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In Triplicate · Revisionist History

• 0:15
  Speaker 1: Pushkin Hello, Hello, Revision's History listeners. I'm excited to announce
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  Speaker 1: that this season I'm offering a bunch of perks from
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• 0:52
  Speaker 1: Podcasts or at pushkin FM. When I was in my
• 0:58
  Speaker 1: twenties many years ago, I was a reporter for the
• 1:01
  Speaker 1: Washington Post. A newsroom the size of a football field,
• 1:05
  Speaker 1: phones ringing, keyboards clattering, the glory days of print journalism.
• 1:10
  Speaker 1: I want you to describe what is the status in
• 1:13
  Speaker 1: position of a Washington Post reporter in Washington, DC in
• 1:18
  Speaker 1: nineteen eighty nine.
• 1:20
  Speaker 2: Well, in general, godlike, because the whole city ran on
• 1:25
  Speaker 2: politics and news and there weren't many organizations that produced
• 1:30
  Speaker 2: it excellently, and the Post was sort of the place
• 1:33
  Speaker 2: that everyone cared about.
• 1:35
  Speaker 1: That's my friend Michael Specter. He and I were both
• 1:38
  Speaker 1: on the Health and science speed for the Post. If
• 1:41
  Speaker 1: somebody cured something, discovered something, solved something, or screwed something up,
• 1:47
  Speaker 1: we were on it. In those days, it seemed like
• 1:50
  Speaker 1: everyone read everything we wrote.
• 1:52
  Speaker 2: Well they did. I mean there is an exception, which
• 1:55
  Speaker 2: is we were in the science pod, and at least
• 1:59
  Speaker 2: at the Post that was considered like why would smart
• 2:02
  Speaker 2: people write about science when they could write about the
• 2:05
  Speaker 2: White House and wear yellow ties. But in general we
• 2:08
  Speaker 2: had big readerships, particularly in the when we wrote about
• 2:11
  Speaker 2: science policy.
• 2:17
  Speaker 1: We sat at the center of a giant ecosystem of lobbyists, lawmakers, aids, bureaucrats,
• 2:23
  Speaker 1: policy wonks who tried to get us to see the
• 2:25
  Speaker 1: world their way. If you called someone and said you
• 2:28
  Speaker 1: were from the Washington Post, they called you back. I
• 2:31
  Speaker 1: used to listen to Michael every day on the phone
• 2:34
  Speaker 1: with a source on Capitol Hill.
• 2:36
  Speaker 2: That individual had access to everything, but he didn't mind
• 2:41
  Speaker 2: ratting people out. It was like heaven. I had a
• 2:44
  Speaker 2: couple people like that.
• 2:45
  Speaker 1: It was Heaven. I remember once where you get the
• 2:50
  Speaker 1: plain brown wrappers with stuff inside of it, because nothing,
• 2:53
  Speaker 1: of course was digital in those years, you would get
• 2:56
  Speaker 1: the mysterious phone call and you had to decide whether
• 2:58
  Speaker 1: to return it. So there's one member of this ecosystem
• 3:02
  Speaker 1: that I'm most interested in, ready, Sid Wolf.
• 3:11
  Speaker 2: Sid Wolf. I love Sid. I loved him then, I
• 3:15
  Speaker 2: love him now. But you know, yeah, he is a
• 3:17
  Speaker 2: particular kind of guy.
• 3:18
  Speaker 1: I think I was the most skeptical of Sid.
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  Speaker 2: Yeah, because you were like a right wing lunatic.
• 3:22
  Speaker 1: I was a right wing wunatic, and it was a
• 3:25
  Speaker 1: right wing time Sidney M. Wolf MD versus me thirty
• 3:31
  Speaker 1: years ago, when I was a right wing lunatic. I
• 3:35
  Speaker 1: was different then, which I offer as at least a
• 3:38
  Speaker 1: small explanation from my behavior in the story. I'm about
• 3:41
  Speaker 1: to tell you. My name is Malcolm Gladwell. You're listening
• 3:47
  Speaker 1: to Revisionist History, my podcast about things Overlooked and Misunderstood.
• 3:53
  Speaker 1: This season is devoted entirely to experiments, and this episode
• 3:58
  Speaker 1: is about what happens when an experiment teaches us an
• 4:01
  Speaker 1: important lesson and we don't listen. Sidwulf came to Washington,
• 4:11
  Speaker 1: d C. In the nineteen sixties as a young doctor.
• 4:14
  Speaker 1: He went to work as a postgraduate fellow at the
• 4:17
  Speaker 1: National Institutes of Health, part of the same class as
• 4:20
  Speaker 1: Tony Fauci. One day in nineteen seventy one, someone told
• 4:24
  Speaker 1: him that half of the saline solution being supplied to
• 4:27
  Speaker 1: American hospitals was contaminated with bacteria. And Sid said, oh,
• 4:33
  Speaker 1: where are they going to take it off the market?
