,
Speaker 1: and so, like many chronic pain patients, I entered a
Speaker 1: real slog through the health care system for about three years.
Speaker 1: There was a lot of inflammation in my spine and
Speaker 1: so they thought maybe it was this rare arthritic disorder.
Speaker 1: I had abnormal nerve conduction studies, which isn't so surprising
Speaker 1: since I had, you know, difficulty walking, but they thought
Speaker 1: maybe I had m S. So um, it took a
Speaker 1: long time to get to the bottom of what was
Speaker 1: going on. Meanwhile, you're working throughout this period. Mostly I was.
Speaker 1: I took a few leaves of absence UM because I
Speaker 1: was also being treated throughout this this time UM and
Speaker 1: I tried gosh about thirty seven different kinds of treat
Speaker 1: and some of them were integrated, things like biofeedback and
Speaker 1: self hypnosis. And I tried a lot of different kinds
Speaker 1: of medication, though not opioids, initially, physical therapy, massage, you know,
Speaker 1: just a host of different things. I did have a
Speaker 1: surgery where they tried to go in and separate the
Speaker 1: scarring um, but it was not successful. And so when
Speaker 1: did you start relying on opioids to make it? Was?
Speaker 1: It was that day. It was a really depressing day
Speaker 1: in my life because I went to the doctor. It
Speaker 1: was at this point I'm so disabled that my husband
Speaker 1: was literally having to carry me everywhere, was carrying me
Speaker 1: into the doctor's office. We've had this very hopeful surgery
Speaker 1: that we've been sort of thinking would would address things.
Speaker 1: And it was that day that the doctors basically uh said,
Speaker 1: there will be no cure. Things are not going to
Speaker 1: get better, They're probably gonna get worse. We've tried everything,
Speaker 1: you know, we've tried nerve blocks, we've tried every medication
Speaker 1: and it's not working, and so now we think you
Speaker 1: really need to try prescription opioids. And I had avoided
Speaker 1: them up to that point because I was afraid of them.
Speaker 1: I had read things and was worried about addiction. I
Speaker 1: was afraid that I would become, you know, sort of
Speaker 1: fuzzy and unable to to think, because my only experience
Speaker 1: with taking opioids in the past had been post surgically.
Speaker 1: But it turned out that that none of that was
Speaker 1: really the case. That once I did start them, I
Speaker 1: really improved. I wasn't foggy, I was I was in
Speaker 1: less pain and able to work better and to think better.
Speaker 1: And so they were really enormously helpful to me. Which ones,
Speaker 1: what are you using? We ended up with methodone. Probably
Speaker 1: my doctor's positive. That's because the way it's formulated in
Speaker 1: the US, it also has an agent that helps with
Speaker 1: certain neurological conditions or neuropathic pain. So you get into
Speaker 1: the opioids, you're still doing with the pain. Now the
Speaker 1: opioids are helping, the methodons helping you're able to work.
Speaker 1: And then I just sort of continued my life I
Speaker 1: mean I I still was very limited, so I had
Speaker 1: to argue cases locally lying in a reclining folding lawn chair,
Speaker 1: and overseas litigation across the country using video teleconferencing, which
Speaker 1: was brand new in the early nineties, at least for
Speaker 1: for the kinds of work that I was doing. So
Speaker 1: I remained limited my mobility, but I was able to
Speaker 1: continue to work and function despite those difficult circumstances. And so,
Speaker 1: what's the connection between your being prescribed opioids, successfully deal
Speaker 1: with your pain and UH would then emerge? This is
Speaker 1: this massive over prescribing of opioids. How does your personal
Speaker 1: story fit into the bigger picture of what's going on
Speaker 1: in the in the country. Well, in a couple of ways.
Speaker 1: I mean, first of all, um, there was a liberalization
Speaker 1: prescribing sort of starting in the eighties. In the early nineties,
Speaker 1: there was a recognition that pain was undertreated, and that
Speaker 1: is true, that remains true. Pain is the number one
Speaker 1: cause of disability both globally. In the US, daily pain
Speaker 1: affects some fifty million Americans and profoundly impactful pain like
Speaker 1: mind some twenty millions. So it is still a very
Speaker 1: serious problem. But that genuine concern was in some ways
Speaker 1: sort of hijacked by pharmaceutical malfeasance and the promotion of
Speaker 1: the idea that if you had pain, you couldn't become
Speaker 1: addicted to these medications, the understatement of the risks, and
Speaker 1: and there were and really the risks are relatively low,
Speaker 1: but it's still a small but significant group of people
Speaker 1: who were harmed. Right, So that was the connection. But
Speaker 1: also the other connection with me is that I didn't
Speaker 1: have cancer pain, so it is quite possible that I
Speaker 1: would never have been offered opioids, even after trying thirty
Speaker 1: seven different kinds of treatment over three years. Because when
Speaker 1: the Big CEA is involved, doctors are ready to prescribe opioids,
Speaker 1: but if it's something else, even back then, they would
Speaker 1: be leery of this sort of thing. I remember when
Speaker 1: the late nineties mid nineties when Perdue Pharma, you know,
Speaker 1: the now infamous pharmaceutical comely owned by the Sackler family,
Speaker 1: came up with oxycontent and it initially appeared to be
Speaker 1: virtually racle drug, right that people dealing with serious pain,
Speaker 1: we're finding great relief from this thing, and it seemed
Speaker 1: like a very positive development. Um But obviously things, and
Speaker 1: it may have been true for many people. UM, Yet
Speaker 1: at the same time we then see them beginning to
Speaker 1: promote these drugs much more aggressively to all sorts of people.
Speaker 1: UM And what's your take about what happened with that
Speaker 1: with a Perduce farm in the other companies. The theory
Speaker 1: behind oxycoton is that if you have pain that lasts,
Speaker 1: you know, all the time, that taking a pill that's
Speaker 1: going to spike and then wear off every few hours
Speaker 1: might not be as effective as something that's going to
Speaker 1: have a slow, extended release through a period of time.
Speaker 1: UM and Oxyconton was marketed to do that. It wasn't
Speaker 1: as effective as it was marketed to be in terms
Speaker 1: of how long the range lasted, and there were some
Speaker 1: problems with it. But I think the bigger issue with
Speaker 1: oxyconton was in the way it was marketed, the understatement
Speaker 1: of the risks and um the larger availability of it,
Speaker 1: and pitching to a lot of doctors and medical professionals
Speaker 1: who really are not very trained in dealing with pain,
Speaker 1: right right. Again, That's that's the other problem. And I
Speaker 1: sort of have this under acknowledge condition pain partly because
Speaker 1: it's ubiquitous, because we all have pain at some level,
Speaker 1: but most people don't really understand that. Well. Acute pain
Speaker 1: is adaptive and normal, and people who have a genetic
Speaker 1: condition that makes them not able to feel pain will
Speaker 1: not live very long. So it's necessary that we experience
Speaker 1: pain to teach us to rest or seek medical care.
