WEBVTT - In Triplicate 0:00:15.356 --> 0:00:21.996 Pushkin Hello, Hello, Revision's History listeners. I'm excited to announce 0:00:21.996 --> 0:00:24.916 that this season I'm offering a bunch of perks from 0:00:24.956 --> 0:00:29.316 my most loyal listeners, the ones who subscribe to Pushkin 0:00:29.356 --> 0:00:32.876 Plus for those who just can't get enough. We're giving 0:00:32.916 --> 0:00:37.476 every episode to our subscribers one week early. Plus We've 0:00:37.516 --> 0:00:42.676 created many episodes released weekly, and I'm calling them tangents. 0:00:43.156 --> 0:00:48.316 And of course you'll never hear any ads. Subscribe to 0:00:48.356 --> 0:00:52.036 Pushkin Plus on the Revisionist History Show page in Apple 0:00:52.076 --> 0:00:57.956 Podcasts or at pushkin FM. When I was in my 0:00:58.036 --> 0:01:01.276 twenties many years ago, I was a reporter for the 0:01:01.356 --> 0:01:05.196 Washington Post. A newsroom the size of a football field, 0:01:05.716 --> 0:01:10.076 phones ringing, keyboards clattering, the glory days of print journalism. 0:01:10.636 --> 0:01:13.716 I want you to describe what is the status in 0:01:13.836 --> 0:01:18.196 position of a Washington Post reporter in Washington, DC in 0:01:18.316 --> 0:01:20.036 nineteen eighty nine. 0:01:20.516 --> 0:01:25.196 Well, in general, godlike, because the whole city ran on 0:01:25.356 --> 0:01:30.956 politics and news and there weren't many organizations that produced 0:01:30.996 --> 0:01:33.956 it excellently, and the Post was sort of the place 0:01:33.996 --> 0:01:35.116 that everyone cared about. 0:01:35.996 --> 0:01:38.476 That's my friend Michael Specter. He and I were both 0:01:38.476 --> 0:01:41.236 on the Health and science speed for the Post. If 0:01:41.236 --> 0:01:46.756 somebody cured something, discovered something, solved something, or screwed something up, 0:01:47.316 --> 0:01:50.196 we were on it. In those days, it seemed like 0:01:50.356 --> 0:01:52.476 everyone read everything we wrote. 0:01:52.996 --> 0:01:55.796 Well they did. I mean there is an exception, which 0:01:55.876 --> 0:01:59.876 is we were in the science pod, and at least 0:01:59.956 --> 0:02:02.716 at the Post that was considered like why would smart 0:02:02.756 --> 0:02:04.996 people write about science when they could write about the 0:02:05.036 --> 0:02:08.556 White House and wear yellow ties. But in general we 0:02:08.636 --> 0:02:11.636 had big readerships, particularly in the when we wrote about 0:02:11.636 --> 0:02:12.876 science policy. 0:02:17.276 --> 0:02:22.996 We sat at the center of a giant ecosystem of lobbyists, lawmakers, aids, bureaucrats, 0:02:23.116 --> 0:02:25.516 policy wonks who tried to get us to see the 0:02:25.516 --> 0:02:28.556 world their way. If you called someone and said you 0:02:28.596 --> 0:02:31.796 were from the Washington Post, they called you back. I 0:02:31.876 --> 0:02:34.156 used to listen to Michael every day on the phone 0:02:34.156 --> 0:02:35.556 with a source on Capitol Hill. 0:02:36.676 --> 0:02:41.836 That individual had access to everything, but he didn't mind 0:02:41.916 --> 0:02:44.596 ratting people out. It was like heaven. I had a 0:02:44.596 --> 0:02:45.596 couple people like that. 0:02:45.676 --> 0:02:50.156 It was Heaven. I remember once where you get the 0:02:50.156 --> 0:02:53.396 plain brown wrappers with stuff inside of it, because nothing, 0:02:53.436 --> 0:02:56.236 of course was digital in those years, you would get 0:02:56.236 --> 0:02:58.676 the mysterious phone call and you had to decide whether 0:02:58.716 --> 0:03:02.236 to return it. So there's one member of this ecosystem 0:03:02.236 --> 0:03:10.076 that I'm most interested in, ready, Sid Wolf. 0:03:11.076 --> 0:03:15.076 Sid Wolf. I love Sid. I loved him then, I 0:03:15.116 --> 0:03:17.316 love him now. But you know, yeah, he is a 0:03:17.356 --> 0:03:18.316 particular kind of guy. 0:03:18.516 --> 0:03:20.836 I think I was the most skeptical of Sid. 0:03:20.956 --> 0:03:22.876 Yeah, because you were like a right wing lunatic. 