The David & Lyn Silfen Forum 2019: “Is There an Antidote for the Opioid Epidemic?”

The David & Lyn Silfen Forum 2019: “Is There an Antidote for the Opioid Epidemic?”


– More than 130 people
in the United States will die of an opioid
overdose today. Americans now face
greater lifetime odds of dying of an opioid overdose
than from a car crash. The global scourge cuts
across all communities and effects every
corner of society. No family is immune. No single culprit is to blame. We know of no clear
and simple fix. We do however, have
good reason to hope as well as we have great
leaders in myriad fields and multiple sectors working to better understand
and meet this crisis. This crisis must be met. Today’s program is very
special because our panelists bring an important mix
of insight and expertise to this incredibly
complex epidemic. So please join me in welcoming
onstage, Bertha Madras, Jeb Bush, Jim Kenney, Jeanmarie
Perrone and Joe Biden. (applause) So there’s no better place
than Penn for this forum because we have long played a
role in this essential effort. One of our panelists
recalls that back in 2005, the United States faced
a fentanyl outbreak. Philadelphia was one of
the major cities effected. When the time urgently came
to convene the very first national forum on fentanyl, Bertha’s first phone
call was to Penn. And as a result, in 2006 a
multi disciplinary gathering of clinicians and
researchers, students, lawyers and law enforcement
officials all met here to share knowledge and plan action. That Penn gathering
was a landmark meeting and it brought national
attention to the rising threat of fentanyl in
communities nationwide. So now, in 2019,
Penn gathers anew to confront the opioid epidemic. We’re so grateful to the
special friends of Penn who made this program possible. We honor the memory of
Penn’s former trustee leader, David Silfen. Together with his wife,
Lyn they generously endowed the David and Lyn
Silfen University Forum. Let us all thank them with
a big round of applause. (applause) We’re also grateful
to the five remarkable expert panelists
with us here today. Let’s meet them now. Joe Biden served as
the 47th Vice President to the United States after 36 years as a U.S.
Senator from Delaware. One of the outstanding
statesmen of our time, he is the recipient of our
nation’s highest civilian honor, the Presidential Medal of
Freedom with Distinction. Vice President Biden
is also Penn’s own, Benjamin Franklin Presidential
Practice Professor. He leads the Penn Biden
Center for Diplomacy and Global Engagement
in our nation’s capital. Vice President Biden
and his family, as I think you all know
have long and close affiliations with Penn. Thank you for being
with us Vice President. (applause) Former Florida
Governor, Jeb Bush served two terms
leading our nation’s third most populous state. Governor Bush has been
celebrated for his success in reforming education
and helping to close the achievement gap
between rich and poor. He became a leading voice
in the national discussion about immigration reform
and political consensus. Governor Bush also has a
very special connection, right here to us in
Philadelphia as formerly serving as Chairman of the
National Constitution Center. And of course, he has
a special connection to the Penn community
as our second esteemed Presidential Practice Professor. Thank you so much for being
with us, Governor Bush. (applause) The honorable Jim Kenney is
the 99th Mayor of Philadelphia, a native son of our city and
a lifelong public servant devoted to the welfare
of Philadelphia’s people. Mayor Kenney’s
administration is committed to expanding access
to education, investing in the city’s
commercial growth and pursuing greater health,
happiness and prosperity for all Philadelphians. Foremost among these
priorities to the cities is the cities response
to the opioid epidemic including the Philadelphia
resilience project which is mobilized, community
organizations, residents and thirty-five city departments
to combat the crisis. At Penn, we are enormously
proud that Mayor Kenney was for years, a lecturer at our Fels Institute for Government. Mayor Kenney, we love
your relationship to Penn and we’re proud of your
leadership of our city. Welcome. (applause) The honorable Bertha Madras
is Professor of Psychobiology at Harvard Medical School. She served as Deputy
Director for Demand Reduction in the White House Office of
National Drug Control Policy. A presidential appointment
confirmed by the U.S. Senate with unanimous consent. A prolific researcher
and author, Bertha focuses on
neurobiology, brain imaging and medications development. In 2017, she was appointed
to the President’s commission on combating drug addiction
and the opioid crisis. And was asked by the chair
to shepherd and write the final commission report. She currently is a member of the National Academy of
Medicine Collaborative on the opioid crisis. Thank you so much
for being with us. (applause) Doctor Jeanmarie
Perrone is a professor in Penn Medicine’s department
of Emergency Medicine and she directs the addiction
medicine initiatives. She has led many investigations
into opioid stewardship and has advocated the
state and national level for emergency treatment
for opioid use disorder. She has served Philadelphia’s
Mayor’s task force. She served on the Pennsylvania
state opioid task force. The national quality forum
and advisory committees with the CDC and FDA to address
opioid over prescribing. She is triple certified in the
fields of emergency medicine, medical toxicology and
addiction medicine. And she was inducted into the Penn Academy of Master
Clinicians in 2015. Thank you so much for
being here, Jeanmarie. (applause) So as you can see, we have an
exceptional group of panelists to share their insights with us. So let’s get started. Mr. Vice President.
(laughs) – Start with the least informed. – No, you wrote and I
think I quote you that “America’s opioid crisis
is tearing the heart out of this country”. In your opinion, how did
we get to this place? What’s happened? – We have some real
experts on this panel but I have a, look. More people die in a yearly
basis in this opioid crisis than died in the
entire war in Vietnam. To put it in perspective,
this is not a minor thing. And I think, we can’t
look at this crisis, but I’d yield to the
two docs on the panel. Without looking at
the abandon with which the drug companies
advertise pain killers without requisite, in my view, the requisite warnings
of what it’s about. You know, and quite
frankly, docs who I believe willy-nilly overly prescribe. I wrote this statistic down. 282 million prescriptions were written at
the peak in 2012. 215 million prescriptions
for pain killers in 2016. That’s enough prescriptions
written to keep the entire American
population medicated around the clock
for three weeks. Now look, we desperately
need people with chronic pain to have this access but
you cannot convince me, anywhere near that is the case. And the millions and
millions of dollars, hundreds of millions of
dollars, these drug companies spend on advertising.