Speaker 1: Chronic pain is something very different. It's often described by
Speaker 1: experts as a disease because it actually isn't adaptive. It
Speaker 1: damages the body, affecting almost every organ system, and that's
Speaker 1: why it requires treatment. And I'm just thinking, you know,
Speaker 1: because also people talk about real pain or unreal pain,
Speaker 1: or physical pain versus emotional pain, or or how it's
Speaker 1: all mixed up, or pain exists in the brain, or
Speaker 1: you know, different cultures experience pain differently. What's you're thinking
Speaker 1: about this reality of pain? Well, I think it's all real,
Speaker 1: whether it's physical or emotional pain, right, I don't I
Speaker 1: think it's all real. I think there are spectrums, Like
Speaker 1: I said, the difference between sort of the kind of
Speaker 1: pain that everyone experiences in a small pain and having
Speaker 1: intractable pain that's more like a disease, just as there's
Speaker 1: a difference between people feeling sad and people having intractable depression.
Speaker 1: I think there are there are spectrums in many illnesses,
Speaker 1: and it is in the brain. It is experience in
Speaker 1: the brain, but a lot of our body operates from
Speaker 1: our brain. Um So that's that's, you know, sort of
Speaker 1: a funny Cartesian idea of the division between mind and
Speaker 1: body that that just isn't biologically accurate. The thing that
Speaker 1: is true about the connection between emotions and pain is
Speaker 1: that the way pain works is it's a you know,
Speaker 1: a noxious signal. But if we didn't have an emotional
Speaker 1: response to it, we wouldn't react to that signal. And
Speaker 1: so there is a connection between how we experience pain
Speaker 1: and the emotional experience of pain. So I think it's
Speaker 1: it's a spectrum. But um so you lived with this
Speaker 1: pain in a very serious way for what almost twenty years,
Speaker 1: So you had this relatively successful surgery that moderated quite
Speaker 1: a bit. That's true. I mean it was a little
Speaker 1: more complicated than that. Um. I was using a medical
Speaker 1: device that has advanced a lot, called a spinal stimulator
Speaker 1: that was starting to improve things for me a little bit.
Speaker 1: And then I had the surgery on the spinal cord
Speaker 1: issue UM and moved to Colorado, was starting to learn
Speaker 1: to walk again and was really improving. UM. And that's
Speaker 1: what brought me into this current conversation because I was finally,
Speaker 1: after you know, almost two decades of trying to trying
Speaker 1: to get a better quality of life, that possibility was
Speaker 1: really in front of me. And I was rehabilitating and
Speaker 1: learning to walk again and going down on the medication.
Speaker 1: And I went into my doctor's office one day, UM,
Speaker 1: and she said, I'm not going to prescribe opioids anymore
Speaker 1: to any of my patients, and you won't find anyone
Speaker 1: else in the area who's willing to either. And this
Speaker 1: was and what had happened is that a local clinician
Speaker 1: who was well respected had fallen under d e a
Speaker 1: investigation for opia prescribing, and that really just sent shock
Speaker 1: waves through the whole medical community locally. And this was
Speaker 1: coming at a time and prescribing in America started to
Speaker 1: drop in there was a growing awareness UM and pushed
Speaker 1: back in the press. I was worried. I said, well,
Speaker 1: can't you at least give me a taper plan? Because
Speaker 1: I knew that people who take opioids long term become
Speaker 1: physically dependent on them, which is different from being addicted it.
Speaker 1: It lacks the sort of compulsive use, but it's dangerous
Speaker 1: to stop the medication abruptly, and she just wasn't willing
Speaker 1: to help me. It's luckily I had a prior treatment
Speaker 1: team in d C where I lived before, and I
Speaker 1: was able to go back there and they gave me
Speaker 1: a taper plan, and um, I was to get off
Speaker 1: of them, and as I said, I was already improving,
Speaker 1: and so it didn't cause any major problems in my
Speaker 1: personal condition, but it did let me see what was
Speaker 1: coming in the environment. So now you're able to live
Speaker 1: a life where you have occasional pain and the opioids
Speaker 1: or what. I still have continual pain, but it's it's
Speaker 1: at a very low level. It's not nearly as severe.
Speaker 1: Um it doesn't limit my activities very much, and I
Speaker 1: don't require use of any medications anymore. I do use
Speaker 1: a lot of complimentary and adjunctive techniques, and I started
Speaker 1: meditating very early on when I had pain, and using
Speaker 1: mindfulness techniques. But yeah, I no longer require use of
Speaker 1: prescribed opioids. So it instigated you to get into this
Speaker 1: issue as an advocate. Was that experience of having a
Speaker 1: doctor I want to cut you off the opioids right
Speaker 1: away like that. I mean, you must have been furious
Speaker 1: exactly what I was mostly scared. I mean, I've been
Speaker 1: working so hard to get better and and I thought
Speaker 1: everything was gonna, you know, collapse in front of me.
Speaker 1: And I had been hearing through the DISAPL the rights
Speaker 1: community about more and more people being cut off of
Speaker 1: their pain medication. So I got up and did a
Speaker 1: ted X talk and started advocating about you know, the
Speaker 1: appropriate use of opioids and people being denied care. And
Speaker 1: I was also interested in that because of some of
Speaker 1: my previous work. As I mentioned to you, I was
Speaker 1: a health related civil rights attorney, and some of my
Speaker 1: early cases were in the HIV and AIDS crisis. And
Speaker 1: what we saw was that in these public health crises,
Speaker 1: the people were trying to help often become stigmatized and
Speaker 1: then denied care. And so one of my big cases
Speaker 1: was this case called Bragdon versus Abbott, which was about
Speaker 1: whether someone even with asymptomatic HIV could have access to
Speaker 1: basic dental care. And we had to win that right
Speaker 1: all the way in the U. S. Supreme Court. So
Speaker 1: it is a phenomenon of the I think public health crisis,
Speaker 1: that people often become stigmatized, and that that those stigmas
Speaker 1: can result in discrimination and barriers to healthcare. And so
Speaker 1: having had that professional experience and then the personal experience,
Speaker 1: it seemed important for me to be able to get
Speaker 1: up and talk about it. And people were sadly going
Speaker 1: to take me seriously because I was someone who used
Speaker 1: them for many years, got off of them with no trouble,
Speaker 1: and was not using them anymore. And did you find
Speaker 1: that there was already a substantial advocacy world of people
Speaker 1: trying to make this an issue, or were medical associations
Speaker 1: alert to this, or the or the doctors mostly running
Speaker 1: scared as well like your doctor had been. I think
Speaker 1: mostly when I first stepped into it, there were a
Speaker 1: lot of people running scared. Uh. Since that time, there's
Speaker 1: been more advocacy, I meet, the American Medical Association has
Speaker 1: certainly become more involved. A lot of things changed in
Speaker 1: the conversation In the United States when the Centers for
Speaker 1: Disease Control and Prevention issued guidance for prescribing opioids for
Speaker 1: chronic pain um and a lot of the recommendations in
Speaker 1: the guideline are very sensible, but a couple of the
Speaker 1: provisions were very concrete, and they became a really weaponized
Speaker 1: and used by law enforcement, insurers, UH, and a lot
Speaker 1: of policy actors to limit prescribed opioids in a way
Speaker 1: that meant that people who need them to manage serious conditions,
Speaker 1: including cancer and sickle cell disease and multiple scurosis, had
Speaker 1: trouble getting access at the pharmacy, and doctors either abandoned
Speaker 1: their patients, stopped prescribing forcibly tapered people, which is a
Speaker 1: dangerous practice that public health agencies have now come out against,
Speaker 1: but it's still happening to people all the time. There
Speaker 1: was a recent update to a survey done the University
Speaker 1: of Michigan that looked at nine different states, and they
Speaker 1: found that more than fifty percent of primary care providers
Speaker 1: will not take on a new patient who uses opioids
Speaker 1: to manage paint. A different survey found are reluctant to
Speaker 1: so people are losing access not just to medication, but
Speaker 1: to healthcare altogether. It's such another example of sort of
Speaker 1: widespread physician fear and ignorance undermining effective treatment for people.