0:03:22.996 --> 0:03:25.636 I was a right wing wunatic, and it was a 0:03:25.716 --> 0:03:31.916 right wing time Sidney M. Wolf MD versus me thirty 0:03:31.996 --> 0:03:35.356 years ago, when I was a right wing lunatic. I 0:03:35.476 --> 0:03:38.036 was different then, which I offer as at least a 0:03:38.076 --> 0:03:41.876 small explanation from my behavior in the story. I'm about 0:03:41.916 --> 0:03:47.836 to tell you. My name is Malcolm Gladwell. You're listening 0:03:47.836 --> 0:03:52.476 to Revisionist History, my podcast about things Overlooked and Misunderstood. 0:03:53.116 --> 0:03:57.996 This season is devoted entirely to experiments, and this episode 0:03:58.356 --> 0:04:01.036 is about what happens when an experiment teaches us an 0:04:01.036 --> 0:04:11.316 important lesson and we don't listen. Sidwulf came to Washington, 0:04:11.356 --> 0:04:14.356 d C. In the nineteen sixties as a young doctor. 0:04:14.836 --> 0:04:17.116 He went to work as a postgraduate fellow at the 0:04:17.196 --> 0:04:20.356 National Institutes of Health, part of the same class as 0:04:20.356 --> 0:04:24.756 Tony Fauci. One day in nineteen seventy one, someone told 0:04:24.796 --> 0:04:27.716 him that half of the saline solution being supplied to 0:04:27.756 --> 0:04:32.836 American hospitals was contaminated with bacteria. And Sid said, oh, 0:04:33.436 --> 0:04:34.956 where are they going to take it off the market? 0:04:35.316 --> 0:04:38.436 And the person said they aren't because if we do, 0:04:38.756 --> 0:04:41.396 hospitals will run out of ivy fluid and will have 0:04:41.436 --> 0:04:44.916 a disaster on our hands. And Sid said, that can't 0:04:44.956 --> 0:04:47.996 be right. There have to be other sources of ivy fluid. 0:04:48.596 --> 0:04:51.876 He did his research, found out there were other sources, 0:04:52.276 --> 0:04:55.556 and went public, called the press, got his friend, the 0:04:55.596 --> 0:04:58.756 political crusader Ralph Nader, to hold a press conference, and 0:04:58.836 --> 0:05:02.596 the bad ivy fluid was pulled from the market. Sid 0:05:03.036 --> 0:05:06.116 had found his calling as a consumer advocate. 0:05:07.516 --> 0:05:10.276 I am sick and tired of the paper attitude of 0:05:10.276 --> 0:05:13.156 American Medical Association towards American patients patients. 0:05:13.156 --> 0:05:17.996 SID was unstoppable. He started something called the Public Citizens 0:05:17.996 --> 0:05:21.676 Health Research Group and became one of the angriest voices 0:05:21.716 --> 0:05:22.316 in Washington. 0:05:23.596 --> 0:05:26.516 As many of you know, our organization has now for 0:05:26.556 --> 0:05:29.756 twenty five years, been the most outspoken critic of the FDA. 0:05:30.516 --> 0:05:33.796 More than fifty times we've submitted petitions, sometimes resulting in 0:05:33.876 --> 0:05:36.036 lawsuits against the agency to try and get them to 0:05:36.076 --> 0:05:38.196 do what we think the law requires them. 0:05:38.196 --> 0:05:41.996 Example, in the c SPAN archives, there's practically a SID division. 0:05:42.556 --> 0:05:46.116 Sit against the drug companies, sit against the doctors, sit 0:05:46.156 --> 0:05:47.036 against the FDA. 0:05:48.036 --> 0:05:51.876 It is clear that of the seventeen years since we 0:05:51.956 --> 0:05:55.196 have been running the Health Research Group and watching the FDA, 0:05:55.316 --> 0:05:58.276 this is by far the worst period of time ever. 0:05:59.916 --> 0:06:02.676 SID didn't like anyone except those who are willing to 0:06:02.756 --> 0:06:07.436 join him on the lonely ice flow of his sixties radicalism. Okay, 0:06:07.556 --> 0:06:11.396 that's not fair. It's not that SID disliked people. It 0:06:11.476 --> 0:06:15.316 was never personal for him. Sid's battle was with institutions. 0:06:15.956 --> 0:06:20.396 SID believed that bureaucracies and companies and legislatures would behave 0:06:20.476 --> 0:06:25.156 better only when constrained by the right laws, the right regulations, 0:06:25.356 --> 0:06:28.996 and the right kind of relentless nudging from people like Sid. 0:06:29.676 --> 0:06:32.076 He was the nudge of Washington DC. 0:06:33.036 --> 0:06:37.636 Sid's very smart and very colorful and a great quote. 