• 4:35
  Speaker 1: And the person said they aren't because if we do,
• 4:38
  Speaker 1: hospitals will run out of ivy fluid and will have
• 4:41
  Speaker 1: a disaster on our hands. And Sid said, that can't
• 4:44
  Speaker 1: be right. There have to be other sources of ivy fluid.
• 4:48
  Speaker 1: He did his research, found out there were other sources,
• 4:52
  Speaker 1: and went public, called the press, got his friend, the
• 4:55
  Speaker 1: political crusader Ralph Nader, to hold a press conference, and
• 4:58
  Speaker 1: the bad ivy fluid was pulled from the market. Sid
• 5:03
  Speaker 1: had found his calling as a consumer advocate.
• 5:07
  Speaker 3: I am sick and tired of the paper attitude of
• 5:10
  Speaker 3: American Medical Association towards American patients patients.
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  Speaker 1: SID was unstoppable. He started something called the Public Citizens
• 5:17
  Speaker 1: Health Research Group and became one of the angriest voices
• 5:21
  Speaker 1: in Washington.
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  Speaker 3: As many of you know, our organization has now for
• 5:26
  Speaker 3: twenty five years, been the most outspoken critic of the FDA.
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  Speaker 3: More than fifty times we've submitted petitions, sometimes resulting in
• 5:33
  Speaker 3: lawsuits against the agency to try and get them to
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  Speaker 3: do what we think the law requires them.
• 5:38
  Speaker 1: Example, in the c SPAN archives, there's practically a SID division.
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  Speaker 1: Sit against the drug companies, sit against the doctors, sit
• 5:46
  Speaker 1: against the FDA.
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  Speaker 4: It is clear that of the seventeen years since we
• 5:51
  Speaker 4: have been running the Health Research Group and watching the FDA,
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  Speaker 4: this is by far the worst period of time ever.
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  Speaker 1: SID didn't like anyone except those who are willing to
• 6:02
  Speaker 1: join him on the lonely ice flow of his sixties radicalism. Okay,
• 6:07
  Speaker 1: that's not fair. It's not that SID disliked people. It
• 6:11
  Speaker 1: was never personal for him. Sid's battle was with institutions.
• 6:15
  Speaker 1: SID believed that bureaucracies and companies and legislatures would behave
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  Speaker 1: better only when constrained by the right laws, the right regulations,
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  Speaker 1: and the right kind of relentless nudging from people like Sid.
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  Speaker 1: He was the nudge of Washington DC.
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  Speaker 2: Sid's very smart and very colorful and a great quote.
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  Speaker 2: But there's only one way in that's Sid's way. You
• 6:41
  Speaker 2: don't have like a deep, meaningful conversation on both sides
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  Speaker 2: with SID. But some people, and he was one, were
• 6:50
  Speaker 2: just excellent at knowing what we needed and what we
• 6:53
  Speaker 2: wanted and how to package it. And that was Sid.
• 7:00
  Speaker 1: I hadn't thought of Sidwolf in years, but then I
• 7:02
  Speaker 1: started reading about someone named Paul Madden, one of those
• 7:05
  Speaker 1: forgotten figures from the mid century. If you lived in
• 7:08
  Speaker 1: California in the nineteen forties, you would hear Madden from
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  Speaker 1: time to time on the radio.
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  Speaker 5: Good Evening, ladies and gentlemen. There may be hotter jobs
• 7:18
  Speaker 5: than breaking up a narcotic brain.
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  Speaker 6: I don't know.
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  Speaker 5: I've never seen one. Especially difficult is a job of
• 7:26
  Speaker 5: rounding up a band of narcotic pedlars, including the brains
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  Speaker 5: of the gang.
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  Speaker 1: Madden was a progressive that progressives believed that government could
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  Speaker 1: fix things, that systems and regulations and rules properly written
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  Speaker 1: could make the world a fair place. Progressives were activists
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  Speaker 1: full of zeal. In nineteen thirty nine, Paul Madden was
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  Speaker 1: appointed to run the California Bureau of Narcotic Enforcement. He
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  Speaker 1: was the man responsible for stopping the use of illegal
• 8:01
  Speaker 1: drugs in the state of California, a job he tackled
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  Speaker 1: with enthusiasm and his customary hyperbole. Let me quot directly
• 8:09
  Speaker 1: from his writing on the effects of marijuana, Madden wrote
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  Speaker 1: that the user might quote believe himself so small that
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  Speaker 1: he is afraid to step off the curbstone into the street,
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  Speaker 1: or he may feel himself of enormous size and of
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  Speaker 1: superhuman strength and passion, and in that condition commit crimes
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  Speaker 1: altogether foreign to his nature. But because Paul Madden was
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  Speaker 1: a progressive, he didn't just fulminate against a problem. He
• 8:35
  Speaker 1: had a whole, carefully thought out scheme for using the
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  Speaker 1: enlightened power of government to fix it. Consider the great
• 8:42
  Speaker 1: fear of anti drug crusaders of that era, which was
• 8:45
  Speaker 1: that doctors might be driving drug addiction.