Speaker 1: We'll be talking more after we hear this ad you
Speaker 1: and I have talked briefly about. I sometimes see more
Speaker 1: and more analogies between what's going on in this issue
Speaker 1: of pain management and what's going on in the issue
Speaker 1: of tobacco harm reduction, where you have these vaping devices
Speaker 1: and heat not burn device and East cigarettes which are
Speaker 1: actually can be quite effective in helping long term smokers
Speaker 1: quit smoking. But because people got so freaked out about
Speaker 1: young people, you know, using East SIGs and vaping and jeweling,
Speaker 1: that there's massive crackdown, and you now have doctors believing
Speaker 1: all sorts of things are absolutely false according to the
Speaker 1: scientific evidence, and being fearful of giving correct information, are
Speaker 1: oftentimes being more guided by inaccurate headlines than they are
Speaker 1: by what's really going on. And people read about, you know,
Speaker 1: the opioid overdose crisis, which is very real and very serious,
Speaker 1: and then they think they can't prescribe opioids. And meanwhile,
Speaker 1: I think, right, I mean early twenty years ago, fifteen
Speaker 1: years ago, what was driving the increase in drug addiction
Speaker 1: and over those fatalities. I think was this over aggressive
Speaker 1: marketing by the pharmaceutical companies, by the produce pharmers in
Speaker 1: a range of others. But for the last ten to
Speaker 1: fifteen years. You know, pharmaceuticals opioids I think play less
Speaker 1: and less of a role, and doctor over prescribing plays
Speaker 1: even less of a role and more and more it
Speaker 1: has to do with heroin or fenenal, or people getting
Speaker 1: drugs that are legally prescribed to somebody else but now
Speaker 1: they're getting their hands on it. Basically, that's what's going on,
Speaker 1: right right, I mean, I think it's always been the
Speaker 1: case if you look at the Service for Drug Use
Speaker 1: and Health that even in the days when UH prescription
Speaker 1: opioids were showing up in in overdose stats, if you
Speaker 1: look at all the surveys, it looks like most people
Speaker 1: who were using non medically or misusing them in the
Speaker 1: greatest risk for addiction or overdose, or were not actually
Speaker 1: the direct recipients of a prescription from a doctor. The
Speaker 1: biggest problem even with prescribed opioids was diversion. And that
Speaker 1: doesn't mean that some people weren't prescribed and opioid and
Speaker 1: became addicted. That of course happened as well, but it's
Speaker 1: a relatively small percentage of people. The bigger problem where
Speaker 1: these leftover supplies and medicine cabinets are uh, distribution channels
Speaker 1: in hospitals where people were able to get their hands
Speaker 1: on prescribed opioid that wasn't given to them by a
Speaker 1: doctor directly, but because there was liberalized prescribing, the supply
Speaker 1: was it was so much greater. So, I mean, I
Speaker 1: think that's certainly true. There are lots of sort of
Speaker 1: chinks in the armor and the discussion of the addictiveness
Speaker 1: of these medications. Neither. Director Nora Volcaw, who I think
Speaker 1: has very little interest in understating the problem since her
Speaker 1: job is fighting, you know, sort of against addiction UH
Speaker 1: and misuse, says that even when they're prescribed for chronic pain,
Speaker 1: which is sort of longer term prescribing, and so the
Speaker 1: risks are higher um and even in groups of people
Speaker 1: who have pre existing risk factors, whether they speaking commin
Speaker 1: at mental health issues or prior substance huse, problematic prior
Speaker 1: substance huose. She says that well documented studies say the
Speaker 1: risk is less than eight percent, and often you know,
Speaker 1: it's it's much lower than that. Now, that's still a
Speaker 1: significant it's a small percentage, but it's a significant percentage
Speaker 1: of right. But my understanding also is that if you
Speaker 1: look at the people who are being prescribed opioids by
Speaker 1: physicians for their pain. That among the people who have
Speaker 1: never had an issue with misuse of substances before, the
Speaker 1: likelihood that they're now going to get addicted exists, but
Speaker 1: it's very low. It's one percent, it's less than one percent.
Speaker 1: Whereas most of the people getting in trouble are oftentimes
Speaker 1: people who had issues with substance abuse earlier and now
Speaker 1: they're in a pain situation, and uh, they may be
Speaker 1: more susceptible to getting in trouble. And of course that
Speaker 1: people who do have pain and are prescribed to opioids
Speaker 1: and then end up what they used to sort of too,
Speaker 1: are probably the most vulnerable in the current environment. Well,
Speaker 1: you know, I remember there was a doctor, his name
Speaker 1: was Hurwitz. I think he was the subject of a
Speaker 1: sixty minute special report, And there was a certain category
Speaker 1: of physicians that I regard as basically among the most
Speaker 1: courageous physicians on the face of the earth, right, And
Speaker 1: these are physicians who were willing to deal with pain
Speaker 1: management issues among people who were or had been addicted
Speaker 1: to illegal drugs, because the reality is using these opioids
Speaker 1: illegally doesn't necessarily prevent you from having pain, and you
Speaker 1: walk into a doctor's office and the doctor's got a
Speaker 1: hard time saying, does this person in real pain or
Speaker 1: they just trying to scare me so that they can
Speaker 1: get a prescription for opioids if they want to use
Speaker 1: for their whether it's recreational, whatever you want to call it.
Speaker 1: And the doctors willing to live on the edge in
Speaker 1: dealing with that sort of stuff I just immense admiration for.
Speaker 1: And they went after him with a vengeance. I remember
Speaker 1: reading the cases, the appellate cases in his matter. I
Speaker 1: do think that, you know, the physicians who are willing
Speaker 1: to deal with the people who have pain and a
Speaker 1: use disorder are very few and far between. And the
Speaker 1: problem is, you know, it's already dangerous just to cut
Speaker 1: someone off precipitously or forcibly taper them who has pain
Speaker 1: and no evidence of a use disorder. There are many
Speaker 1: studies that show it puts people in a much threefold
Speaker 1: greater risk of overdose or death by suicide. I mean,
Speaker 1: it's a very dangerous practice that's happening to lots of
Speaker 1: pain patients today. But it's even more dangerous if someone
Speaker 1: may have a use disorder right there in some ways
Speaker 1: the most vulnerable patients. But you're right about what you
Speaker 1: said a little while ago about what's driving the overdose
Speaker 1: crisis at least since we started paying attention to it
Speaker 1: in the last decade um, and that is largely a
Speaker 1: very potent, tampered with street supply. The latest numbers from
Speaker 1: the CDC show that it's you know, deaths orrupt related
Speaker 1: to illicit ventnyl stimulants play an increasing role. Heroin also
Speaker 1: plays a role. Dess related to preserved opioids are actually
Speaker 1: down at this point, but we never saw the huge
Speaker 1: numbers that we've seen until people were really using this
Speaker 1: sort of dangerous street supply. A lot of policymakers now
Speaker 1: believe that pain isn't really undertreated, that it's just a
Speaker 1: pharmaceutical ruse. I mean, what we see is these crazy
Speaker 1: pendulance things in this country, and what I've seen the
Speaker 1: sacklers put in scare quotes opioid crisis to try and
Speaker 1: pretend that it didn't exist or understate it um And
Speaker 1: today in laws and policies, policymakers are putting undertreated pain
Speaker 1: when they talk about the history of what happened. Also
Speaker 1: in these quotes to say that that didn't really exist,
Speaker 1: And so I would definitely say that, you know, pharmaceutical
Speaker 1: companies in the Sackler family in particular, you know, hijacked
Speaker 1: the conversation and did a lot of damage. Um. But
Speaker 1: it's a more complicated than that, right, I mean, there
Speaker 1: are some studies that show that drug over to deaths
Speaker 1: have been on a steady upward trajectory since the nineteen forties,
Speaker 1: and the drug of choice is just changed. You know.