– Absolutely. – Is just, and deductible
as a business expense. I’d take away the
deduction if I could. The fact is, as the
docs can tell you, and the mayor and the governor, that a lot of people can get
addicted within five days of the use of Percocet and
these painkillers, five days. And I think, doc it may not
be the case but I remember reading something where
you said that close to 80% of the people who have a
wisdom tooth out are given seven to ten days
worth of pain killers. – So, that’s, go ahead– – So, I think you have
to look at two things. One, we got here, I believe
in part because of the greed of the drug companies and
their responsibility of them. And, quite frankly, the lack
of sufficient responsibility in the part of the
medical profession. I think there’s a lot of things, I think that we can
do to change it. I’m not gonna talk anymore
but there’s a lot of things we can do to impact on that
without in any way violating any of the elements of
the medical profession and without punishing drug
companies unnecessarily. But you can’t convince me, look there’s one town
in West Virginia, I wrote this down too. One town in West Virginia,
between 2006 and 2016, drug companies shipped
21 million prescriptions of painkillers to two pharmacies
in a town of 2,900 people. That’s criminal on my view. I can say more but I won’t. There’s a lot of people to talk. – Yeah, I will welcome
anyone to jump in. I’m gonna ask questions to
each of you but feel free. But I’m gonna pass the
baton to Dr. Perrone because you’re on the front
lines of this epidemic. I’d like you to tell us, and
I’d really be interested, this effects all of us and
make no mistake about it there’s nobody here who
doesn’t know somebody who’s been effected
by this crisis. I’d like to know
from your perspective because you’re on
the front lines. What does this look like
from the perspective of and emergency room
clinician who specializes in understanding and
treating this problem. – Yeah, so I feel like
I’m the only physician, I think on the panel. So, I wanna half defend and
half support what you’re saying. Because I think, absolutely
the drug companies perpetuated this concept
that opioids were safe when they absolutely were not. The FDA propagated
that even further and supported prescribing. The joint commission, all
these federal regulatory bodies fell into the very convincing
campaign that the drug companies came across with
saying that these drugs were safe and that we really had a
responsibility as physicians to not let anyone suffer at all. And that we must make pain, that pain is perceived as
a score of ten out of ten, we need to get it down to zero. And so that created this cycle. When I trained,
in the early 90’s, we didn’t prescribe like that. And I watched it happen
between 95 and 2005 where we were just
pushed to prescribe. And it happened
across the board. – [Amy] So you actually
saw that happen? – I saw the whole thing evolve. And it really wasn’t until
mid 2000’s when we said, and in the emergency department
because what we would see is people would come in,
they had become addicted because of the therapy
that was being prescribed in an effort to treat pain. But, someone said the same
thing that opioid dependence and tolerance
happens very quickly. You need escalating
doses immediately. If you think about the story
of the amazing singer, Prince. So Prince was prescribed
opioids for a condition, acutely which was just a
muscular skeletal injury. But he rapidly became
dependent and tolerant. Over time he developed
abhorrent behavior, his family maybe said,
you’re using too much, we don’t want you to do
that so then he had to get secretive about it. Which is the beginning
of addictive behavior. But because he had
money and resources, people were still
prescribing to him. So he wasn’t on the
street necessarily. A week before he died, he
had a sentinel overdose, which people may know about. That was a time we could
have intervened and saved him but his family
was facing stigma. They tried to do it
in a secretive way. All these things happen to
people in the United States every single day. And then lastly, he died
of a fentanyl overdose. Which is exactly what’s
happening in Philadelphia so that is the paradigm
from beginning to end. What we’re seeing in the
emergency department now is picking up the pieces of
the 220 million prescriptions that five or 10% of
people get addicted to. We see overdoses, we see
people who don’t get revived from overdoses and we see
people who are seeking treatment and that’s a lot of what
we’re working on now. – So Mayor Kenney, your
administration has declared and I’ll quote on
this, “Philadelphia’s
facing the greatest public health crisis
in a century”. And you’ve aggressively
sought to stem the deaths. With some notable success. So how has the Philadelphia
resilience project worked? What lessons can
we learn from it? – I think the biggest
lessons that we’ve learned is not to criminalize addiction. Which is what happened in
the 80’s and 90’s with crack. We tried to approach
this multi agency wise. Police of course are
on the front lines. Health department,
behavioral health department. Streets, actually things like
sanitation and other issues that you wouldn’t
think directly related to opioid addiction or heroine. Mostly heroine now, when
they get to the street it’s mostly heroine. And we had people living
on train tracks for almost 15 – 20 years. Conrail tracks and they
were down in the gulfs so you couldn’t really see it. Neighbors and elected
officials wanted that cleaned up and
moved and secured. Which we did. It took a lot of time and
a lot of money to do it. And finally we
cleaned up the tracks, put up the security wall. Why’d I say wall, sorry. (laughing)
– Security fence, slats. (laughing and clapping) It’s not funny cause we’re
dealing with a serious issue. In then what happened was
the people who were moved, and then they went and camped
under four train trusses near the tracks. We just can’t and we’re
not going to do this, we just can’t drag people away. It’s not legal, it’s
not constitutional. People, well minded people,
well intentioned people started bringing tents
and heaters and fans and all kinds of things which kind of entrenched
them even more. We’ve cleaned up two worries,
two were easily dealt with. Two more were more intractable. The fourth one we
finally did get rid of. But in order for us to do
that, to clean up the area. We need to offer
people treatment beds. I think the last time I
looked we had a 160 people either in housing
or in treatment. We had place assisted diversion,
instead of taking people to a station house
they passed them off to one of the addiction