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  Speaker 7: What if the person gets the script from the doctor
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  Speaker 7: and goes down and keeps some of the drugs for
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  Speaker 7: himself and then sell some of the drugs on the street,
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  Speaker 7: then you're going to have the problem of the initiation
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  Speaker 7: of new addicts potentially if that happens.
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  Speaker 1: David Courtwright, who is America's leading historiander the drug trade,
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  Speaker 1: says that people who were worried that patients could walk
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  Speaker 1: into the doctor's office asking for an addictive drug like
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  Speaker 1: morphine and the doctor would just give it to them.
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  Speaker 1: So stading, we're a small number of doctors who are
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  Speaker 1: relatively unscrupulous, who are simply writing prescriptions for maintenance, and
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  Speaker 1: much of that drug may end up being diverted. How
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  Speaker 1: would I identify the doctor who's doing that.
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  Speaker 7: So one of the things you might do is send
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  Speaker 7: an informer to the doctor and he would try to
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  Speaker 7: persuade Typically it was a he. He would try to
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  Speaker 7: persuade the doctor to write a prescription.
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  Speaker 1: In California, Paul Madden looks at that practice of running
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  Speaker 1: sting operations against shady doctors and says, that's a crude
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  Speaker 1: and inefficient way of dealing with the problem. Remember, he's
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  Speaker 1: a good progressive, a man who believes in systems and procedures.
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  Speaker 1: So Madden decides to create a bureaucratic solution. First, Madden
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  Speaker 1: makes a list of all the prescription painkillers that he
• 10:13
  Speaker 1: considers dangerously addictive morphine, opium coding, chloral hydrate, and then
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  Speaker 1: he convinces the state legislature to create a new regulation
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  Speaker 1: for doctors Chapter three, ARTCA one, Section one one one
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  Speaker 1: six six six of the California Narcotics Act, the Madden
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  Speaker 1: Amendment of nineteen thirty nine.
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  Speaker 8: The prescription blanks shall be printed on distinctive paper, serial
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  Speaker 8: number of the book being shown on each form, and
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  Speaker 8: also each form being serially numbered. Each prescription blank shall
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  Speaker 8: be printed in triplicate, with one blank attached to the
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  Speaker 8: book in such a manner that it will be readily removed,
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  Speaker 8: while two of the blanks shall be perforated for removal.
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  Speaker 1: Meaning every time a physician prescribes one of the listed
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  Speaker 1: pain killers, they have to use a special state issued
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  Speaker 1: prescription pad where every prescription page comes equipped with two
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  Speaker 1: additional carbon copies. To use a contemporary turn of phrase,
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  Speaker 1: he wants to create a back up of every narcotic
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  Speaker 1: prescription in the state. The first copy was to be
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  Speaker 1: kept at the office of the prescribing physician for a
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  Speaker 1: minimum of two years, available for scrutiny at any time
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  Speaker 1: by one of Madden's team of inspectors. Copy number two
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  Speaker 1: had to be kept by the pharmacist for two years.
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  Speaker 1: At number three had to be mailed by the pharmacist
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  Speaker 1: to the Bureau of Narcotic's head office in San Francisco.
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  Speaker 1: A record of physician and pharmacist behavior in triplicate a
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  Speaker 1: textbook example a progressive big brother in action. Now, why
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  Speaker 1: did I think of Sid Wolf when I heard about
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  Speaker 1: Paul Madden? Because Madden seemed to me like Sid one
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  Speaker 1: point zero the nineteen thirties edition. Different context and emphasis,
• 12:07
  Speaker 1: of course, but the same place book, the same urgency,
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  Speaker 1: the same relentlessness. The government needs to fix things. And
• 12:15
  Speaker 1: here is my twenty nine point plan to accomplish that,
• 12:18
  Speaker 1: which I'm forwarding over to you right now. Call me
• 12:21
  Speaker 1: when you get it right away. This is too big
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  Speaker 1: to way.
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  Speaker 2: So you know, Sid was his hair was always on
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  Speaker 2: fire about something.
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  Speaker 1: My memories of Sid is you would never know when
• 12:32
  Speaker 1: you would get off the phone.
• 12:33
  Speaker 2: That's true, that's true. I mean I've even talked to
• 12:36
  Speaker 2: him recently about some stuff I've done, and he'll not
• 12:41
  Speaker 2: just talk to you. Then the information starts flowing. In
• 12:44
  Speaker 2: those days, the facts started to churn because that's how
• 12:47
  Speaker 2: we got stuff. But Sid was like I would go
• 12:50
  Speaker 2: out to lunch and if there was a pile of
• 12:52
  Speaker 2: fax paper on my desk, it'd be like Sid struck.