Speaker 1: My own view is that aggressive pharmaceutical marketing and liberal
Speaker 1: prescribing did harm, and that the gen is a little
Speaker 1: hard to put back in the bottle, you know, because
Speaker 1: once you start with prohibition, you end up getting a
Speaker 1: more dangerous supply. Yeah, I was gonna say, I just remember,
Speaker 1: you know, years ago, maybe back in the late seventies
Speaker 1: or eighties. Uh, there was a friend of mine, a
Speaker 1: drug expert named Dr John Morrigan at the Cuney Medical School,
Speaker 1: and he loved puncturing popular myths about drugs, and he
Speaker 1: coined the term opiophobia to refer to the irrational fear
Speaker 1: of opioids. Uh. And what he meant by this was
Speaker 1: that you had cases of patients who would be lying
Speaker 1: on their deathbed, dying from cancer and horrific pain, and
Speaker 1: would be refusing opioids to manage their pain because quote
Speaker 1: unquote they didn't want to die in addict or their
Speaker 1: family members who were re using the pain medication, or
Speaker 1: nurses and doctors who actually believe that stuff. And we're
Speaker 1: allowing people to die in horrific pain because of this
Speaker 1: pervasive opiophobia. You know, I guess in a way it
Speaker 1: almost seems like a semi American sort of perspective that
Speaker 1: we have a hard time finding that reasonable balance. Either
Speaker 1: we're in a kind of super moralistic, prohibitionist mentality about
Speaker 1: this drug or that, or on the other hand, we're
Speaker 1: in some super capitalistic marketing. There is nothing wrong here,
Speaker 1: and finding that middle ground is the one that becomes
Speaker 1: such a challenge. Absolutely, the lack of nuances is extraordinary.
Speaker 1: And even though as I said, I could see some
Speaker 1: of this swing even in stigmatization with HIV, now that
Speaker 1: I've sort of entered the drug policy conversation, nowhere are
Speaker 1: there more myths, um and is there more sort of
Speaker 1: shame and misperception than in anything related to drugs? Right,
Speaker 1: And a lot of this has been going on in
Speaker 1: the US for centuries, and so when they're being cautious
Speaker 1: now in the crackdown, I mean, part of this comes
Speaker 1: from greater wariness. Part of this comes from law enforcement
Speaker 1: agencies beginning to go after some doctors. Some of it
Speaker 1: comes from new state laws and regulations, things like, I mean,
Speaker 1: how does this movement to you know, so dramatically restrict
Speaker 1: access to opioids happen? Well, I think a lot of
Speaker 1: it was driven by sort of the media narrative and
Speaker 1: the way the story is told, where you had a
Speaker 1: lot of stories about, um, you know, a teenager who
Speaker 1: had a bum ankle uh and went to the doctor
Speaker 1: and you know it was the high school football star
Speaker 1: or the cheerleader and then became addicted. They were very
Speaker 1: compelling stories. No one wants to believe that they're sending
Speaker 1: their child to a doctor and condemning them eventually to death. Uh.
Speaker 1: And we did have, of course, arise in overdose deaths.
Speaker 1: Now it's interesting because MIAs Lobbits wrote a really interesting
Speaker 1: piece for the Columbia Journalism Review, and she talked to
Speaker 1: some folks who were keeping databases of stories, and journalists
Speaker 1: were really just interested in that story they were looking
Speaker 1: for people who had never had issues before, who were
Speaker 1: not using them at a party, but who had been
Speaker 1: prescribed in opia by a doctor, because that's a compelling victim.
Speaker 1: And I think doctors became shamed and blamed for causing
Speaker 1: people's teenagers to die on the streets, which just a
Speaker 1: pretty pretty powerful message. And you know, we did let
Speaker 1: it go on for a way too long before anybody
Speaker 1: stepped in to do a lot about it. But you know,
Speaker 1: one thing that also kind of piste me off about
Speaker 1: that whole period was obviously you have these stories that
Speaker 1: you're talking about and and doctors being careless and incautious,
Speaker 1: but the fact of the matter was was that even
Speaker 1: among people getting addicted in that way, you know, what
Speaker 1: was called iatrogenically addicted by by physician prescribing huge numbers
Speaker 1: of these fatalities were actually not taking too much of
Speaker 1: the one drug they're being prescribed. They involved what might
Speaker 1: be called fatal drug combinations. You know, it might have
Speaker 1: been a football player, you know, who was injured and
Speaker 1: was taking oxies, but he goes to a party and
Speaker 1: gets drunk, not being aware that combining alcohol and oxyes
Speaker 1: um is a thing that will kill you or oxyes
Speaker 1: and benzoiazepines valiant type drugs. And meanwhile, the government and
Speaker 1: all the sort of drug educators are reverse to putting
Speaker 1: out the information that is really dangerous is the combination
Speaker 1: of drugs that may feel really good if you combine
Speaker 1: them in the right amount, but it just double that
Speaker 1: level may stop your breathing. So, yes, doctors were to blame,
Speaker 1: but the failure of public health authorities and government officials
Speaker 1: and school authorities I think also played a very big
Speaker 1: role in educating people about what were the safer or
Speaker 1: more dangerous ways to be using these substances, whether you
Speaker 1: already be using the medically or whether you were using
Speaker 1: them recreationally or something in between without question, and that
Speaker 1: continues to be a problem. I mean, these deaths were
Speaker 1: always like what they call polypharmacy deaths, right, They usually
Speaker 1: involved multiple drugs used in combination. One of the states
Speaker 1: that had higher death rates found that the average number
Speaker 1: of substances in someone's body who died was six. Right,
Speaker 1: But the headline would read heroin death oftentimes oxy death,
Speaker 1: and there's I mean, and the fatal drug combination thing
Speaker 1: would either never show up in the article, maybe because
Speaker 1: they didn't have the autopsy report as yet, or when
Speaker 1: it did, it wasn't part of the headline because it
Speaker 1: wasn't provocative and because talking about what was it, Polly
Speaker 1: drug overdose doesn't make for a catchy headline in the
Speaker 1: way that heroin or OxyContin or something like that does.