services or to a hospital or to some place
that can take them. We don’t want to lock people up, it makes things that much worse. We’re doing our best. Our overdose numbers are
slightly ticking down, we spend more money on
naloxone that I ever– I didn’t know what naloxone was. Thankfully it’s there. Librarians have it, recreation
department workers have it. Police all have it,
firefighters, paramedics, everybody has an access to it. – So how many of you all
are carrying naloxone? Narcan and naloxone is
more likely to save lives than any of you who
are trained in CPR. So the police carry it now,
the ambulances carry it and all of you can
carry it as well. So this is a real opportunity
in our city to save lives. – [Jeb] How do
you administer it? – Yeah, so this is
just a little device, this is a Narcan nasal
spray and if somebody is unresponsive it just
goes right up their nose. There’s no needles,
there’s no injections. It’s very safe. You just press it
and it atomizes an antidote that can save lives. – And just, criminalizing
it is making people go to jail because of
this, just fills our jail. Our jails now are
filled with people with mental health
issues and drug issues and they’re not equipped
to deal with that. There’s no easy answer to
this but that isn’t working. – [Joe] Madam President,
there is some answer. – Go ahead, go ahead. – I know I get beat
up on the crime bill but what the crime bill
did was put in drug courts. They put in drug
courts that a lot of police departments won’t use. A lot of states don’t use. They’d rather lock people up than divert them
into a drug court. To move them from, instead
of going to a prison, going to a treatment facility. And I think we have to do
a whole lot more of that diversion in order
to have some impact on what we’re gonna
be able to do. – Good, really– – [Jim] The other
controversial issue that we’re dealing with– – I love that fact
we’re getting quickly, just here to some things
that actually can be done. – We’re dealing with a
very difficult issue, very controversial issue
with the over dose, we call them over
dose prevention sites, as opposed to what
you called them. – Yeah. – There’s 120 of them
across Europe and Canada. It’s very, very difficult
to explain to neighbors that this is a good thing
because we are saving lives. We won’t operate it if it opens, it would operated by
a separate nonprofit but we’ll have our social
service people and other folks there to be able to hand
off those folks to us. – Terrific. So, Governor Bush, I
have to applaud you. You were one of the first
leaders in our nation, as Governor of Florida
to call attention to and actually start
dealing with the crisis. You declared the opioid epidemic a national emergency
very early on. And as Florida’s Governor
you had to address addiction issues across our third
most populous state. I would like to know from
you, what the challenges are in addressing this epidemic
in diverse communities? Ranging from Miami to Pensacola,
you have an incredibly diverse state and
you addressed it. So what can you tell us
about what’s effective? – Well first I don’t want
to contradict the president of the University
of Pennsylvania, since I’m a
professor of practice and she could probably fire me. (audience laughter) In your introductory marks, you said that we consume a
third of the painkillers. We consume 85% of the
painkillers in the world. – [Amy] Oh, that is news
to me, that’s amazing. – So, it brings to bear– – [Amy] If that wasn’t
shocking enough, that’s why we have
professors, right? – It’s breathtaking. The kind of cultural, at some point our culture
needs to recognize that’s way over the top crazy. That, zero pain is, look
as human beings we’re going to have joy and we’re
going to have pain. You can’t level it
out to have something that is incredibly boring. I mean, life’s full
of ups and downs and that pursuit creates
a purposeful life in so many ways. I’ll leave that aside
’cause there’s no solutions there other than recognizing
that that’s a challenge. In Florida, I had a personal
experience with my daughter that had significant issues
related to mental health challenges as well
as addiction issues. One thing I’d say is that they
normally go, hand and glove. They normally go together. The mental health
challenges are hard to see, you have a problem with, your ribs bruised you can take
a pill to alleviate the pain. When you’re seeking drugs
because you have schizophrenia or some other disorder, it’s
a lot harder for doctors to diagnose and people
spiral out of control. I think one of the things
we need to do as a society, talk about moon launches,
Mr. Vice President, a launch of the brain
might be one of the things that we should do to
really study the brain to try to understand it
better so that people don’t spiral out of control
and become drug seeking. Really because of seeing this
challenge all across our state and then being motivated by
my high publicized daughter’s challenges which were really,
really hard for my wife and I. We committed ourselves
to create a strategy to deal with this and I
guess the advice I would have for people that are
focused on this, similar to what the mayor said is that it’s gotta
be comprehensive. It can’t be one thing. Prevention is a key
element of this. It’s not cool to take
drugs in general, there ought to be a higher
understanding of that and the path that that leads. You need to fund treatment and
it needs to be research based ’cause there’s a lot of
treatment that doesn’t work. I’m a big fan of focusing on,
we didn’t do this in Florida but other states now are doing
this, I think in Pennsylvania they’re doing it,
certainly in Massachusetts of recovery professionals that
need to be certified as such. Because this is a
long-term issue. You can deal with this in a
thirty day treatment facility but this is a lifetime
challenge for people that are addicted to drugs and alcohol. There are real professionals
but we haven’t created the certification
process to recognize them and federal funding doesn’t flow necessarily because of that. I think you need to get law
enforcement more engaged in a comprehensive way. We’re a bottom up country. We have more police officers
in Philadelphia than the DEA has probably, agents. But there’s very
little coordination. So, I’m a big fan and we used
them in Florida, the HITDA, the high impact whatever
the rest of the acronym is. – [Bertha] High Intensity Drug
Trafficking Administration – Thank you
(laughing) Washington comes up with
these acronyms that are like, they don’t want you
to know what it is so they create an acronym. This one’s one that it works. – Is that the reason?