0:06:38.116 --> 0:06:41.036 But there's only one way in that's Sid's way. You 0:06:41.116 --> 0:06:45.076 don't have like a deep, meaningful conversation on both sides 0:06:45.156 --> 0:06:50.156 with SID. But some people, and he was one, were 0:06:50.236 --> 0:06:53.036 just excellent at knowing what we needed and what we 0:06:53.276 --> 0:06:56.516 wanted and how to package it. And that was Sid. 0:07:00.076 --> 0:07:02.956 I hadn't thought of Sidwolf in years, but then I 0:07:02.956 --> 0:07:05.836 started reading about someone named Paul Madden, one of those 0:07:05.876 --> 0:07:08.636 forgotten figures from the mid century. If you lived in 0:07:08.676 --> 0:07:11.996 California in the nineteen forties, you would hear Madden from 0:07:12.036 --> 0:07:13.476 time to time on the radio. 0:07:13.836 --> 0:07:18.196 Good Evening, ladies and gentlemen. There may be hotter jobs 0:07:18.196 --> 0:07:19.916 than breaking up a narcotic brain. 0:07:20.436 --> 0:07:21.036 I don't know. 0:07:21.876 --> 0:07:26.356 I've never seen one. Especially difficult is a job of 0:07:26.476 --> 0:07:30.476 rounding up a band of narcotic pedlars, including the brains 0:07:30.716 --> 0:07:31.276 of the gang. 0:07:32.956 --> 0:07:37.476 Madden was a progressive that progressives believed that government could 0:07:37.476 --> 0:07:42.356 fix things, that systems and regulations and rules properly written 0:07:42.556 --> 0:07:46.636 could make the world a fair place. Progressives were activists 0:07:46.996 --> 0:07:54.836 full of zeal. In nineteen thirty nine, Paul Madden was 0:07:54.836 --> 0:07:58.476 appointed to run the California Bureau of Narcotic Enforcement. He 0:07:58.636 --> 0:08:01.436 was the man responsible for stopping the use of illegal 0:08:01.516 --> 0:08:04.476 drugs in the state of California, a job he tackled 0:08:04.636 --> 0:08:09.676 with enthusiasm and his customary hyperbole. Let me quot directly 0:08:09.796 --> 0:08:12.876 from his writing on the effects of marijuana, Madden wrote 0:08:12.996 --> 0:08:16.836 that the user might quote believe himself so small that 0:08:16.916 --> 0:08:19.636 he is afraid to step off the curbstone into the street, 0:08:20.036 --> 0:08:22.876 or he may feel himself of enormous size and of 0:08:22.956 --> 0:08:26.796 superhuman strength and passion, and in that condition commit crimes 0:08:26.956 --> 0:08:32.356 altogether foreign to his nature. But because Paul Madden was 0:08:32.396 --> 0:08:35.796 a progressive, he didn't just fulminate against a problem. He 0:08:35.836 --> 0:08:38.556 had a whole, carefully thought out scheme for using the 0:08:38.676 --> 0:08:42.516 enlightened power of government to fix it. Consider the great 0:08:42.556 --> 0:08:45.676 fear of anti drug crusaders of that era, which was 0:08:45.676 --> 0:08:48.076 that doctors might be driving drug addiction. 0:08:48.956 --> 0:08:52.676 What if the person gets the script from the doctor 0:08:52.716 --> 0:08:54.796 and goes down and keeps some of the drugs for 0:08:54.876 --> 0:08:57.236 himself and then sell some of the drugs on the street, 0:08:58.316 --> 0:09:01.436 then you're going to have the problem of the initiation 0:09:01.556 --> 0:09:04.156 of new addicts potentially if that happens. 0:09:04.676 --> 0:09:08.116 David Courtwright, who is America's leading historiander the drug trade, 0:09:08.316 --> 0:09:10.676 says that people who were worried that patients could walk 0:09:10.676 --> 0:09:13.756 into the doctor's office asking for an addictive drug like 0:09:13.836 --> 0:09:16.876 morphine and the doctor would just give it to them. 0:09:17.236 --> 0:09:19.956 So stading, we're a small number of doctors who are 0:09:19.996 --> 0:09:25.756 relatively unscrupulous, who are simply writing prescriptions for maintenance, and 0:09:25.956 --> 0:09:28.636 much of that drug may end up being diverted. How 0:09:28.676 --> 0:09:32.156 would I identify the doctor who's doing that. 0:09:32.756 --> 0:09:35.716 So one of the things you might do is send 0:09:35.996 --> 0:09:40.876 an informer to the doctor and he would try to 0:09:40.916 --> 0:09:43.476 persuade Typically it was a he. He would try to 0:09:43.516 --> 0:09:45.516 persuade the doctor to write a prescription. 