Speaker 1: Absolutely um and in fact, all of the drugs, even
Speaker 1: the drugs that are attributed to prescription opioids, the way
Speaker 1: they're counted, that doesn't mean that the opioid, prescription opioid
Speaker 1: caused death. That means that a prescription opioid was in
Speaker 1: someone's system at the time of death. They could have
Speaker 1: also had fentinyl, heroin, alcohol, benzo diazepine in their system
Speaker 1: and cocaine, right, but it would still be counted as
Speaker 1: a prescription opioid related to death. It caused this culture
Speaker 1: of real fear, I think, and you know, not very
Speaker 1: scientific conveyance of the problem, and that continues to be
Speaker 1: the case. I mean, very few people talk about drug combinations,
Speaker 1: certainly in the media. Fentinyl is now in the media
Speaker 1: a lot, but you know, even then, they don't really
Speaker 1: talk about the difference between illicitly produced fentyl and you know,
Speaker 1: pharmaceutical use and and all of that. It's just sort
Speaker 1: of you know, this the scare tactics. Yeah. I mean
Speaker 1: what's different about the fentanyl now, of course, right, is
Speaker 1: that fentanyl is the drug that can kill you all
Speaker 1: by itself. I mean, it's fifty times more potent per
Speaker 1: graham or whatever than morphine, and so that is a
Speaker 1: real issue. But it's typically you know, being uh mixed
Speaker 1: with other things as well, so we we can suspect
Speaker 1: the fentanyl is the primary thing driving it, you know,
Speaker 1: But meanwhile, hundreds of thousands of people are receiving fentanyl
Speaker 1: post surgery and hospitals. It's one of the best drugs
Speaker 1: you can give for that sort of thing. And the
Speaker 1: fentanyl overdose problem in America has nothing to do with
Speaker 1: fentinyl being diverted, right, It's fentanyl being produced illegally in China,
Speaker 1: Mexico and being imported here in ways that are impossible
Speaker 1: for law enforcement to stop, which is why accurate information
Speaker 1: is all the more important. So so, so, okay, I
Speaker 1: mean the evolution of this thing, you know, as the
Speaker 1: crackdown mounts um on openly prescribing what are the key
Speaker 1: ingredients to all of this? Well, I think that, as
Speaker 1: I mentioned, I think we were caught a little as
Speaker 1: a society flat footed. And in sixteen, the Centers for
Speaker 1: Disease Control and Prevention in the United States issued this
Speaker 1: guidance to try and sort of help guide doctors in
Speaker 1: safer prescribing practices, because, as you mentioned, because pain is
Speaker 1: sort of ignored as a as a condition and under
Speaker 1: undertreated and underrepresented, it's also underrepresented in medical education doctors.
Speaker 1: Even though pain is one of the top clinical complaints
Speaker 1: in the world, very little uh in medical education addresses
Speaker 1: the treatment of pain, at least in basic medical education.
Speaker 1: And so the CDC stepped in and said, well, we
Speaker 1: need to, you know, explain what the risks areta doctors
Speaker 1: and encourage them, you know, to try other things first
Speaker 1: to treat pain, and when they are prescribing, to prescribe
Speaker 1: at the lowest effective dose for the shortest effective period
Speaker 1: of time. And all of that was a sense able thing.
Speaker 1: What happened, though, is that there were a couple of
Speaker 1: provisions related to this problem, like the dentist who prescribe
Speaker 1: fifty oxygotten after dental surgery. Um, the attempt to kind
Speaker 1: of contain prescribing for acute pain, so you didn't have
Speaker 1: a lot of people with this leftover supply in their
Speaker 1: in their medicine chests, and the cd said CDC said
Speaker 1: that with a lot of apute pain conditions, you're not
Speaker 1: going to need more than a three to seven day supply.
Speaker 1: And then then in a different provision, there was this
Speaker 1: other problem that they identified, which was in the nineties,
Speaker 1: there was this idea that you just titrated dose to
Speaker 1: to palliation, so um you kept going up, and there
Speaker 1: was as long as someone was still in pain, there
Speaker 1: wasn't a danger in giving them increasingly higher doses. And
Speaker 1: so there was this feeling that people were on an
Speaker 1: unsafe level, or that we didn't want to start people
Speaker 1: on an unsafe level because there were some studies coming
Speaker 1: out showing that there was, you know, an elevation of
Speaker 1: risk with an elevation of dose. The absolute risk still
Speaker 1: isn't extraordinarily high. There was a study in North Carolina
Speaker 1: that looked at people who'd been prescribed even at higher
Speaker 1: doses and found that their risk of overdose was something
Speaker 1: like point zero to two. It wasn't hugely high as
Speaker 1: an absolute matter, but your risk definitely goes up depending
Speaker 1: on the dosage you're prescribed, and so in that provision
Speaker 1: they said be careful prescribing more than fifty to ninety
Speaker 1: morphine milligram equivalence. And that's just an attempt to take
Speaker 1: all of these different medications and put them on the
Speaker 1: same scale. That's what they mean by equivalence. What happened is,
Speaker 1: in the haste to address what people saw as many
Speaker 1: people dying on the streets, state legislatures enacted strict limits
Speaker 1: to opioid prescribing for keep prescribing. Insurance companies came in
Speaker 1: and said they want to prove more than a certain
Speaker 1: morphine milligram equivalent. The d e A and state medical
Speaker 1: boards started to look at prescribing patterns through prescription drug
Speaker 1: monitoring programs. Then doctors started getting letters, letters from police agencies,
Speaker 1: or from medical review boards, or from d e A agents,
Speaker 1: from medical boards, from the use attorney's offices, just you know,
Speaker 1: different levels of law enforcement. And that's sort of the
Speaker 1: thing had been going on. I think back in the
Speaker 1: eighties and early nineties, right there was a period when
Speaker 1: the d e A Office of Diversion Control and others
Speaker 1: were sending these letters, and I guess they backed off,
Speaker 1: maybe backed off too much and then started redoing it again. Maybe,
Speaker 1: But in those days, we didn't have prescription drug monitory
Speaker 1: programs in all the states. Now that information is pretty
Speaker 1: widely available, and what's happening now is even worse. There's
Speaker 1: sort of the companies that run these agencies come up
Speaker 1: with what they call a knarc's care score. They have
Speaker 1: an algorithm that tries to rate someone's risk for misuse,
Speaker 1: and people are being denied care based on that. And
Speaker 1: you know, dosage is one thing. Whether you have had
Speaker 1: more than one providers is another, which can be a
Speaker 1: proxy for doctor shopping and trying to get medication that
Speaker 1: way to misuse. But it also it can be that
Speaker 1: you live in a rural area and have to go
Speaker 1: to an urban area to see a doctor, or your
Speaker 1: doctor's practice clothes so you had to go get a
Speaker 1: new doctor. I mean, there are lots of more innocent reasons.