– That’s my theory I don’t know I could be wrong. – That’s as good
an argument as any. – That’s very effective. In New England, you
have five little states and if you can’t coordinate
in terms of law enforcement to keep the heroine
out of the communities and keep fentanyl out
of the communities, you have to have the
federal government be actively involved. The final thing I’d say as
it relates to drug treatment, Washington provides a
significant amount of money but they have so many
strings attached. There’s 56 different
drug treatment programs that Washington funds. I would think maybe
one flow of money and allow the states and
local, in large urban areas to create the strategies because
we’re on the front lines. Particularly mayors. They’re on the front
lines, they’re the ones dealing with this.
– I think you have one person here who would certainly
agree with you. – And then measure it.
– But we’re all nodding yes. – Measure it, measure it
so that you can see if it’s successful or not. And if it’s not, stop funding
it for crying out loud. And reward success
when it’s working. The final thing I’d say
to validate what the Vice President said. Florida was the first
state to create, first drug court in
the United States was Dayton County where I live. Janet Reno, state
attorney did that and under my watch we
created drug courts throughout the state. We were the first state, at
least of scale to do that. It is phenomenally successful. – Exactly
– Phenomenally successful – I think everybody here
needs to, yes let’s… (applause) I think it’s incredibly
important that all of us here take note of these things
because as concerned citizens we can actually use our
voice and put pressure on public officials and drug
companies to fund what works and don’t fund what doesn’t. So you said something very
important that actually Professor Madras
has worked on a lot, which is the connection
between mental illness and treating mental illness
and drug prevention. How you actually reduce
demand, it’s one thing to treat and it’s quite another thing
to look at what causes this and try to find how
you reduce demand. Dr. Madras, you have really– Professor Madras you have
really devoted a large portion of your career to
demand reduction. Can you tell us something
about what you think works and what’s happening or not
happening in this regard? – Let’s just dissect the
word demand reduction into three components. It means prevention,
intervention and treatment. Prevention is a
multi faceted organ which includes supply reduction, which means fewer prescriptions, fewer first
exposures to opioids. It also includes
understanding who is at risk for substance use. We know without a shadow
of a doubt, the children who come from abusive homes, 50% are likely to
become addicted to drugs and the severity of their
addiction is higher than others. So we have to understand
that a lot of this begins at home and families. There’s also a
contagious factor. Parents who use drugs, their children are much
more likely to use them. So that’s part of prevention. Prevention is understanding
what the risk factors are. Prevention is including
supply reduction. The second phase of
this is intervention. Intervention means trying
to understand who’s using, who’s at risk and how to
intervene before they progress to addiction. And the first thing I
did when I was at ONDCP was take a flight to
Chicago to the headquarters of the American
Medical Association. And I spoke to the executive
director and I said, “I want to medicalize
addiction in our country.” Bring it back into the
high quality standards of medicine which we certainly
did not have at that time. And he responded by saying, “We take care of alcohol
and smoking and medicine. We can’t take care of
all human problems”. And I said to him, “You are prescribing
prescription opioids and we are beginning to
develop a vast problem with addiction and
overdose deaths to the prescriptions that you as
a medical community are”. – [Amy] When was that? – That was in 2006. – So that was already when
the medical profession was part of the problem. – They were part of the
problem and his response was, at that instant, slamming his
hand on the desk and saying, “You’ve got me. I understand.” and as a result of
that encounter, I said, “We need billing codes for
physicians in order for them to screen for people who are
on the path to addiction”. May not be there yet but
they’re engaged in risky, problematic and to
screen for people who are misusing opioids. And at that point, I got an
invitation to their CPT board in order to get billing codes. The final component of demand
reduction is treatment. And the problem is, we have
14,000 treatment centers in the United States of which, less than a third, less than a
third have quality treatment. And we have to do a
lot better than that. And we have to bring
those into the domain of the medical community where
the standards for outcomes, for continuing month care, for
quality care are much higher. – [Joe] Can I make a comment? – [Amy] Please. – The governors dad was
president when I wrote the office, that combined all
the agencies to work together on drugs. And this is a question
I have for everybody. What I found was I got
stuck with, because I was chairman of the judiciary
committee, writing most of the drug legislation that
occurred in that period. Big mistake was us buying into
the idea that crack cocaine was different that powdered
cocaine and having penalties, that should be eliminated. But, one of the things
I found most difficult is in private, when you
talk to your colleagues and I talked to my colleagues, whether they’re in state
legislature or governors or senators or congress persons. They really do not buy into
this, they say they do, that addiction is a disease. They think it’s will power. And one of the reasons why
people are not willing to spend the money that could be,
in fact incredibly useful in reducing demand,
incredibly useful. Is because well,
you should just have the willpower to do that. And one of the things
you’ve done, Doc. And you’ve done, is begin
to convince the American public that this is a disease. It’s a disease of the brain. And the thing that the
governor talked about in terms of the brain, one of the things we did
in our administration was we set up an entire
initiative at NIH, called the Brain Initiative,
to study the brain. Spending a billion dollars
just to study the brain. We know less about how
the brain functions than what’s at the
bottom of the ocean. So, could you speak to
that just a second about the idea of addiction
vs will power? – Absolutely, it’s an
excellent question. Addiction is a bio
behavioral disease. Which means that the brain
undergoes vast changes after the influence of
drugs because the drugs produce signals in the
brain that are so abnormal that the brain adapts and
once you remove the drug from the brain, the adaptation takes over
and you no longer feel normal unless the drug is
reintroduced into the brain. So that is a very simple
way of looking at it. The operational
definition of addiction is compulsive,
uncontrollable use despite adverse consequences. But that’s a
behavioral definition. It’s not a biological. The problem is for many people, is that people age
out of addiction. They may have an
alcohol problem, they may have a cocaine problem but if you look at the data, you see this upsurge of
addiction that occurs and then it just declines
as a function of age. So people say, if
people age out, if they quit smoking cigarettes and they don’t need
even to go to rehab then why are we
calling this a disease? The problem is, that that
may be true for some people but certainly not for others. – [Amy] Some people
age out by dying. – Some people age out by dying
but there are many people who have such severe,
profound brain changes that unless you help them,
in the case of opioids the help is with
certain medications, you cannot really climb out
of that uncontrollable urge. Now for many addictions,
and we should not only be speaking of opioids, we have many drug
challenges in our country. 50,000 died last year of
opioids but 20,000 died of cocaine and methamphetamine. What we have is no
medication for many of them and it is clear that behavior, behavioral control,
volitional control is part. It is absolutely
part of treatment. – So, Dr. Perrone, we know
there’s a lot of stigma surrounding opioid use
disorder and even greater levels of misinformation
out there about treatments that are evidence based
and those that are not. What are some top facts that
you would want everybody to know that would really
be useful for us to know and take, not only
to mind but to heart. When in our roles as concerned
citizens and professionals. – Yes, thank you, it’s
such a great opportunity. There is treatment. There are medications
that help substantially. These are not medications
that are, there are some medications stigmatized. There is the drug methadone,
which is a full opioid agonist so it acts like heroine. Some people say it’s like
one addiction for another but that’s completely
untrue because it stabilizes the brain, like Dr. Madras said. There is a need to replace that
drug that’s been taken away but it prevents the
addictive behavior, prevents that behavioral impulse
to go out and seek the drug and so they can
stabilize, they can work, they can go back
to their families, they can take care
of their kids. So methadone is an amazing
drug that has been around since the late 1960’s but
it can only be available by going to a treatment
program every single day. It’s highly regulated. The government was
very concerned when
that became approved. In 2002, another drug got
approved which was called buprenorphine, I’m
gonna call it suboxone, which is a trade name. But, suboxone is another
very viable treatment for opioid use disorder. The problem with suboxone, well first I’ll tell
you the benefits. It works like methadone
except it’s safer. Its’ not a full agonist,
it’s a partial agonist but it has a ceiling effect so it prevents people
from over dosing. But it also prevents them from
using heroine or fentanyl. So it’s tremendously
helpful and what we’re doing in our emergency department
is we want people to get into treatment. People can’t make appointments
when they’re going through the cycle of withdrawal
and craving and using. So they can’t get into
treatment so we need low barrier treatment
and what we have done is we’ve started from
our emergency department, getting people into treatment
by giving them buprenorphine when they come to the
emergency department and they’re in cycle of
crisis or seeking treatment. We can start them with their
very first dose on that visit and that makes a
huge difference. But, in concert with
that, they need support and the advocates that we
have, Nicole and Bryant, two people that I’ve been
working so closely with in the past couple of
years, are amazing. They’re certified
recovery specialists, they take that patients
hand and they guide them to their first appointment,
to their treatment. Nicole just drove
a patient to an in-patient treatment center
last Saturday morning. – [Amy] Nicole,
will you stand up? (applause)
Yes, yes. – So, as Governor Bush said, certified recovery specialists
in concert with medications, there is treatment. So the stigma of AIDs, ten
years ago, 15 years ago was that there’s no
treatment so people were keeping their families
members at home. There is treatment. We can help, but we need
resources and opportunities to get to these patients. – Part of the difficulty from
local government standpoint is the citing of the
locations of these facilities. No one wants them in
their neighborhood. The people who are
living in neighborhoods that are suffering from,
non addictive people who are suffering
from the scourge don’t want the treatment
facilities anywhere near them but that’s where the people who need the addiction
services are. – So one acronym, I bet a lot
of people have heard of is, NIMBY, right? How many have heard of NIMBY? Not In My Back Yard, right? – But legitimately,
they’re scared. They’re in the epicenter,
they’re in the center of the core of the problem.
– Absolutely. – And their kids are in
the center of the core of the problem. We put up needle disposal boxes
near elevated train lines, exits and entrances so we could
reduce the number of needles in the street. When we do cleanups. We’ve done four major
cleanups in Kensington and Fair Hill in the last year. The number of discarded
needles is just amazing. People when they’re walking
their kids to school are scared. What we’ve tried to do is
we try to find facilities that are somewhat
in close campuses, whether they’re like
a community hospital, things of that nature. But again, with the
overdose prevention site, that is extremely controversial and extremely
frightening to people. And the other issue is that
people who were meeting just the other
night were saying, what if we put those in our
neighborhood or allow it, are we giving up. Are we just throwing our
hands up and letting people inject legal substances
without any consequences. We have to explain to them
that when the person comes to a facility like this, in
addition to being able to inject relatively safely
and not overdose. There is showers,
there’s lounge space, there’s space to interact
with social workers and addiction specialists. There’s the opportunity to
get your arms around them and to try to get them
into another place. You can’t do that when a
person’s under a train tressel, in the dark, by themselves. We just have to pick up the
body at the end of the night. – So another fact that people
have to take to mind and heart is that there isn’t one
single, simple bullet solution that’s part of a larger
program that’s needed here. – First of all–
– Governor. – I would add a little
context to this. A lot of the people that are
suffering with this addiction aren’t living on the streets. I mean, a ton of them.