0:09:46.196 --> 0:09:49.356 In California, Paul Madden looks at that practice of running 0:09:49.396 --> 0:09:53.636 sting operations against shady doctors and says, that's a crude 0:09:53.996 --> 0:09:57.516 and inefficient way of dealing with the problem. Remember, he's 0:09:57.516 --> 0:10:00.716 a good progressive, a man who believes in systems and procedures. 0:10:01.436 --> 0:10:10.476 So Madden decides to create a bureaucratic solution. First, Madden 0:10:10.516 --> 0:10:13.756 makes a list of all the prescription painkillers that he 0:10:13.796 --> 0:10:19.836 considers dangerously addictive morphine, opium coding, chloral hydrate, and then 0:10:19.876 --> 0:10:23.556 he convinces the state legislature to create a new regulation 0:10:23.676 --> 0:10:28.156 for doctors Chapter three, ARTCA one, Section one one one 0:10:28.476 --> 0:10:33.036 six six six of the California Narcotics Act, the Madden 0:10:33.156 --> 0:10:35.396 Amendment of nineteen thirty nine. 0:10:36.596 --> 0:10:40.996 The prescription blanks shall be printed on distinctive paper, serial 0:10:41.076 --> 0:10:44.076 number of the book being shown on each form, and 0:10:44.276 --> 0:10:48.596 also each form being serially numbered. Each prescription blank shall 0:10:48.636 --> 0:10:51.876 be printed in triplicate, with one blank attached to the 0:10:51.916 --> 0:10:55.036 book in such a manner that it will be readily removed, 0:10:55.316 --> 0:10:58.436 while two of the blanks shall be perforated for removal. 0:11:00.916 --> 0:11:04.356 Meaning every time a physician prescribes one of the listed 0:11:04.396 --> 0:11:07.916 pain killers, they have to use a special state issued 0:11:08.156 --> 0:11:12.076 prescription pad where every prescription page comes equipped with two 0:11:12.156 --> 0:11:15.956 additional carbon copies. To use a contemporary turn of phrase, 0:11:16.156 --> 0:11:18.956 he wants to create a back up of every narcotic 0:11:18.996 --> 0:11:23.116 prescription in the state. The first copy was to be 0:11:23.196 --> 0:11:25.876 kept at the office of the prescribing physician for a 0:11:25.876 --> 0:11:29.796 minimum of two years, available for scrutiny at any time 0:11:30.076 --> 0:11:33.476 by one of Madden's team of inspectors. Copy number two 0:11:33.836 --> 0:11:36.476 had to be kept by the pharmacist for two years. 0:11:37.196 --> 0:11:39.916 At number three had to be mailed by the pharmacist 0:11:40.116 --> 0:11:43.076 to the Bureau of Narcotic's head office in San Francisco. 0:11:43.876 --> 0:11:49.236 A record of physician and pharmacist behavior in triplicate a 0:11:49.356 --> 0:11:56.556 textbook example a progressive big brother in action. Now, why 0:11:56.596 --> 0:11:58.876 did I think of Sid Wolf when I heard about 0:11:58.876 --> 0:12:02.716 Paul Madden? Because Madden seemed to me like Sid one 0:12:02.756 --> 0:12:07.356 point zero the nineteen thirties edition. Different context and emphasis, 0:12:07.356 --> 0:12:10.836 of course, but the same place book, the same urgency, 0:12:11.196 --> 0:12:15.316 the same relentlessness. The government needs to fix things. And 0:12:15.396 --> 0:12:17.996 here is my twenty nine point plan to accomplish that, 0:12:18.236 --> 0:12:21.156 which I'm forwarding over to you right now. Call me 0:12:21.196 --> 0:12:23.116 when you get it right away. This is too big 0:12:23.156 --> 0:12:23.436 to way. 0:12:24.636 --> 0:12:27.916 So you know, Sid was his hair was always on 0:12:27.956 --> 0:12:28.916 fire about something. 0:12:29.556 --> 0:12:32.076 My memories of Sid is you would never know when 0:12:32.116 --> 0:12:33.116 you would get off the phone. 0:12:33.796 --> 0:12:36.356 That's true, that's true. I mean I've even talked to 0:12:36.436 --> 0:12:41.076 him recently about some stuff I've done, and he'll not 0:12:41.396 --> 0:12:44.636 just talk to you. Then the information starts flowing. In 0:12:44.676 --> 0:12:47.556 those days, the facts started to churn because that's how 0:12:47.556 --> 0:12:50.276 we got stuff. But Sid was like I would go 0:12:50.316 --> 0:12:52.036 out to lunch and if there was a pile of 0:12:52.076 --> 0:12:54.836 fax paper on my desk, it'd be like Sid struck. 