Speaker 1: There was just this huge proliferation of policies. I mean,
Speaker 1: one study found out was something like almost five hundred
Speaker 1: in a period of a few years, and a lot
Speaker 1: of them are very strict and um I actually met
Speaker 1: with this the CDC, as did some others who were
Speaker 1: seeing problems in this area, and the CDC came out
Speaker 1: and issued a corrective and said that was a misapplication
Speaker 1: of its guideline. But that correction has not filtered down
Speaker 1: to the lives of patients, and so there are a
Speaker 1: lot of a lot of patients who are really caught
Speaker 1: in the lurch. And I would say that, you know,
Speaker 1: there's also this problem, of course, that it doesn't affect
Speaker 1: everyone equally, you know, because of the way we've waged
Speaker 1: the drug war disproportionately against communities of color, and because
Speaker 1: of systemic racism. Even in pain treatment, there are lots
Speaker 1: of studies that show that the pain of BIPOC folks
Speaker 1: are rated less severe by many clinicians because of false
Speaker 1: beliefs about biological differences that do not scientifically exists. I mean,
Speaker 1: we have a woman in our group went into an
Speaker 1: e er black woman and the nurse called the cops
Speaker 1: on her just for reporting pain because they thought she
Speaker 1: was trying to get drugs, right, right, racist beliefs that
Speaker 1: black people don't experience pain in the same degree as
Speaker 1: white And then you have pharmacies in black neighborhoods that
Speaker 1: are less likely to carry opioids. I mean, it's just
Speaker 1: it was pervasive throughout the entire system in many regards, absolutely,
Speaker 1: and even you know, with the pharmacies that's even controlled
Speaker 1: for for income, it's remarkable, but a lot of pharmacies
Speaker 1: in black neighborhoods don't stock opioids. Let's take a break
Speaker 1: here and go to an ad with Drug Policy Alliance,
Speaker 1: and we were fighting some of the stupid policies and
Speaker 1: stigma that people in method on maintenance confronted. And one
Speaker 1: of the issues we we dealt with was that there was,
Speaker 1: first of all, a less is more ideology, so doctors
Speaker 1: were saying, well, sixty milligrams. All the scientific research showed
Speaker 1: that closer to a hundred milligrams would be the appropriate
Speaker 1: dose for maintenance, and that that's what you should aim for.
Speaker 1: But the less is more ideology meant that people were
Speaker 1: being under prescribed method on therefore it wasn't working as well.
Speaker 1: Therefore there was an anti sentiment among patients. And the
Speaker 1: second thing that happened, and this, you know, is that
Speaker 1: whereas a hundred milligrams might be the appropriate dose for
Speaker 1: the majority of people and some could deal with lower,
Speaker 1: then you get these occasional odd balls for whom the
Speaker 1: appropriate dose was three or four or five hundred milligrams
Speaker 1: right just the way that they were wired. And I
Speaker 1: imagine you have the same phenomenon happening in the pain
Speaker 1: management area. Yeah, you definitely do. I mean you have
Speaker 1: people who are hyper and hyper metabolizers of opioids. Lad Europe,
Speaker 1: they actually test for that. We don't do that in
Speaker 1: the US. And so yeah, there are people who are
Speaker 1: going to require more. But because of this range that
Speaker 1: was written in a guideline that was designed as recommendations
Speaker 1: for primary care physicians and not as law policy, we
Speaker 1: now have a rapid uptake throughout the health care system,
Speaker 1: sort of suggesting that anybody over ninety as a risk,
Speaker 1: and so people are being forced to lower doses. There's
Speaker 1: one study of Medicaid patients in Vermont that showed the
Speaker 1: average time of discontinuation was twenty four hours, which is
Speaker 1: really dangerous, and about half of them had to be
Speaker 1: hospitalized as a result. But even for those that are
Speaker 1: just tapered down to ninety, it's being done in a
Speaker 1: quick and reckless manner, and for some people they really
Speaker 1: needed to be on those higher doses, and their quality
Speaker 1: of life suffers. Terribly. And you know, again, the studies
Speaker 1: showed this kind of tapering. You know, there could be
Speaker 1: careful tapering with a lot of other adjunctive therapies thrown
Speaker 1: in that can absolutely you know, improve the lives of
Speaker 1: some people. But the way it's happening in the real
Speaker 1: world is endangering people's health, distables and people. I hear
Speaker 1: from people all the time who are acutely suicidal. I
Speaker 1: hear from people who have lost someone to an overdose
Speaker 1: after the pain medication was denied. I hear from people
Speaker 1: who are now bedridden, who can no longer work, and
Speaker 1: families who are financially devastated. It's causing a great deal
Speaker 1: of harm. And you know, some eight to thirteen million
Speaker 1: people use opioids to manage pain. That's a pretty big
Speaker 1: number of people to be affected. So by and large,
Speaker 1: this proliferation of state laws and regulations and all of
Speaker 1: the other things around it, in terms of the shift
Speaker 1: by physicians and by insurance companies, one could argue then
Speaker 1: that it's done some good in terms of pushing physicians
Speaker 1: to correct a pre existing problem with overprescribing and encouraging
Speaker 1: them to look at alternatives opioids before they go to opioids,
Speaker 1: but that in terms of the harm it's generating, in
Speaker 1: terms of depriving people of access to opioids for legitimate needs,
Speaker 1: that probably this push is doing a lot more armed
Speaker 1: than good. When when push comes to shove, I think
Speaker 1: it's doing both. I mean, I think that's sort of
Speaker 1: the problem. Just like liberal prescribing. I mean, some people
Speaker 1: who may have needed medication got it when it was
Speaker 1: only limited to cancer, but a lot of people were
Speaker 1: harmed as a result of liberal prescribing. And then when
Speaker 1: you have a sort of clampdown yet it's it's helping
Speaker 1: some people who may not be exposed who it would
Speaker 1: have been vulnerable, but it's also hurting a whole other
Speaker 1: group of people. You know, we just talked about the
Speaker 1: issues around race and racism. In terms of pain management,
Speaker 1: we've touched on the issues around class and that people
Speaker 1: a better resources can look around as you did, right
Speaker 1: and able to find somebody, whereas that's not the case. Um.
Speaker 1: But then there's also a gender issue, right, I mean,
Speaker 1: aren't women more likely to request, need or whatever pain killers? Well, yeah,
Speaker 1: there's a huge gender issue in in the pain area.
Speaker 1: Some studies suggest that up to of people with chronic
Speaker 1: pain are women, or at least female identifying, and there
Speaker 1: are studies also showing that women experience more pain, experience
Speaker 1: pain more severely. There is some recent interesting data around
Speaker 1: that that's sort of based in how we've traditionally had testing.
Speaker 1: So all of our biomedical testing is done on animals, rats,
Speaker 1: and mice. And it was only in sten that ni H,
Speaker 1: the National Institutes of Health and United States anyway, started
Speaker 1: to say that you needed to use more than just
Speaker 1: male animals when you're trying to find out more about diseases.
Speaker 1: But at least in animals, entirely different cells are involved
Speaker 1: in what makes pain become chronic in male and female animals,
Speaker 1: uh glial cell activation in males and T cell activation
Speaker 1: in females, And so there may very well be a
Speaker 1: biologic reason for this disparity. Of course, there may also
Speaker 1: be a number of social reasons. But what we find
Speaker 1: is I like to say that pain is sort of
Speaker 1: a me to issue in in a similar way I
Speaker 1: used in the hashtag pain too, because women are far
Speaker 1: more often to missed or disbelieved. We also know that
Speaker 1: relationships matter. You know, whether you go to a provider
Speaker 1: who believes your pain and listens to you, just listening
Speaker 1: to your story. Right, that could be a milierative rather
Speaker 1: than being dismissed. That can actually be a form of treatment.