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  Speaker 1: How many forests were sacrificed to feed Sid's fax machine?
• 13:01
  Speaker 1: God only knows. In any case, I moved on. I
• 13:06
  Speaker 1: left the Washington Post and forgot all about and his fixations,
• 13:11
  Speaker 1: and then I heard about an experiment and it all
• 13:14
  Speaker 1: came flooding back.
• 13:31
  Speaker 9: Once you've found the right doctor and have told him
• 13:33
  Speaker 9: or her about your pain. Don't be afraid to take
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  Speaker 9: what they give you. Often it will be an opioid medication.
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  Speaker 1: Beginning in the late nineteen nineties, a catastrophe unfolded in
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  Speaker 1: cities and towns around the United States. Opioid overdoses people
• 13:51
  Speaker 1: suffering a cascade of terrifying effects, pinpoint pupils, labored breathing,
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  Speaker 1: respiratory arrest, choking, purple lips, loss of consciousness, and, in
• 14:02
  Speaker 1: what has now been over eight hundred thousand cases, death.
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  Speaker 10: There's no question that our best, strongest pain medicines are
• 14:10
  Speaker 10: the opioids. They don't wear out, they go on working,
• 14:15
  Speaker 10: they do not have serious medical side effects. And so
• 14:18
  Speaker 10: these drugs, which I repeat are our best, strongest pain medications,
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  Speaker 10: should be used much more than they are for patients
• 14:24
  Speaker 10: in pain.
• 14:26
  Speaker 1: At the heart of the crisis was a class of
• 14:28
  Speaker 1: new powerful painkillers that came on the market in the
• 14:31
  Speaker 1: nineteen nineties, especially OxyContin, launched in nineteen ninety six by
• 14:37
  Speaker 1: the Purdue Pharmaceutical Company. OxyContin is highly addictive, and Purdue
• 14:43
  Speaker 1: promoted it to doctors more heavily than any other pain
• 14:46
  Speaker 1: color in history. By two thousand and two, Purdue had
• 14:50
  Speaker 1: thousands of salespeople around the country pushing OxyContin. This went
• 14:54
  Speaker 1: on for more than a decade, until doctors were prescribing
• 14:58
  Speaker 1: three billion dollars worth of OxyContin a year. But even after,
• 15:09
  Speaker 1: for twenty years of the opioid epidemic, there were all
• 15:12
  Speaker 1: kinds of questions like was OxyContin the cause of the
• 15:16
  Speaker 1: overdose epidemic or just a symptom of something deeper? And
• 15:21
  Speaker 1: even more puzzling, why didn't opioids cause the same level
• 15:25
  Speaker 1: of devastation everywhere? Take Massachusetts and New York, two states
• 15:30
  Speaker 1: side by side. If you run every significant fact about
• 15:34
  Speaker 1: Massachusetts and New York through an algorithm, you'll find there
• 15:37
  Speaker 1: are almost no two states more alike, same population profile,
• 15:42
  Speaker 1: same basic economy, same levels of poverty, very similar rural
• 15:46
  Speaker 1: urban mix. You'd think they would have had similar experiences
• 15:50
  Speaker 1: with overdoses. They didn't. Massachusetts has had a bloodbath, New
• 15:55
  Speaker 1: York not so much. Same thing with New York and
• 15:58
  Speaker 1: New Jersey super similar states by any measure, So why
• 16:02
  Speaker 1: did New Jersey suffer so much more than its neighbor
• 16:06
  Speaker 1: Perdue would end up in bankruptcy courts result of multiple
• 16:10
  Speaker 1: lawsuits launched against them, for misleading marketing practices, and not
• 16:14
  Speaker 1: long ago, four economists Abbey Albert, William Evans, Ethan Lieber,
• 16:19
  Speaker 1: and David Powell realized that the mountains of internal Purdue
• 16:23
  Speaker 1: documents unearthed in those lawsuits might hold some answers.
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  Speaker 11: I mean, so there were hundreds and hundreds of pages
• 16:29
  Speaker 11: of documents, some of which was not very interesting.
• 16:32
  Speaker 1: That's Abby Albert, lead author of the paper The for
• 16:35
  Speaker 1: them ended up publishing origins of the opioid crisis and
• 16:39
  Speaker 1: its enduring impacts.
• 16:41
  Speaker 11: But then when we happened upon the focus group research
• 16:45
  Speaker 11: especially and the launch plan, that really was the basis
• 16:49
  Speaker 11: for a lot of what we talk about in this paper.
• 16:53
  Speaker 1: Buried in that mountain of documents was an internal Purdue
• 16:57
  Speaker 1: report on a series of focus groups that the company
• 16:59
  Speaker 1: held with physicians. This was in the spring of nineteen
• 17:03
  Speaker 1: ninety five, right before the launch of OxyContin. The focus
• 17:07
  Speaker 1: group report runs to almost sixty pages, and in that
• 17:10
  Speaker 1: long buried document, one phrase kept popping up again and again.