0:12:57.676 --> 0:13:01.196 How many forests were sacrificed to feed Sid's fax machine? 0:13:01.516 --> 0:13:06.676 God only knows. In any case, I moved on. I 0:13:06.756 --> 0:13:10.476 left the Washington Post and forgot all about and his fixations, 0:13:11.156 --> 0:13:14.836 and then I heard about an experiment and it all 0:13:14.876 --> 0:13:15.836 came flooding back. 0:13:31.036 --> 0:13:33.836 Once you've found the right doctor and have told him 0:13:33.956 --> 0:13:37.356 or her about your pain. Don't be afraid to take 0:13:37.396 --> 0:13:40.996 what they give you. Often it will be an opioid medication. 0:13:42.196 --> 0:13:46.076 Beginning in the late nineteen nineties, a catastrophe unfolded in 0:13:46.196 --> 0:13:51.036 cities and towns around the United States. Opioid overdoses people 0:13:51.116 --> 0:13:56.436 suffering a cascade of terrifying effects, pinpoint pupils, labored breathing, 0:13:57.076 --> 0:14:02.596 respiratory arrest, choking, purple lips, loss of consciousness, and, in 0:14:02.636 --> 0:14:06.556 what has now been over eight hundred thousand cases, death. 0:14:07.556 --> 0:14:10.956 There's no question that our best, strongest pain medicines are 0:14:10.956 --> 0:14:15.036 the opioids. They don't wear out, they go on working, 0:14:15.316 --> 0:14:18.516 they do not have serious medical side effects. And so 0:14:18.716 --> 0:14:22.516 these drugs, which I repeat are our best, strongest pain medications, 0:14:22.676 --> 0:14:24.916 should be used much more than they are for patients 0:14:24.916 --> 0:14:25.396 in pain. 0:14:26.196 --> 0:14:28.516 At the heart of the crisis was a class of 0:14:28.596 --> 0:14:31.556 new powerful painkillers that came on the market in the 0:14:31.676 --> 0:14:37.556 nineteen nineties, especially OxyContin, launched in nineteen ninety six by 0:14:37.596 --> 0:14:43.076 the Purdue Pharmaceutical Company. OxyContin is highly addictive, and Purdue 0:14:43.116 --> 0:14:46.316 promoted it to doctors more heavily than any other pain 0:14:46.396 --> 0:14:50.596 color in history. By two thousand and two, Purdue had 0:14:50.756 --> 0:14:54.916 thousands of salespeople around the country pushing OxyContin. This went 0:14:54.996 --> 0:14:58.556 on for more than a decade, until doctors were prescribing 0:14:58.996 --> 0:15:09.116 three billion dollars worth of OxyContin a year. But even after, 0:15:09.196 --> 0:15:12.156 for twenty years of the opioid epidemic, there were all 0:15:12.236 --> 0:15:16.516 kinds of questions like was OxyContin the cause of the 0:15:16.556 --> 0:15:21.156 overdose epidemic or just a symptom of something deeper? And 0:15:21.636 --> 0:15:25.436 even more puzzling, why didn't opioids cause the same level 0:15:25.476 --> 0:15:30.636 of devastation everywhere? Take Massachusetts and New York, two states 0:15:30.756 --> 0:15:34.076 side by side. If you run every significant fact about 0:15:34.156 --> 0:15:37.596 Massachusetts and New York through an algorithm, you'll find there 0:15:37.636 --> 0:15:41.756 are almost no two states more alike, same population profile, 0:15:42.036 --> 0:15:46.076 same basic economy, same levels of poverty, very similar rural 0:15:46.236 --> 0:15:50.196 urban mix. You'd think they would have had similar experiences 0:15:50.276 --> 0:15:55.436 with overdoses. They didn't. Massachusetts has had a bloodbath, New 0:15:55.556 --> 0:15:58.516 York not so much. Same thing with New York and 0:15:58.556 --> 0:16:02.156 New Jersey super similar states by any measure, So why 0:16:02.156 --> 0:16:05.156 did New Jersey suffer so much more than its neighbor 0:16:06.916 --> 0:16:10.196 Perdue would end up in bankruptcy courts result of multiple 0:16:10.276 --> 0:16:14.076 lawsuits launched against them, for misleading marketing practices, and not 0:16:14.196 --> 0:16:19.356 long ago, four economists Abbey Albert, William Evans, Ethan Lieber, 0:16:19.476 --> 0:16:23.516 and David Powell realized that the mountains of internal Purdue 0:16:23.516 --> 0:16:27.156 documents unearthed in those lawsuits might hold some answers. 0:16:27.996 --> 0:16:29.836 I mean, so there were hundreds and hundreds of pages 0:16:29.876 --> 0:16:32.556 of documents, some of which was not very interesting. 