Speaker 1: Or these studies where they show that a physician who
Speaker 1: sits down by the bedside and touches the patient for
Speaker 1: a few minutes and talks to them for ten minutes,
Speaker 1: people to require less prescription drugs, get out of a
Speaker 1: hospital fast, suffer less pain you know, goes up significantly
Speaker 1: as a result of that simple human interaction. Right. Other
Speaker 1: countries have fewer problems, I think, at least in sort
Speaker 1: of Western Europe and other places. And that is they
Speaker 1: also I think their healthcare systems are set up to
Speaker 1: deal with pain, that they'll let people off of work
Speaker 1: long enough to really heal from something. You know that
Speaker 1: the incentive in this country is very much, you know,
Speaker 1: take a pillcy you can get back to work. So yeah,
Speaker 1: I think there are structural, interpersonal, and and belief systems
Speaker 1: all play a role. The tough thing is that, you know,
Speaker 1: pain responses is really individual. It's individual because pain comes
Speaker 1: from a variety of conditions and ideologies. You know, you
Speaker 1: may have inflammatory pain from an autoimmune disorder, you may
Speaker 1: have neuropathic pain from a neurological problem. They're going to
Speaker 1: be treating me to be really treated differently. They're not
Speaker 1: the same kind of problems. So diagnosis matters a lot. Severity,
Speaker 1: you know, is wide ranging, and so a system like
Speaker 1: we have in the United States for for payers, for
Speaker 1: insurers covering some things and not others, different incentives come in.
Speaker 1: But I think we do need to expand access to
Speaker 1: these other modes. That's what's happening sometimes is that insurers
Speaker 1: will say, Okay, you have to do this or that,
Speaker 1: or you have to try all of these things, and
Speaker 1: only if you exhaust them do you get this. And
Speaker 1: and people are also pushed into things like you know,
Speaker 1: in more interventional things, um like nerve blocks or surgeries
Speaker 1: or medical devices which you know also have a pharma
Speaker 1: related potential issue. I think that maybe the next big
Speaker 1: issue we see. And all of those things were helpful
Speaker 1: to me, right, I had a spinal stimulator, which is
Speaker 1: an a planet surgical device that helped me. But you're
Speaker 1: you're sometimes seeing people being pushed into procedures that also
Speaker 1: are more dangerous to that person than taking you know,
Speaker 1: a prescribed opioid is I'm curious when you talk about,
Speaker 1: you know, doctor viewers who cut you off suddenly, you know,
Speaker 1: and you're a lawyer. Um, has any doctor ever been
Speaker 1: successfully sued from malpractice for suddenly cutting somebody off their
Speaker 1: opioids and having that patient die or something that's terrible happening?
Speaker 1: You know. I haven't heard of a lawsuit. I have
Speaker 1: heard of a lot of people, you know, having heart
Speaker 1: attacks or things like checkcardia, you know, and then there's this,
Speaker 1: you know, as a lawyer, their causation arguments, and people
Speaker 1: like to poke holes and say that sort of like
Speaker 1: what we sound the George Floyd trial, right, you know,
Speaker 1: it was the fimal But anyway, there are lots of
Speaker 1: attempts to muddy the waters about why someone had something
Speaker 1: medically happened. Um, the only thing I know of that
Speaker 1: happened is that I believe in New Hampshire, for the
Speaker 1: first time, maybe last year, a state medical board actually
Speaker 1: sanctioned to doctor for doing that. So most of the
Speaker 1: letters and sanctions that go out are about you're prescribing
Speaker 1: too much and this was you endangered this person's life.
Speaker 1: I'd love to see a story like that get major
Speaker 1: media attention because that's the only way to some extent,
Speaker 1: to correct what's been going on, you know. Now, you know,
Speaker 1: I should also just come clean in this because even
Speaker 1: as I've been sympathetic and actually you know, devoted part
Speaker 1: of my organization's resources to advocating for the sorts of
Speaker 1: things that that your organization is now advocating for, I
Speaker 1: had my own personal pain experience, you know, I mean
Speaker 1: I had you know, when I was twenty four, I
Speaker 1: suddenly had a terrible back pain where I couldn't stand
Speaker 1: up straight for a few weeks, and it was terrible.
Speaker 1: Finally got so bad and the doctor said, well, this
Speaker 1: was in the in the mid eighties, and he said, well,
Speaker 1: there is an intervention. It's called chemo pap pain. We
Speaker 1: inject something into your spine and and it can work well,
Speaker 1: but there's a one percent chance of paralysis. So I
Speaker 1: turned down that treatment and miraculously got better. And then
Speaker 1: when I was in my young third ease, the pain
Speaker 1: just became overwhelming and I got m R I or
Speaker 1: cat scan, and they diagnosed you know, herniated disks, and
Speaker 1: I was on pain killers and this and that and
Speaker 1: and some massage would work a little bit for an
Speaker 1: hour or two, but not really, and a surgeon was
Speaker 1: going to operate on me, and um, you know, under
Speaker 1: the advice of a of a friend who was physician,
Speaker 1: he said, don't get it. And what he suggested. I
Speaker 1: read a book called Healing Back Pain by John Sarnol
Speaker 1: and he was, you know, a serious physician at the
Speaker 1: Rusk Instituted at n y U Medical Center. And his view,
Speaker 1: in fact was that the vast majority of people who
Speaker 1: got diagnosed with herniated disks and we're suffering lower back pain,
Speaker 1: that in fact their pain had nothing to do with
Speaker 1: the herniated disc right. And he had a whole theory
Speaker 1: basically that said that when you look at m RIS
Speaker 1: and cat scans, you see huge numbers of people with
Speaker 1: hernia this and no pain. And conversely you have used
Speaker 1: numbers of with pain but no herniated diss So the
Speaker 1: notion that there was a cause of relationship between the
Speaker 1: two didn't seem to work for a well. And his
Speaker 1: theory was that in fact, what was going on was
Speaker 1: that one was suffering from an underlying emotional pain, anger, frustrations, whatever,
Speaker 1: and that the brain played a trick whereby the emotional
Speaker 1: pain got converted into a physical pain and and and
Speaker 1: he assumed that the method was that the brain would
Speaker 1: curtel the flow of blood around the nerves and muscles
Speaker 1: to that part of the body. And what the pain was,
Speaker 1: whether it was back pain or sciatic or something else,
Speaker 1: was to something think culturally determined, and that in the
Speaker 1: end when that there was basically nothing wrong with my back,
Speaker 1: and I just needed to accept this diagnosis. I needed
Speaker 1: to get right off the opioids and the benzos, benz
Speaker 1: andi esopines. The doctor put me on and I followed
Speaker 1: his approach, and it worked, and it caused me to
Speaker 1: believe that maybe a very significant number of people in
Speaker 1: the country suffering from kind of a chronic back pain
Speaker 1: or sciatica might have something similar. That we're living in
Speaker 1: a culture where this type of form of pain and
Speaker 1: disability is very culturally accepted. It's mostly it's number one
Speaker 1: caused the misdays of work, that yes, people do have
Speaker 1: conditions like you had, and many others have where they
Speaker 1: have an accident or you know, other sorts of things,
Speaker 1: but that in fact it was a type of emotional
Speaker 1: pain being morphed into a physical pain for which opioids
Speaker 1: um basically didn't work, and for which surgery was inappropriate.