• 17:15
  Speaker 1: The phrase coined by Paul Madden half a century earlier,
• 17:19
  Speaker 1: triplicate prescriptions.
• 17:23
  Speaker 11: So I had never heard of a triplicate program, and
• 17:26
  Speaker 11: it's not something that was being discussed in the research
• 17:29
  Speaker 11: on opioids.
• 17:31
  Speaker 1: I mean, why would it be? Nobody really liked triplicates.
• 17:35
  Speaker 1: For decades, no one followed California's lead in imposing this
• 17:39
  Speaker 1: special requirement for prescribing painkillers. Drugmakers, of course, hated the idea,
• 17:44
  Speaker 1: so did doctors and state lawmakers. In the early nineteen eighties,
• 17:48
  Speaker 1: the state of Texas did start a Tripica program, and
• 17:51
  Speaker 1: the state Narcotics Division in Austin had to hire thirty
• 17:55
  Speaker 1: three data entry clerks who in the first year mailed
• 17:58
  Speaker 1: out twenty seven eight hundred Tripica prescription pads to doctors
• 18:02
  Speaker 1: around the state. The doctors then had to write a
• 18:05
  Speaker 1: check for seven dollars for every pad they used, mailed
• 18:09
  Speaker 1: check back to Austin. Use the special pad every time
• 18:12
  Speaker 1: they prescribe anything off the restricted list, keep the pink
• 18:16
  Speaker 1: copy in their office for two years, send the green
• 18:19
  Speaker 1: and the blue copy with the patient to the pharmacists, etc.
• 18:21
  Speaker 5: Etc.
• 18:22
  Speaker 1: I mean, triplicate was the kind of bureaucratic nitpickiness that
• 18:26
  Speaker 1: drives people in the medical world crazy. The few states
• 18:30
  Speaker 1: that did triotriplicate programs usually drop them. By the early
• 18:39
  Speaker 1: nineteen nineties, they were just five states with triplica programs
• 18:43
  Speaker 1: in place, California, the Pioneer Texas, which somehow managed to
• 18:48
  Speaker 1: stick it out, and then Illinois, Idaho, and New York,
• 18:52
  Speaker 1: five states with warehouses full of carbon copies of doctor's prescriptions.
• 18:58
  Speaker 12: Every time you pick up that prescription pad, it was like, boy,
• 19:02
  Speaker 12: I'm prescribing and someone's watching me. And that's what a
• 19:05
  Speaker 12: lot of folks call the chilling effect.
• 19:07
  Speaker 1: Linda Westilla, who teach which is at the University of
• 19:10
  Speaker 1: Maryland School of Pharmacy, she did her dissertation on triplicate programs.
• 19:14
  Speaker 1: The chilling effect she's talking about was the knowledge that
• 19:17
  Speaker 1: physicians in those states had that their behavior was being watched,
• 19:22
  Speaker 1: that there was a permanent record of every prescription they
• 19:25
  Speaker 1: wrote in three places on paper, not in some abstract,
• 19:30
  Speaker 1: invisible computer file up in the cloud. Presumably each physician
• 19:35
  Speaker 1: has got a filing cabinet in his or her office
• 19:39
  Speaker 1: just full of prescription forms which they're holding on to
• 19:43
  Speaker 1: for years. So it is a powerful psychological reminder of
• 19:48
  Speaker 1: the way you have handled this specific kind of medication exactly,
• 19:53
  Speaker 1: And the doctor knows that there's a corresponding filing cabinet
• 19:57
  Speaker 1: somewhere in the state Capitol with a team of investigators
• 20:00
  Speaker 1: attached who can look at every prescription and see the
• 20:03
  Speaker 1: name of the patient, the name of the pharmacist, and
• 20:05
  Speaker 1: the name of which doctor has the biggest bulging file,
• 20:09
  Speaker 1: a file that says, just by its size, something fishy
• 20:14
  Speaker 1: may be going on. This is exactly what Purdue Pharmaceutical
• 20:18
  Speaker 1: discovered when it did its focus group with doctors in
• 20:21
  Speaker 1: nineteen ninety five, just prior to the launch of OxyContin.
• 20:25
  Speaker 1: One of their sessions was in a tripicate state in Houston, Texas,
• 20:29
  Speaker 1: and Purdue's takeaway after meeting with a group of Houston
• 20:31
  Speaker 1: doctors was clear, quote the triplicate laws seemed to have
• 20:36
  Speaker 1: a dramatic effect on the product usage behavior of the physicians.