0:16:32.876 --> 0:16:35.596 That's Abby Albert, lead author of the paper The for 0:16:35.796 --> 0:16:39.916 them ended up publishing origins of the opioid crisis and 0:16:39.996 --> 0:16:41.356 its enduring impacts. 0:16:41.916 --> 0:16:45.036 But then when we happened upon the focus group research 0:16:45.156 --> 0:16:49.076 especially and the launch plan, that really was the basis 0:16:49.116 --> 0:16:51.156 for a lot of what we talk about in this paper. 0:16:53.196 --> 0:16:57.036 Buried in that mountain of documents was an internal Purdue 0:16:57.076 --> 0:16:59.956 report on a series of focus groups that the company 0:16:59.996 --> 0:17:03.116 held with physicians. This was in the spring of nineteen 0:17:03.156 --> 0:17:07.196 ninety five, right before the launch of OxyContin. The focus 0:17:07.236 --> 0:17:10.516 group report runs to almost sixty pages, and in that 0:17:10.636 --> 0:17:15.116 long buried document, one phrase kept popping up again and again. 0:17:15.796 --> 0:17:19.316 The phrase coined by Paul Madden half a century earlier, 0:17:19.956 --> 0:17:21.796 triplicate prescriptions. 0:17:23.756 --> 0:17:26.356 So I had never heard of a triplicate program, and 0:17:26.436 --> 0:17:29.916 it's not something that was being discussed in the research 0:17:29.996 --> 0:17:30.796 on opioids. 0:17:31.356 --> 0:17:35.116 I mean, why would it be? Nobody really liked triplicates. 0:17:35.636 --> 0:17:39.076 For decades, no one followed California's lead in imposing this 0:17:39.156 --> 0:17:44.716 special requirement for prescribing painkillers. Drugmakers, of course, hated the idea, 0:17:44.876 --> 0:17:48.876 so did doctors and state lawmakers. In the early nineteen eighties, 0:17:48.996 --> 0:17:51.916 the state of Texas did start a Tripica program, and 0:17:51.996 --> 0:17:55.476 the state Narcotics Division in Austin had to hire thirty 0:17:55.516 --> 0:17:58.636 three data entry clerks who in the first year mailed 0:17:58.676 --> 0:18:02.716 out twenty seven eight hundred Tripica prescription pads to doctors 0:18:02.716 --> 0:18:05.596 around the state. The doctors then had to write a 0:18:05.676 --> 0:18:08.996 check for seven dollars for every pad they used, mailed 0:18:09.236 --> 0:18:12.676 check back to Austin. Use the special pad every time 0:18:12.716 --> 0:18:16.476 they prescribe anything off the restricted list, keep the pink 0:18:16.516 --> 0:18:19.076 copy in their office for two years, send the green 0:18:19.116 --> 0:18:21.396 and the blue copy with the patient to the pharmacists, etc. 0:18:21.596 --> 0:18:21.796 Etc. 0:18:22.316 --> 0:18:26.796 I mean, triplicate was the kind of bureaucratic nitpickiness that 0:18:26.876 --> 0:18:30.676 drives people in the medical world crazy. The few states 0:18:30.836 --> 0:18:39.316 that did triotriplicate programs usually drop them. By the early 0:18:39.476 --> 0:18:43.156 nineteen nineties, they were just five states with triplica programs 0:18:43.156 --> 0:18:48.076 in place, California, the Pioneer Texas, which somehow managed to 0:18:48.076 --> 0:18:52.116 stick it out, and then Illinois, Idaho, and New York, 0:18:52.556 --> 0:18:57.636 five states with warehouses full of carbon copies of doctor's prescriptions. 0:18:58.076 --> 0:19:01.396 Every time you pick up that prescription pad, it was like, boy, 0:19:02.436 --> 0:19:05.556 I'm prescribing and someone's watching me. And that's what a 0:19:05.556 --> 0:19:07.116 lot of folks call the chilling effect. 0:19:07.756 --> 0:19:10.116 Linda Westilla, who teach which is at the University of 0:19:10.156 --> 0:19:14.676 Maryland School of Pharmacy, she did her dissertation on triplicate programs. 