Speaker 1: He pointed out that people who had had surgery for
Speaker 1: herniated disks were just as likely to suffer recurrence of
Speaker 1: pain three years later as people who had never had
Speaker 1: the surgery. And so it caused me to believe that
Speaker 1: when you look at a lot of the people suffering
Speaker 1: from these these addiction and the misuse of opioids, it
Speaker 1: may be from certain types of pain that we believe
Speaker 1: is physical that feels incredibly physical, because you can't believe
Speaker 1: that that level of pain could actually just be caused
Speaker 1: by emotional stuff. Absolutely, And I have friends who had
Speaker 1: told me that exact same story about John Sarno's book
Speaker 1: changing their lots. So I have I've heard that many times.
Speaker 1: Do you think now that the pendulum is swinging back
Speaker 1: towards a more balanced perspective, that the CDC is getting
Speaker 1: his act together, that maybe the doctors are being to learn,
Speaker 1: or are we still swinging in the wrong direction. I
Speaker 1: think that we will remain opiophobic for a while. I
Speaker 1: have seen public health agencies, including the CDC and the
Speaker 1: f d A and the Department of Health and Human
Speaker 1: Services come out against, for example, force tapering. I have
Speaker 1: seen no slowing in the number of random, you know,
Speaker 1: daily emails and phone calls I received from desperate people
Speaker 1: all over the country. It has not filtered down to
Speaker 1: the lives of the people that you know who are
Speaker 1: most deeply affected. And although I do think there was
Speaker 1: some recognition UM, Otherwise these public health agencies wouldn't have
Speaker 1: come out and said, you know this, and this is
Speaker 1: a problem and we're trying to you know. And the
Speaker 1: CDC did say to policy makers, hey, you know, these
Speaker 1: were not intended to be strict limits. The science behind
Speaker 1: these recommendations is nowhere in the or where it would
Speaker 1: need to be to do what you've done with it.
Speaker 1: I still think that we will be in um an
Speaker 1: opioid phobic period for some time. I think the general
Speaker 1: public still thinks we are in a place where prescription
Speaker 1: opioids and over prescribing are driving desks on the street.
Speaker 1: Politicians still think that we are back ten years ago
Speaker 1: and that they need to be really aggressive, and frankly,
Speaker 1: the progressive media has no appetite for this side. They
Speaker 1: have bought the big bad pharma, opiids, bad narratives so
Speaker 1: completely that they do not want to touch. Do you
Speaker 1: have any any significant allies among elected officials in Congress
Speaker 1: or even at the gubernatorial level in places yes, um
Speaker 1: I can not be terribly public, but there are some
Speaker 1: who are who are allies. Some of them unfortunately are
Speaker 1: no longer. There where allies a few years ago. But
Speaker 1: there's no public champions on this issue, not many. There
Speaker 1: are a couple, ironically, they intend to be the doctors
Speaker 1: who are in the Congress who have a deeper understanding
Speaker 1: of this um it is. It's so interesting as someone
Speaker 1: who is politically progressive myself at you know, oftentimes it's
Speaker 1: the more libertarian or conservative representatives that can see the
Speaker 1: side of it. I think a lot of progressives other
Speaker 1: they're not all just see this as a pharmaceutical ruse.
Speaker 1: Part of my doing this program is the hope that
Speaker 1: people will listen to this and have a more enlightened
Speaker 1: view of drugs and drug policy and drug treatment in
Speaker 1: their own lives right, whether it means about the drugs
Speaker 1: they take, or about the patients they have, or about
Speaker 1: the politicians they support. Now you started this organization, I'm
Speaker 1: very excited about it. I know other people as well.
Speaker 1: I mean, where do you see the places where you
Speaker 1: think you're going to be able to make the greatest
Speaker 1: difference in the coming years. Well, one aspect is just
Speaker 1: bringing together I think the pain community and the sort
Speaker 1: of drug policy and addiction communities that these communities have
Speaker 1: been divided largely because of the stigma around drug use.
Speaker 1: Um pain patients for the first time had the stigma
Speaker 1: of addiction thrown their way, and so they want to
Speaker 1: point finger and blame people who they see as misusing
Speaker 1: medication or who become addicted. People with addiction some want
Speaker 1: to say, hey, it's you people in pain who messed
Speaker 1: it up. If you people hadn't been such whiners, then
Speaker 1: evil pharma wouldn't have come in here, and we wouldn't
Speaker 1: have all of these people dead and all of these
Speaker 1: people addicted, and so there's a lot of finger pointing,
Speaker 1: and so one of the things the organization does is
Speaker 1: sort of bring those groups together. And we have a
Speaker 1: significant community council of people with a lot of different
Speaker 1: types of pain. We have a community council people in
Speaker 1: recovery from addiction. We have a science and policy council
Speaker 1: of people who are experts in drug policy and addiction
Speaker 1: and pain management, as well as a number of health
Speaker 1: policy and civil rights and disability rights experts and sort
Speaker 1: of legislation. And one of the things we're trying to
Speaker 1: do is, in addition to playing whackable and reacting and
Speaker 1: stopping these policies, which we have been fairly successful at
Speaker 1: at doing, is to get everyone at the table and
Speaker 1: come up, you know, what do we need? What would
Speaker 1: good policy, good paid policy look like that represents everyone's
Speaker 1: needs because the problem has been that no one has
Speaker 1: looked at this very comprehensively. I mean, we know we
Speaker 1: need more coverage of certain things, and I've worked with
Speaker 1: that in some issues, and I'm on a task force
Speaker 1: for women in pain, and they're all of these silos
Speaker 1: focusing on different subsegments of the issue. But I feel
Speaker 1: like there's not enough coming together with a variety of
Speaker 1: lived experiences and expertise to really tackle the big picture.
Speaker 1: See that this is a complicated situation that requires some
Speaker 1: complicated answers. Okay, listen, I mean, I'm just incredibly impressed
Speaker 1: with the work that you're doing. I'm very grateful for
Speaker 1: your taking the time to have this long conversation with me,
Speaker 1: So thank you so much for joining me, and uh,
Speaker 1: you know, more power and everything you're trying to accomplish
Speaker 1: the organization that you started. Drug Policy Alliances is by
Speaker 1: far the superstar in this arena and has been such
Speaker 1: a great ally, um and I've learned so much from
Speaker 1: people within that organization and community, so uh, it's just
Speaker 1: an absolute it honor. Psychoactive is a production of I
Speaker 1: Heart Radio and Protozoa Pictures. It's hosted by me Ethan Nadelman.
Speaker 1: It's produced by Katcha Kumkova and Ben Kbrick. The executive
Speaker 1: producers are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren
Speaker 1: Aronovski for Protozoa Pictures, Alex Williams and Matt Frederick for
Speaker 1: I Heart Radio and me Ethan Nadelman. Our music is
Speaker 1: by Ari Belusian and a special thanks to Avivit Brio,
Speaker 1: Sef Bianca Grimshaw and Robert Beatty. If you'd like to
Speaker 1: share your own stories, comments, or ideas, please leave us
Speaker 1: a message at eight three three seven seven nine sixty.
Speaker 1: That's one eight three three psycho zero. You can also
Speaker 1: email us as Psychoactive at Protozoa dot com or find
Speaker 1: me on Twitter at Ethan Nadelman. And if you couldn't
Speaker 1: keep track of all this. Find the information in the
Speaker 1: show notes.