– Right, right. – My ill fated run for
president, which I recommend people do that if they’re
thinking about it. (laughter) – Are you thinking
about it, mayor? I was talking about the
mayor but that’s okay. – Right, just a little
random advice, well done. – I’m looking for a beach. – My first trip to Manchester
– Speaking of addiction (laughter) First trip to Manchester,
I met the receptionist at the Hilton Garden Inn. Her daughter died
of an overdose, the waitress at this
tiny little restaurant that I was with the
mayor of Manchester. He told me that she had a
son that died of an overdose and the guy that traveled
with me throughout my time in New Hampshire, his
brother died of an overdose. Literally within two hours, I
met three people whose lives, whose families were
gonna be altered for the rest of their life and
they had three deaths. There’s a 20% increase
in foster care in places, in West
Virginia and other places where the most severe outbreak
of this epidemic exists. And so my point is, this
is a national challenge. If we marginalize it
to the most vulnerable, the people that we see
sadly on the streets, which is something that I
applaud local governments doing what they have to do. I think they miss the
point that this effects a broad number of people. And I would add another
thing, this may be a little off field but there’s a
problem with alcohol abuse and the public health challenges
that deal with alcohol is even probably, from
a health perspective, the universe of people
that deal with that issue and the families that deal
with that are extensive. So if we’re focused on the
public health challenges of addiction, I think we
need to look at it in the broadest possible way. – Every socioeconomic
background, every race, every creed in this country
is effected by this. Mr. Vice President. – I wanna ask my
elected colleagues this. Do you guys find that–
– There’s only one of us. (laughter) – See, I don’t need
to ask questions. – Those of us who’ve
run for office. – Oh, okay that’s different. – You were a hell of a governor. One of the things I find, and I suspect you’re
still hearing. So many people come up
to us and ask for help from literally the
husbands and wives of millionaires to
people on the street. And the thing that I
most often get asked is, is there any treatment? How many of you know
someone and raise your hand, who sought treatment,
went to a facility where the recovery rate was one,
two, three, four, five percent. That virtually did nothing
for them, raise your hand. How many of you know people? And I don’t mean you,
I mean people you know. And so one of the things
you talked with me about backstage, doctor is, is
there a way to get to a certification level
where people can identify treatment facilities that
really have some muscle to them. Have people who know
what they’re doing. – Know where to go that works. – So, at Penn, at the hospital. We have to report our
successes in cardiac surgery. There would be no reason
why we wouldn’t mandate that a rehab place
would look at the outcomes of their rehab. It is a difficult disease
to treat but if you have failure rates that are
in the range of 80-90%, part of that is the
disease of addiction and that’s what
they’re hiding behind. But part of it is not having
to follow those outcomes so absolutely, we
definitely need regulations and outcomes and
more visibility. Because what happens is,
everybody with private insurance and extra money pays
thousands of dollars. Hundreds of thousands of
dollars to get their kid into one of these
treatment facilities. And on day 31 or at
the end of six months, you know they’re still
walking out, looking to use. They just don’t get better
unless they’re getting evidence based treatment
which is these medications or a combination of treatments. So, I wanna ask a question
that we haven’t touched on here but it’s in the news
a lot and it’s another one of those really complex
issues that I wonder if, particularly our public
officials, your views on this. A substantial factor in
this epidemic is said to be all the illegal drugs coming
into our country from abroad. They include powerful,
synthetic narcotics that make their way
into less powerful drugs which are leading, we’re told,
to a spike in overdosing. How are we doing in
detecting and intercepting illegal drugs and are we
doing as well as we can do? Or anybody who knows about this. – It’s really hard, we’re not
doing as well as we can do and it’s clear ’cause we have
the problems so pervasive. But our police department
works very closely with our federal partners. The Department of Justice, the
FBI, ATF and all the agencies and they do a good job and
they work very well together. There’s been a couple
of large interdiction drug busts in the
last number of months. I think part of it is,
on a larger global scale. From my understanding and
correct me if I’m wrong, much of the fentanyl
comes from China and having the ability
to negotiate these kind of international deals
to get the Chinese to crack down on it at
home, I think is another answer to the problem. By the time we get it,
and we’re on the street. We’re under the L and it’s hard. And the other issue is that
for people with a small possession amount. What do you do with them? – By that time, it’s already in. – I’m kind of at the lower
end of, I think maybe a governor has more ability– – What at the state and
fed, Mr. Vice President, what do you see that we
are doing and what more could we be doing here? – I spent five years of my
life working on this particular issue and we ended up
with the commission that Doc worked on. Look, there’s three
things we can do. One, is, and it’s
all demand driven. One, we can negotiate with
the countries of origin of the material that
they’re sending in. We did that fairly successfully
with Columbia early on. – [Bertha] We did the
Columbia plan and the Merida. – Yeah, I put together this
plan called, Plan Columbia. It wasn’t very well greeted
at first but what we did was, we went in and we
actually worked with their law enforcement. For example, we did
lie detector tests. We brought our FBI
down to Bogota. There were over
7,000 federal police. We were able to get to the
point where we convinced them to fire almost 5,000 of them. And we helped them hire
non-corrupt elements of the police department
and it had an impact. It didn’t stop everything. In China right now,
China made a commitment to our administration that
they were going to regulate all elements of fentanyl. There’s various degrees
of which, it constitutes how much of a problem it is. But what we can do, most
of the fentanyl is coming from China but it’s also
going through Mexico. And the vast majority as
you’ll learn with these trials of El Chapo, the drug
lord is it comes through legal ports of entry and
one of the things we argued for for a long time
but is very expensive. That we have the ability
to have these large, look like containers
that are x-ray machines that you literally drop
over top of an entire tractor trailer and you
can determine the density within that trailer of
what’s in the trailer. For example, the largest drug
bust was carrying cucumbers but they found all this
fentanyl in the bottom because they could tell by the density
it was something different. Well, we have a 37,
38 ports of entry. We’re now up to having
34 of these big machines but we need probably
three times that many. But the administration, and
we didn’t do enough either, resisting the cost of
them coupled with the fact they need at least four
people operating them. They’re very
expensive to operate. I’m not being a wise guy about
the wall and the president and all that, for real my word. But instead of building
more barriers, if it’s drugs you’re talking about, we could
take one tenth the amount of money we’re talking
about building in a wall and significantly increase
the technological capability at legal points of entry. Because that’s where 95% of all
the stuff is coming through. And so we can, A, negotiate
with the countries in question and have consequences for
their failure to cooperate. As well as have a significantly
more sophisticated technological capability
and additional personnel at the ports of entry. – I think there’s
more than that. One of the interesting
things in 2006 is that there was a super lab in Mexico. In Toluca, Mexico that
produced all the fentanyl that killed 1,000
Americans at the time. When that super
lab was taken out, the fentanyl deaths
went back to near zero. So that was a point source. We know have at least five
point sources from China. And one of the things that
our government can do, is number one, do the type of
tracking that federal express does which our postal
system does not do. And the second issue is we
can use our vast economic leverage with China to have
them enforce their own laws on fentanyl production and
that is one way to squeeze the Chinese government
into curtailing production. – Cause a lot of it comes
through the postal service from China, directly from China. But if the same package came
through Federal Express, it has a different method by
which you can check it out. But not for all postage
coming out of China, you could do that. – Governor Bush. – I was gonna say
the exact same thing, the postal service is
treated differently than UPS and FedEx. There’s a bill in the senate, I don’t know where it is in
the house, to change that. To raise the standards, it costs a little bit
more but fentanyl, such small quantities
creates such dramatic impact, we have to do it. We’re in the midst
of negotiating with, being an optimist I
hope this happens, a new trade arrangement
with China that is really essential for, it will be
a big deal if it happens. This should be part of
that and there should be no lifting of any kind
of tariffs until it happens. This is a national problem. They can solve it. – Can this be a bipartisan– – And by the way, that
legislation passed and the deadline was the end
of 18 to implement it but the administration is not
implementing it now. It’s supposed to be implemented. Dealing with post– – They raised the God
dang stamp to 51 cents (laughter) – No, no, no
– This is an outrage and they can’t do that? – But it has not been
implemented, that’s the problem. The administration
hasn’t implemented it. – Well that’s a big
deal to implement this. Let me ask you, Governor Bush. You implemented a
multi faceted strategy when you were governor. What do you think governors
today can do that would be most effective? What would your advice be here? Well first of all, a lot of
Governors are doing this. This is the number one
issue in most places. New England was the place where
it was the quickest to hit. The governors of New Hampshire
and certainly Massachusetts, Charlie Baker has
done a phenomenal job
building grass roots support from the bottom up to create a
comprehensive strategy. Ohio is another place where
I think there’s been a lot of great work. I’m relatively
optimistic and confident and you’re seeing a decline
in the number of overdoses with prescription drugs. Sadly, fentanyl now is the place where there’s been an increase. This is a never
ending challenge. I think looking at this
in a comprehensive fashion is part of it. The one place where in
Florida there was the most dramatic impact of
restricting prescription drug illegal use was the
prescription drug monitoring system that was developed. That was not during my watch. In fact, the legislature
rejected it like four straight years because
of civil liberties concerns but they were wrong and the
minute it got implemented in the last four years, we went from South Florida
being the pill mill capital of literally, of the
United States to getting it wiped out entirely. – Wow.