0:19:14.956 --> 0:19:17.916 The chilling effect she's talking about was the knowledge that 0:19:17.956 --> 0:19:21.876 physicians in those states had that their behavior was being watched, 0:19:22.636 --> 0:19:25.916 that there was a permanent record of every prescription they 0:19:25.956 --> 0:19:30.716 wrote in three places on paper, not in some abstract, 0:19:30.836 --> 0:19:35.556 invisible computer file up in the cloud. Presumably each physician 0:19:35.556 --> 0:19:39.036 has got a filing cabinet in his or her office 0:19:39.556 --> 0:19:43.236 just full of prescription forms which they're holding on to 0:19:43.356 --> 0:19:48.396 for years. So it is a powerful psychological reminder of 0:19:48.636 --> 0:19:53.156 the way you have handled this specific kind of medication exactly, 0:19:53.876 --> 0:19:56.996 And the doctor knows that there's a corresponding filing cabinet 0:19:57.036 --> 0:20:00.316 somewhere in the state Capitol with a team of investigators 0:20:00.356 --> 0:20:03.076 attached who can look at every prescription and see the 0:20:03.116 --> 0:20:05.756 name of the patient, the name of the pharmacist, and 0:20:05.836 --> 0:20:09.036 the name of which doctor has the biggest bulging file, 0:20:09.636 --> 0:20:13.876 a file that says, just by its size, something fishy 0:20:14.036 --> 0:20:18.756 may be going on. This is exactly what Purdue Pharmaceutical 0:20:18.796 --> 0:20:21.476 discovered when it did its focus group with doctors in 0:20:21.556 --> 0:20:24.756 nineteen ninety five, just prior to the launch of OxyContin. 0:20:25.356 --> 0:20:28.836 One of their sessions was in a tripicate state in Houston, Texas, 0:20:29.196 --> 0:20:31.556 and Purdue's takeaway after meeting with a group of Houston 0:20:31.636 --> 0:20:36.676 doctors was clear, quote the triplicate laws seemed to have 0:20:36.956 --> 0:20:41.276 a dramatic effect on the product usage behavior of the physicians. 0:20:42.076 --> 0:20:45.156 It went on. The mere thought of the government questioning 0:20:45.196 --> 0:20:48.956 their judgment created a high level of anxiety in the 0:20:48.996 --> 0:20:54.436 focus group room among the doctors. Prideue looked at that 0:20:54.916 --> 0:20:58.596 high level of anxiety and asked, is it even worth 0:20:58.716 --> 0:21:03.316 marketing OxyContin in tripicate states at all? Years later, Abbey 0:21:03.356 --> 0:21:07.636 Albert's group of economists finds this long forgotten focus group report, 0:21:07.796 --> 0:21:11.196 and they realized that stumbled on a beautiful example of 0:21:11.236 --> 0:21:15.996 a natural experiment. Natural experiments are the economists dream. You 0:21:16.076 --> 0:21:18.676 don't have to create a treatment group and a control 0:21:18.716 --> 0:21:22.436 group then laboriously compare what happens to the two groups. 0:21:22.476 --> 0:21:26.276 Someone else has created the experiment for you. In this case, 0:21:26.756 --> 0:21:35.196 the someone else was Purdue. A third of the American 0:21:35.236 --> 0:21:39.596 population lived in the triplicate states. Those states got passed 0:21:39.596 --> 0:21:42.556 over by the Purdue marketing squads. The rest of the 0:21:42.596 --> 0:21:45.916 American population lived in states without Big Brother looking over 0:21:45.956 --> 0:21:50.316 their doctor's shoulders. They got the full Purdue treatment. If 0:21:50.316 --> 0:21:53.156 you wanted to know how much of the opioid crisis 0:21:53.196 --> 0:21:56.316 was caused by OxyContin, all you had to do was 0:21:56.396 --> 0:21:59.556 compare what happened to the Tripicut states with everywhere else. 0:22:00.676 --> 0:22:03.716 So that's what Albert did, and what she and her 0:22:03.716 --> 0:22:07.556 colleagues found was that the triplicate rule was everything. 0:22:08.676 --> 0:22:12.796 What we found was that, in fact, the non triplicate 0:22:12.876 --> 0:22:16.956 states had much more oxycon use per capita than the 0:22:16.956 --> 0:22:19.116 Triplicut states, almost twice as much. 0:22:19.276 --> 0:22:25.636 In most years, more OxyContin means more OxyContin overdoses, and 0:22:25.716 --> 0:22:28.236 not just that, because many of those who got addicted 0:22:28.276 --> 0:22:31.756 to opioids with OxyContin went on to get addicted to 0:22:31.836 --> 0:22:33.316 heroin and fentanyl. 0:22:34.196 --> 0:22:39.556 We see very quick increase in overdose deaths in the 0:22:39.596 --> 0:22:44.356 non triplicate states and much slower growth in the triplicate states. 0:22:44.516 --> 0:22:47.716 And these trends continue even twenty years after the launch. 0:22:48.596 --> 0:22:52.996 Let's go back to comparing outcomes in New York and Massachusetts. 