• 20:42
  Speaker 1: It went on. The mere thought of the government questioning
• 20:45
  Speaker 1: their judgment created a high level of anxiety in the
• 20:48
  Speaker 1: focus group room among the doctors. Prideue looked at that
• 20:54
  Speaker 1: high level of anxiety and asked, is it even worth
• 20:58
  Speaker 1: marketing OxyContin in tripicate states at all? Years later, Abbey
• 21:03
  Speaker 1: Albert's group of economists finds this long forgotten focus group report,
• 21:07
  Speaker 1: and they realized that stumbled on a beautiful example of
• 21:11
  Speaker 1: a natural experiment. Natural experiments are the economists dream. You
• 21:16
  Speaker 1: don't have to create a treatment group and a control
• 21:18
  Speaker 1: group then laboriously compare what happens to the two groups.
• 21:22
  Speaker 1: Someone else has created the experiment for you. In this case,
• 21:26
  Speaker 1: the someone else was Purdue. A third of the American
• 21:35
  Speaker 1: population lived in the triplicate states. Those states got passed
• 21:39
  Speaker 1: over by the Purdue marketing squads. The rest of the
• 21:42
  Speaker 1: American population lived in states without Big Brother looking over
• 21:45
  Speaker 1: their doctor's shoulders. They got the full Purdue treatment. If
• 21:50
  Speaker 1: you wanted to know how much of the opioid crisis
• 21:53
  Speaker 1: was caused by OxyContin, all you had to do was
• 21:56
  Speaker 1: compare what happened to the Tripicut states with everywhere else.
• 22:00
  Speaker 1: So that's what Albert did, and what she and her
• 22:03
  Speaker 1: colleagues found was that the triplicate rule was everything.
• 22:08
  Speaker 11: What we found was that, in fact, the non triplicate
• 22:12
  Speaker 11: states had much more oxycon use per capita than the
• 22:16
  Speaker 11: Triplicut states, almost twice as much.
• 22:19
  Speaker 1: In most years, more OxyContin means more OxyContin overdoses, and
• 22:25
  Speaker 1: not just that, because many of those who got addicted
• 22:28
  Speaker 1: to opioids with OxyContin went on to get addicted to
• 22:31
  Speaker 1: heroin and fentanyl.
• 22:34
  Speaker 11: We see very quick increase in overdose deaths in the
• 22:39
  Speaker 11: non triplicate states and much slower growth in the triplicate states.
• 22:44
  Speaker 11: And these trends continue even twenty years after the launch.
• 22:48
  Speaker 1: Let's go back to comparing outcomes in New York and Massachusetts.
• 22:53
  Speaker 1: New York was triplicate, Massachusetts was not. So how much
• 22:58
  Speaker 1: of a difference did death single requirement make the two
• 23:01
  Speaker 1: extra carbon copies on the New York prescription pad. Well,
• 23:05
  Speaker 1: if New York had Massachusetts opioid overdose rate between the
• 23:09
  Speaker 1: years two thousand and twenty nineteen, an additional twenty five
• 23:14
  Speaker 1: thousand New Yorkers would have died of overdoses twenty five thousand.
• 23:19
  Speaker 1: Not only that, it turns out that economic growth is
• 23:22
  Speaker 1: higher in triplicate states than nontripicate states, health outcomes of
• 23:26
  Speaker 1: babies are better, and violent crime is lower in triplicate states,
• 23:31
  Speaker 1: astonishingly lower as much as twenty five percent. Exactly eighty
• 23:37
  Speaker 1: years after Paul Madden wrote his amendment to the California
• 23:40
  Speaker 1: Narcotics Act, His bureaucratic nitpicking gets vindicated by social science,
• 23:46
  Speaker 1: and who else gets vindicated? Sidney M. Wolf, MD. In
• 24:03
  Speaker 1: the early nineteen nineties, someone in the White House wondered
• 24:07
  Speaker 1: what was known about the value of triplicate programs. The
• 24:11
  Speaker 1: requests got kicked over to the National Institute of Drug
• 24:14
  Speaker 1: Abuse NIDA, and NIDA rounded up everyone who might know
• 24:18
  Speaker 1: something about triplicates and invited them to a conference at
• 24:22
  Speaker 1: a hotel near its headquarters in Rockville, Maryland. So you
• 24:26
  Speaker 1: attended the symposium, yes, Linda Westilla, who had done her
• 24:30
  Speaker 1: dissertation on triplicates, was one of the attendees.
• 24:33
  Speaker 12: I do remember the venue, and I do remember this
• 24:36
  Speaker 12: is really ridiculous. We couldn't have coffee.
• 24:38
  Speaker 1: NIDA was very hardcore about these kinds of things.
• 24:42
  Speaker 12: They wouldn't sponsor anything that had an addiction potential, including caffeine.
• 24:47
  Speaker 12: So at any rate, what I remember about that was
• 24:51
  Speaker 12: sort of the excitement of this is the first big
• 24:55
  Speaker 12: thing we've had about trying to control opioid use in
• 24:59
  Speaker 12: the United States.