(applause) – Drug seeking people
find the pharmacists that are prescribing illegally. Medicaid is a principle
source of reimbursement for a lot of this. We have the ability in this
country to know when people are over prescribing,
exponentially more
than they deserve. And the hammer ought to be
brought down on them like nobody’s business. It shouldn’t take three
years for investigation because during
those three years, my frustration as governor
was the US attorneys office, methodically going
about their business, didn’t let us go and take
the guys’ license away as he was over prescribing. And we had to pay
the consequences of a lot of pain and
suffering in families. I think accelerating the
law enforcement prosecution of this stuff, there’s just a
handful of doctors that open up this market in a way that
provides the illicit drugs. – Yeah and I think that’s
important point just for us to know because while doctors
are a source of this problem, it is a tiny fraction
of the doctors. Most doctors do and want
to do the right thing but a tiny fraction
can make enormous– – Part of it is education, you
have to educate these doctors in these communities
or neighborhoods. Neighborhood docs on the corner. You have to really go
out and talk to them and explain to them and
give them information because they don’t always have, you assume that they’re
doctors, they’re smart, they know everything, well they don’t have
all the information. You do, you do
(laughter) They don’t have the
information and we’ve done that with our health department going
out to individual practices and giving them information,
engaging them and explaining what role they can play
in a positive stance. – Another thing that
the states are doing, I don’t know if it’s every state but every state should do it, limit the first
prescription to seven. – Yeah, I had surgery
a couple of years ago and I left the hospital and
they handed me a pill bottle with 30 oxycodone.
– That’s ridiculous. – What am I gonna do with this? And what happens I
think sometimes, you
don’t need anymore. You take three or four then
you find a got a Tylenol 800 and you’re fine, glass
of wine and you’re good. (laughter) But it sits in your
medicine cabinet. And if you have
children in the house, that’s where some of
this stuff starts. – Doc, you said a statistic but I think it’s
important to know. I mean I don’t think doctors
are bad, they’re good, they’re trying to save lives
but it’s kinda willy nilly. You, I remember reading
a report where you said, the people who show up
in the emergency room with a sprained ankle, 25% of them get an
opioid prescription. – That’s really, yeah.
– What the hell’s that about? – It was actually–
– That is malpractice. – Right, we found out,
we did a geographic study across the country and the
range was something like maybe five or ten
percent in Nebraska and up to 40% in Alabama
or some southern state. So tremendous variability. And that was for an
uncomplicated ankle sprain. And so that is
egregious prescribing but that is a result of
a generation of doctors starting in 1995 who are now,
2015, 20 years of practice where they were tuned
into this pain score. – Zero pain
– Not only that but patient satisfaction scores,
you know you rate your Uber driver, well
they now rate doctors. Nobody can afford to have
a four star rating when everybody comes down on you for not having a
five star rating. – How about hospitals and pain? I’m serious.
– It’s all, I totally agree. – Hospitals get rated and
the patients determine when they leave the hospital,
did they leave in pain? Well one way to make
sure your rating stays up is make sure you
don’t leave in pain. I guarantee you’re not
gonna leave in pain if you’re taking an opioid. – Yeah.
– Yeah. – But serious, why don’t
we talk about this? – The good news is that there
is a 50% drop in new opioid prescriptions for
drug naive people. Which is excellent news. And the other excellent news,
that I believe is that the physician prescribing
issue is solvable and it’s getting solved. I don’t think that that’s where
the future of policy lies. The future of policy
lies in the new psychoactive substances,
fentanyl analogs of which there are a thousand
possibilities in fentanyl. – So, let me ask because I have
time for one final question. We’re gonna do a lightning
round down the row here and then we’re gonna open it up. I have some questions
from the audience. The final question is,
if you could have all Americans know one thing
that is misunderstood or take one collective action. What would it be, to
help solve this problem? – My first priority would
be to not introduce drugs into the developing adolescent
brain because that is– (applause) – [Amy] Amen, amen. Governor. – Well if I had a fairy
godmother land on my shoulder and give me any wish, it
would be to change our culture so that we don’t default to
taking a pill to resolve our problems. The way to solve our
problems is to solve them. (Applause) – Mayor. Do you realize we have
professor, governor, mayor, doctor, Vice President,
what more could you ask for? Mayor Kenney. – Substantially more financial
help for local communities to deal with this problem. (Applause) – This is an under, so we
may spend more than any other country, almost
twice as much per capita for healthcare but we
vastly underspend for mental health, for drug
problems and for public health. So vastly underspend.
(Applause) – We stretch. We’re gonna spend 36 million
dollars over the next few years dealing with this issue. Plus police overtime, all
the other issues that effect trying to manage it
and deal with it. Every time I think of
spending money on misery, which were like
the misery dollars. I think of spending that money
on schools and facilities and infrastructure and transit. There’s so many other things
to spend money on but we have to spend the money to
save people’s lives. We have no choice. (Applause) – Dr. Perrone. – Keeping opioid naive
people, opioid naive. Nobody should take these
medicines for treatment one, two, three there’s alternatives
in almost all cases as first, second and third line. And we just need to prevent
people from getting started in most cases. – Could you add on that? ‘Cause I know we talked
on that before we started about what are the role of
places like CVS and Rite-Aid, the places people actually
go to get their prescriptions fulfilled and now more and more are opening store front places. – Those store front places
are dangerous because they want to get you
in and out quickly. They still have that perception
that patient satisfaction is driven by receiving
an opioid prescription. Like, you take your kid to the
doctor for an ear infection. People think that
you want antibiotics. You may not want antibiotics
but the doctors perception might be that you
want antibiotics. Instead of just giving
them the prescription, having a discussion but
that takes ten, 15 minutes instead of just one minute
to write a prescription. So it’s much easier but
wrong to go the easy path. We need to go the harder path. Education, don’t take
these drugs therapeutically when there’s many very
effective alternatives. – Mr. Vice President. – Little pain’s not bad. I would point out. I would wish if everyone
went to sleep tonight in the United States
of America and woke up understanding how
addictive Percocet is, how addictive these
pain killers are. They don’t understand it. They don’t know how
addictive it is. And not everyone who
uses them gets addicted but a significant
portion do get addicted. And people just don’t know it. So when the pharmacist or
the doctor or the hospital as you’re walking
out of the door, you have great faith in them. The one place we still are
reluctant to question is our doctor. Of all people. And he hands you a little
plastic bottle and it has twenty Percocet in them. You have to believe
it must be right. I don’t know because I’ve
been through this a lot, I’ve been a great
consumer of health care. No I really have. Hospitalized myself for
seven months myself in ICU, lost family members, I spent
a lot of time in hospitals. And I want to tell you
something, I’ve not seen any doctor say, “Now look,
you understand this. If you take this, this can be
really, really debilitating. You understand? And by the way,
try Advil first”. By the way, not a joke! – It happened to me. I was in the hospital
and I was on dilaudid. Which is–
– Everyone’s looking at me, like I prescribed it.
(laughter) – I mean, it’s kind of fun. The nurse came in and she said, “Honey, you like
that button too much. You’re coming off today”. – Good for nurses.