0:22:53.636 --> 0:22:58.476 New York was triplicate, Massachusetts was not. So how much 0:22:58.476 --> 0:23:01.556 of a difference did death single requirement make the two 0:23:01.596 --> 0:23:05.476 extra carbon copies on the New York prescription pad. Well, 0:23:05.636 --> 0:23:09.596 if New York had Massachusetts opioid overdose rate between the 0:23:09.676 --> 0:23:13.996 years two thousand and twenty nineteen, an additional twenty five 0:23:14.196 --> 0:23:18.876 thousand New Yorkers would have died of overdoses twenty five thousand. 0:23:19.556 --> 0:23:22.356 Not only that, it turns out that economic growth is 0:23:22.436 --> 0:23:26.716 higher in triplicate states than nontripicate states, health outcomes of 0:23:26.796 --> 0:23:30.636 babies are better, and violent crime is lower in triplicate states, 0:23:31.116 --> 0:23:37.436 astonishingly lower as much as twenty five percent. Exactly eighty 0:23:37.516 --> 0:23:40.476 years after Paul Madden wrote his amendment to the California 0:23:40.596 --> 0:23:45.916 Narcotics Act, His bureaucratic nitpicking gets vindicated by social science, 0:23:46.676 --> 0:24:03.756 and who else gets vindicated? Sidney M. Wolf, MD. In 0:24:03.836 --> 0:24:06.916 the early nineteen nineties, someone in the White House wondered 0:24:07.236 --> 0:24:10.916 what was known about the value of triplicate programs. The 0:24:11.036 --> 0:24:14.356 requests got kicked over to the National Institute of Drug 0:24:14.396 --> 0:24:18.276 Abuse NIDA, and NIDA rounded up everyone who might know 0:24:18.356 --> 0:24:22.196 something about triplicates and invited them to a conference at 0:24:22.196 --> 0:24:26.036 a hotel near its headquarters in Rockville, Maryland. So you 0:24:26.076 --> 0:24:30.076 attended the symposium, yes, Linda Westilla, who had done her 0:24:30.116 --> 0:24:32.956 dissertation on triplicates, was one of the attendees. 0:24:33.676 --> 0:24:36.316 I do remember the venue, and I do remember this 0:24:36.356 --> 0:24:38.596 is really ridiculous. We couldn't have coffee. 0:24:38.956 --> 0:24:41.996 NIDA was very hardcore about these kinds of things. 0:24:42.316 --> 0:24:47.236 They wouldn't sponsor anything that had an addiction potential, including caffeine. 0:24:47.276 --> 0:24:51.516 So at any rate, what I remember about that was 0:24:51.556 --> 0:24:55.276 sort of the excitement of this is the first big 0:24:55.436 --> 0:24:59.476 thing we've had about trying to control opioid use in 0:24:59.516 --> 0:25:00.356 the United States. 0:25:01.316 --> 0:25:04.996 This is nineteen ninety one. OxyContin will be introduced in 0:25:05.116 --> 0:25:09.396 nineteen ninety six, five years later, but opioid overdoses were 0:25:09.436 --> 0:25:12.196 still high enough in those years that people were starting 0:25:12.236 --> 0:25:13.876 to get worried about the problem. 0:25:13.996 --> 0:25:16.916 I was a pharmacist with a PhD. There weren't many 0:25:16.916 --> 0:25:20.316 pharmacists with PhDs. So it was like, Wow, this is it, 0:25:20.356 --> 0:25:22.436 and I believed in a lot of these policies. 0:25:23.076 --> 0:25:26.716 The pain specialist Russell Portnoy was at the Nightis symposium. 0:25:27.116 --> 0:25:29.316 He would later do as much as anyone to promote 0:25:29.316 --> 0:25:32.716 the aggressive use of OxyContin. He talked about the problem 0:25:33.036 --> 0:25:38.356 of under prescribing opioids. Someone from the American Pharmaceutical Association 0:25:38.516 --> 0:25:41.916 was there to say how strongly the industry's biggest trade 0:25:41.916 --> 0:25:46.516 group was opposed to any kind of federally mandated triplicut requirement. 0:25:46.996 --> 0:25:49.876 After all, this was nineteen ninety one. Why will we 0:25:49.956 --> 0:25:54.076 promoting some half baked idea from nineteen thirty nine. But 0:25:54.236 --> 0:25:57.836 here and there there were other voices. An African American 0:25:57.876 --> 0:26:00.916 doctor who worked in a tough neighborhood in Brooklyn, Gerald 0:26:00.996 --> 0:26:05.356 d'es said this, I wish that anyone who opposes triplicate 0:26:05.436 --> 0:26:09.036 prescription programs could walk with me into the real world 0:26:09.396 --> 0:26:17.436