• 25:01
  Speaker 1: This is nineteen ninety one. OxyContin will be introduced in
• 25:05
  Speaker 1: nineteen ninety six, five years later, but opioid overdoses were
• 25:09
  Speaker 1: still high enough in those years that people were starting
• 25:12
  Speaker 1: to get worried about the problem.
• 25:13
  Speaker 12: I was a pharmacist with a PhD. There weren't many
• 25:16
  Speaker 12: pharmacists with PhDs. So it was like, Wow, this is it,
• 25:20
  Speaker 12: and I believed in a lot of these policies.
• 25:23
  Speaker 1: The pain specialist Russell Portnoy was at the Nightis symposium.
• 25:27
  Speaker 1: He would later do as much as anyone to promote
• 25:29
  Speaker 1: the aggressive use of OxyContin. He talked about the problem
• 25:33
  Speaker 1: of under prescribing opioids. Someone from the American Pharmaceutical Association
• 25:38
  Speaker 1: was there to say how strongly the industry's biggest trade
• 25:41
  Speaker 1: group was opposed to any kind of federally mandated triplicut requirement.
• 25:46
  Speaker 1: After all, this was nineteen ninety one. Why will we
• 25:49
  Speaker 1: promoting some half baked idea from nineteen thirty nine. But
• 25:54
  Speaker 1: here and there there were other voices. An African American
• 25:57
  Speaker 1: doctor who worked in a tough neighborhood in Brooklyn, Gerald
• 26:00
  Speaker 1: d'es said this, I wish that anyone who opposes triplicate
• 26:05
  Speaker 1: prescription programs could walk with me into the real world
• 26:09
  Speaker 1: where these regulations are saving lives unquote. And then at
• 26:17
  Speaker 1: the end of the meeting, who gets up to speak,
• 26:20
  Speaker 1: SID will of course, because what is Sid's great cause
• 26:24
  Speaker 1: In the late eighties and early nineties, it's triplicans. SID
• 26:28
  Speaker 1: has decided that what America needs is a national version
• 26:32
  Speaker 1: of Chapter three, Article one, Section one one one six
• 26:36
  Speaker 1: six six of the California Narcotics Act. Sid, how are you.
• 26:42
  Speaker 6: It's been a long time.
• 26:45
  Speaker 1: So when I see Sid's name in the conference proceedings,
• 26:48
  Speaker 1: I realized I had to talk to Sid again after
• 26:51
  Speaker 1: all these years, so I called him up. Sid always
• 26:54
  Speaker 1: answers his phone, and right away he reminds me of
• 26:57
  Speaker 1: how we used to run into each other in the
• 26:59
  Speaker 1: Adams Morgan neighborhood of Washington, d C. We once played pool.
• 27:02
  Speaker 6: Together Dan's pool room. The last I wanted to Dan's you,
• 27:09
  Speaker 6: I couldn't walk in there because there were about ten
• 27:11
  Speaker 6: people change smoking, so I've never been in there again.
• 27:13
  Speaker 6: I think it's no longer around.
• 27:16
  Speaker 1: Just hearing that voice again, that low rumble, the eyebrow
• 27:20
  Speaker 1: raised at Dan's pool room, brought back all kinds of memories.
• 27:24
  Speaker 1: I think I was nervous. Thank you for joining me.
• 27:30
  Speaker 1: I would like to take a walk down memory lane
• 27:33
  Speaker 1: with you, and I want to talk about triplicate prescriptions.
• 27:40
  Speaker 1: I know this has been an issue that occupied you
• 27:42
  Speaker 1: with various points in your career, but I just wanted you.
• 27:46
  Speaker 1: I want to start at the beginning. When did the
• 27:48
  Speaker 1: subject of triplicate prescriptions first come to your attention.
• 27:51
  Speaker 6: I became aware of it, I would say, in the
• 27:55
  Speaker 6: early eighties, late seventies, something like that.
• 27:59
  Speaker 1: Even back in the nineteen eighties, you are concerned about
• 28:05
  Speaker 1: the problems being caused by opioids, thirty years before the
• 28:08
  Speaker 1: current epidemic. This is something that's very much a matter
• 28:13
  Speaker 1: of concern for you.
• 28:14
  Speaker 6: What's a matter of concern for several reasons. I would
• 28:19
  Speaker 6: attend FDA Advisory Committee means, and not a small number
• 28:22
  Speaker 6: of them had to do with opioids. And there were
• 28:24
  Speaker 6: already some problems with opioids in those days.
• 28:29
  Speaker 1: And SID, like Paul Madden two generations before him, had
• 28:33
  Speaker 1: become convinced that focusing on doctors was a big part
• 28:36
  Speaker 1: of the solution. Let them know they were being watched
• 28:39
  Speaker 1: with a few file cabinets of carbon copies.