(applause) – Good for that nurse. – Anyway, for people that
know how addictive it is so you can make a
rational judgment, a rational judgment about
how much the pain is. If you’re thinking
that I’ve got this pain but if I take this
for five days, I may be one of that percent
that in fact becomes addicted. You make a rational judgment, assuming you don’t have
other problems already. But people don’t know. – Well, there is a problem
in this country called generational forgetting
because we had a terrible opioid addiction epidemic
starting in the 1820’s and it lasted until 1910, until the federal
government intervened. And we forgot. – [Amy] What did the
federal government do? – They forbid physicians from treating addiction
with morphine. And they said–
– That makes sense. (laughter)
– Yeah, yeah. – And what was fascinating
is that from 1914 on until 1990, I would say that
was a precipitating point. There was opioid phobia
amongst the medical profession. – [Joe] Bingo! – Then it went into opioid
philia because nobody – Remembered.
– learned the history. – And the morphine came
because of the civil war. – No, much earlier. – No, but it really
hit with the civil war, that’s when it was being
overwhelmingly prescribed and it was viewed as an answer. – Yes but until then it was
women who were most effected by morphine addiction. – So we not only, right
here have addressed what some of the things that
can be done but also how important it is to remember
when we do do things that are effective and keep,
as Mayor Kenney said, the education going. Hence, this panel but now
is the most important part whereas we have questions
actually from our audience. And I have these questions
and I’m going to throw them out to any of
you to answer them. But I’m going to ask if
the person in the room who wrote this question
would stand up. Her name is Katelyn Crane
and she’s a nursing student. Katelyn are you here? – Hi
– Hi, great. So, Katelyn’s question is
as follows and by the way, I have to say because
Katelyn’s a nursing student, I assume are you a
Penn nursing student? Well, you should all know
that our nursing school is ranked number
one in the world. Not to brag or anything. (applause) And we really care. – [Joe] If there’s
any angels in heaven, they’re all nurses,
male and female. – Correct. How does the current state
of mental health care influence the opioid
epidemic and what can we do? Who would like to begin? – Well I think there has to be– – Why don’t you say what
you’re affiliated with too. – I am currently
at McLean hospital, which is the number one
psychiatric hospital in the country.
(laughter and applause) I think one of the
most important issues we have to introduce
into addiction. Into primary care, into
most branches of medicine is mental health screening. Because mental health
screening whether it gives rise to diagnosis of
severe mental illness or a mild mental
problem, is a co-factor. It’s a precipitant of drug use. And if you don’t treat
the mental heath condition it is very difficult to
get people who have an addiction to drugs to
be treatable as well. You have to do both. – Anybody else?
(applause) Yes, it’s very very important. Anybody else want to
address that, Mayor Kenney. – I do think in general
whether it’s addiction or just mental illness,
the police departments in our country need to
train our officers to deal with people with mental illness. Because, and we do this here. (applause) You know, so many times
around the country, people wind up being
shot by a police officer because they don’t know the
protocols of how to deal with individuals going
through a crisis. And we were very, pay attention
to and train our officers, both in the academy
and ongoing education. Some methods of dealing with
people who are going through this trauma. – Yeah, I know that our vice
president for public safety, Maureen Rush believes in this. And Maureen is here.
(applause) Thank you for all you do. Any other answers to this? Okay, next question. Will Adams, Wharton student
and of course I have to say, Wharton has just been ranked,
unrivaled the number one (applause)
Business school in the world. Thank you, Will. Here’s Will’s question. How can we balance short
term emergency response with long term solutions to
the opioid epidemic? So, how do you balance the
short term response with the long term solutions? I think that’s just
a critical question. Yes, Dr. Perrone. So, I think we’re distributing
the naloxone around the city and that is the short
term response, right? We save lives. But you should know that
about 10% of the people who are resuscitated with
naloxone are dead in a year. If we don’t get them
into treatment right
from that moment, we’re losing an opportunity
and people are dying. Kudos to the mayor and EMS,
the city has now started a new program where when
patients are resuscitated with naloxone but they don’t
want to come to the hospital, something called an
alternative response unit comes to the patient’s side
with social workers and certified
recovery specialists to try to get them
into treatment. We cannot miss
these opportunities so acute resuscitation
needs to followed by treatment, intervention
or just engagement. Just connection to care
with people who are peers who can speak to the patient. Say, you know I’ve been there, I know what you’re
going through, I know now might not be
the time but next week or next month, come back. – [Joe] You have to do both.
– Absolutely. – You can walk and chew
gum at the same time, we have the resources to do it. (applause) – Things on long term. Mr. Vice President, what do
you think the most important long term solution’s here are? – I think two things
at the same time, actually three things. One, what the governor
talked about is significantly more scientific
research on the brain. (applause) and determine how it functions. Number two, I think to
deal with the thing that gets people engaged in the
first place and that is determining whether there
is something in the brain that generates this kind
of behavior or the way in which we distribute these
drugs is the second piece. What gets people hooked
in the first place? And thirdly, once they’re
hooked to spend a great deal more time, energy and expertise. We should be incentivizing
our drug companies to find alternatives to the opioids
they’re producing out. – Can I ask the
doctors a question? – Sure. – What’s the research say
about the use of cannabis in an effort to
reduce the severity– – If anyone doesn’t
know what cannabis is, it’s AKA marijuana and let me
just say one point about that, I’m not gonna answer. I definitely want
Professor Madras to answer but it is quite striking
that our federal policy only allows medical research on
cannabis in one facility, one institution in the
whole United States at the University of Mississippi. That’s bazaar. Now go and if you’d answer
the mayors question. – With all due respect,
that is the source but that is not
the only facility. There are 300 clinical
trials with cannabis, I prefer to call it
marijuana because cannabis is the same as calling
opium, papaverum somniferum. It’s a latin terminology
which applies to – That’s smart.
(laughter) – sanitize the fact that in
this country it’s marijuana. – Weed. – There are many strains which have very
different properties. – But basically, the two
big ones are THC and CBD. And THC now is up
to 90% in some depts and CBD has been essentially
bred out of the plant. – [Amy] So what is
the relationship? – Paul Larkin and
I, who’s a lawyer, have just published,
it’s going to be in the Georgetown Law Review, a complete summary of
the data and the evidence for and against using cannabis. And so there is a level of
familiarity with the question and the answer. At this point there
are two conclusions. Number one, the data does
not show that cannabis is a substitute because if
you actually do longitudinal studies on an individual basis, you find that people are
suffering as much pain as they’re taking marijuana
and their opioid use is not decreasing in most cases. In fact they’re getting
more and more trouble in terms of developing
opioid use disorder and they’re misusing opioids. That’s basically
the latest data, one publication just came
out last night on it. Number two, every single
disease that is treated in this country. Like diabetes, like
infections, like cancer is evidence based and
undergoes randomized control clinical trials and to say
that this is by legislative support or by fiat
from a governors
office that this is how you can treat opioid use
disorder without the clinical trials, without longitudinal
studies to me is purely disrespectful
of patients. – Yeah, agreed
– Well said (applause) – And it’s a totally
different issue what cannabis, what the trials have shown
about how it can decrease pain in other areas. – There’s only, no more to
the best of my knowledge, five randomized controlled
trials in neuropathic pain, which is a very
special type of pain. And of those trials, none of them lasted
more than two weeks. They were all experienced
marijuana users, they were all on opioids and that is exactly
the problem that got us into the opioid crisis
because people did not do longitudinal studies on opioids. They just did it, at the
time this crisis began there were no studies
beyond three months. – Yeah, so you take
real exception to the
national academy– – The national academy
report of chronic pain was in deep, profound error. – [Jeb] (laughing)
There you have it. News at 11. – And even though I am now
on the opioid collaborate, I am willing to come out
and say what is the truth. – Okay, next question. Emily Arthman, who is an
incoming Wharton student. Emily, congratulations. How is government thinking
about its’ role in improving patient access to medication
assisted treatment? So, how is government thinking
about its’ role in improving patient access to medication
assisted treatment? – [James] That’s
above my pay grade. – I can answer for Mayor Kenney. In the city of Philadelphia,
we have treatment capacity for MAT that is not being used. So they have lowered the
barrier, there is lots of opportunity. We are working really hard to
get patients into treatment but we have tremendous capacity. That’s probably unlike
most other cities but we have three patients
dying a day in Philadelphia. We are at a huge crisis
and that’s why we need safe injection facilities,
safe house, other places where we can get people in. If they’re not coming in
to our treatment centers, they’re not coming in to
my emergency department. We need to reach them
some other way and we’re doing a lot and Mayor
Kenney should be applauded cause he’s done a
really amazing job. (applause) – Professor Madras, what’s
your view on the getting people who need to be in
treatment facilities in. – There are a couple of issues. The vast majority of people
with an opioid use disorder do not come to treatment. And when it’s excavated into
granular level, you find that many of these folks
do not want treatment, do not seek it. Another part says they don’t
want to get into treatment because of stigma. They’re afraid their
family will find out, they’re afraid their
employers will find out. Recruiting people who
are not in treatment, to me is one of the
most important issues and having them be offered
medications is a critical feature of this. How do we do it? The federal government
is critical through CMS. Because CMS has
tremendous control. Number two, the federal
government every year, the office of personnel and
management issues a call letter to all the insurance
companies who insure federal employees. That call letter has
tremendous impact on all the insurers in the
country because it sort of glides the entire
country reimbursement model on what the federal
government considers critical. And that call letter should
include that you must make medications available. It is harder to get
approval for medications to treat opioid addiction
than it is to get approval to give someone a
Percocet prescription. And that’s wrong. – That is deeply wrong. – We put that into
the commission report. – Yeah and this actually,
so insurance companies could change that? – They could put the
squeeze in both directions. They could squeeze
the physicians in
terms of prescribing opioids and they can
squeeze physicians, not squeeze them but empower
them to prescribe medication which reduce death rates,
HIV, Hepatitis C and so on. – Hear, hear.
– And maintain people in treatment. – One of the crazy quirks
of our reimbursement system is that doctors, we’ve been
banging on doctors too much. I’m not an anti-doctor guy
but in this particular case, when they prescribe,
they make more money. They get a 6% commission
more or less for prescribing and the natural inclination
is to prescribe non generic drugs and so if you’re looking
at access to medications a lot of times people stop
taking their medication because they don’t
have insurance and
it’s quite expensive. So expanding generics across
the board, in this field. In other areas as well
would be part of this. And I go back to another
point which is that treatment is short term. In the most expensive
places I’m sure it goes on for more than thirty
days but most people have insurance for thirty days
and then they’re out. So reforming the
treatment system, looking at best practices, benchmarking it properly, rewarding the
successful programs, stopping the ones
that don’t work. All those things have to
happen but I think the last part of this is that we need
to create the stigma issue is a serious one and
people are going to be, their life long journey is
gonna require a commitment to recovery. This, whether it’s alcohol
abuse or drug abuse, these addictions don’t go away. You can deal with them and if
you have the courage to do it and the family support and
the support in the community, it’s a lot easier to do. But that’s something that
is foreign to most places in this country. We don’t have that
kind of environment where there’s that support. – So you said earlier, in
our lightning round that if you could change one thing
it would be the culture. Can you just elaborate a
little on a part of our culture that you think we could
all play a role in changing? The two parts I would say. One is if we, if it’s a third
the prescriptions that’s bad. If it’s 85%, which
I think it is, in the world with 6% of the
population, that’s absurd. That’s a cultural problem. We’re not, that’s so unique to
us that we have to deal with the fact that every
problem in life doesn’t – Have a drug
– another pill. And in the second is this
stigma that really isolates people rather than brings
them into a more nurturing environment where the
families and communities are and churches and synagogues
are there to help people to deal with this
illness over the long haul. We’ve torn apart a
lot of these things, the safety net of America and rebuilding that to deal with these kind of issues would be. – Yeah and if you’ll excuse,
to that we should say, Amen. Because it really
does take community, it takes institutions, churches
and synagogues, mosques, Community centers. This is not
something that anyone can struggle with alone, right? So that’s a very important
antidote to the individualist, empathist of our society where, and that feeds in to all you
have to do is take a drug. But you really need a
community of support. – Yeah, and people have to
be committed to do this. The drug core issue works,
not because it’s necessarily diverting someone from jail. It works because the threat
of jail is still there. So you complete your sentence and you have your
judication withheld. That is a powerful
tool to keep people on the straight and narrow. And along the way there may
be, people make mistakes and they stick with it
far more than if you just put them in
jail and they get out and immediately they go
back to their bad behavior. – I would like to paraphrase
Governor Bush and also Vice President Biden. Because I learned in government
that you have to talk in sound bites. We have to de-normalize chemical
coping and chemical reward because that is the
basis of our drug problem in this country. – [Jeb] That’s a soundbite?
(laughing) – Doctor, let me
ask you a question. You know for awhile,
ten, twelve years ago, there were a lot of people
with your collective expertise who were talking
about the need to go back to studying the brain to
find antigens and antagonists that would prevent the
drug from having the effect on the brain that it had. I met with every major
drug company and we talked about an orphan drug act
which we would provide them with significant rewards
if they were to find this. None of them are
interested in it. None of them are
interested in it. Because number one, they
don’t want to be known as the drug company in
terms of illegal drugs. And secondly, there
is little reward. Not withstanding all these
people that are dying and all the people that
are addicted to opioids. There’s still not enough
money to make from that particular population
which can’t buy the drug anyway if they found it. Is there anymore talk
about this anymore? – Well there are a lot more
pharmaceutical companies entering the fray now because
they’re very interested in isolated cannabinoids. They’re interested in what
are called biased agonists, which are opioids that are
going to develop different signaling pathways than
the conventional ones which will not lead to
addiction or over dose but will lead to pain reduction. And there are companies
that are very interested in developing pain medications
that are non addictive. There are also drug companies
that are non addictive. There are also drug companies
that are interested in developing medications
to alleviate. Its become now more
normalized, more centralized than it used to be in the past. – [Joe] I think it is but there’s a small
percentage of money. – Very small.
– Very small percentage. – One of the reasons that
it’s very small besides, and I won’t numerate all of
them but one of the main reasons is the difficulty of
developing clinical trials with people that have
substance use disorders. Because of the high drop out. Once you have a high
drop out rate you have to explain that to the FDA. Once you have a
high failure rate, then you may have invested
two billion dollars and because of the
high failure rate, the 25% or the 10%
that are successful, may not be enough to
convince the regulators. Because the population
is much more difficult than it is for chemotherapy. There is a lot more
problems associated with developing drugs in as for
substance use disorder. – So, I just want to say on
behalf of everybody here, how much we’ve learned. That really could, and I
hope will make a difference to every family in this
country because I just think we need to understand and
underscore what this panel has said. That this is an issue that
knows no economic or racial or religious distinctions. It really effects everybody
here and please join me in thanking
(applause) Professor Madras, Governor
Bush, Mayor Kenney, Dr. Perrone and Vice
President Biden.

Leave a Reply

Your email address will not be published. Required fields are marked *