• 28:43
  Speaker 6: I mean, the data which you've seen showing what happens
• 28:47
  Speaker 6: in a very short period of time after some of
• 28:49
  Speaker 6: these states implement these tripical prescription programs is astounding.
• 28:54
  Speaker 1: At the night of meeting in nineteen ninety one, SID
• 28:57
  Speaker 1: stood up and made the case for a national triplical program.
• 29:02
  Speaker 1: He said, in effect, California started an experiment. New York
• 29:06
  Speaker 1: and Illinois and others have joined, and the results of
• 29:09
  Speaker 1: the experiment are clear. It works. In a perfect world,
• 29:14
  Speaker 1: had everyone listened to whatnot it was saying in ninety one,
• 29:17
  Speaker 1: what all you guys were saying back in ninety one,
• 29:19
  Speaker 1: we would have had a very different and much less
• 29:21
  Speaker 1: damaging opioid epidemic of the last twenty years.
• 29:26
  Speaker 6: Right, there's no question about that, because it's a clear
• 29:30
  Speaker 6: public health problem.
• 29:32
  Speaker 1: He's right. A national triplicate program would clearly have slowed
• 29:37
  Speaker 1: the advance of OxyContin. Eight hundred and forty one thousand
• 29:41
  Speaker 1: people have died of drug overdoses since the nineteen nineties.
• 29:45
  Speaker 1: How many of those would now be alive. In nineteen
• 29:49
  Speaker 1: ninety three, SID published a monograph reiterating the need to
• 29:52
  Speaker 1: get serious about opioid prescriptions. It almost certainly made its
• 29:56
  Speaker 1: way to the Health and science desk at the Washington Post.
• 30:00
  Speaker 1: Did anyone take you up on it?
• 30:02
  Speaker 7: No?
• 30:05
  Speaker 1: I don't know why I bring us up on because
• 30:11
  Speaker 1: and one of the reasons this issue interested me so
• 30:13
  Speaker 1: much was that in the early nineties, when you were
• 30:17
  Speaker 1: thinking very seriously about the importance of triplicates, the person
• 30:22
  Speaker 1: covering the FDA, the Health bureaucracy, and science, all those
• 30:26
  Speaker 1: kinds of medical science, and for the Washington Post was me.
• 30:30
  Speaker 6: That's how we met.
• 30:33
  Speaker 1: We met, But back then my sympathies did not lie
• 30:36
  Speaker 1: with the Sid Wolves of the world. I didn't share
• 30:39
  Speaker 1: Sid's belief that government could fix everything. I thought medicine
• 30:42
  Speaker 1: was full of trustworthy, judicious professionals who did not need
• 30:46
  Speaker 1: Big Brother looking over their shoulder. In my time on
• 30:49
  Speaker 1: the Health and Science desk at the Washington Post, I
• 30:51
  Speaker 1: was in my twenties, a kid too young for nuances.
• 30:55
  Speaker 1: Sid was just the guy who called me up and
• 30:58
  Speaker 1: wouldn't let you off the phone, and sent you so
• 31:01
  Speaker 1: many papers and reports and polemics that you gave up
• 31:04
  Speaker 1: and just threw them in the trash. Sid Wolf was
• 31:11
  Speaker 1: so alert to the frailty of institutions that he seemed
• 31:13
  Speaker 1: to me like chicken little. I'll be candid. At the time,
• 31:18
  Speaker 1: I thought you were way off to the left. I
• 31:21
  Speaker 1: thought you were you know, my position was much more
• 31:25
  Speaker 1: sympathetic to big pharma that I thought you were just
• 31:29
  Speaker 1: a kind of crazy sixties radical who was always who
• 31:33
  Speaker 1: didn't believe in drugs. Now I realize no one was
• 31:36
  Speaker 1: more wrong than me on this issue. I mean, hundreds
• 31:40
  Speaker 1: of thousands of people have died in this country because
• 31:43
  Speaker 1: we didn't pay attention to what you were saying in
• 31:45
  Speaker 1: nineteen ninety one.
• 31:47
  Speaker 6: Well, all I can say is I certainly have been
• 31:51
  Speaker 6: thought by a number of other people that I'm some
• 31:54
  Speaker 6: sort of a sixties radical. So I do not blame
• 31:59
  Speaker 6: you or anyone else that thought that I was some
• 32:02
  Speaker 6: wild eyed.
• 32:04
  Speaker 1: But said I blame myself. It is almost certainly the
• 32:07
  Speaker 1: case that that might ponograph you wrote about Triplica Prescriptions
• 32:12
  Speaker 1: was sent to me at the Washington Post. It is
• 32:15
  Speaker 1: almost certainly the case that I did not read it.
• 32:18
  Speaker 1: And it is almost certainly the case that had I
• 32:21
  Speaker 1: read it, and had I taken it seriously, and had
• 32:24
  Speaker 1: I called you up, and had I educated myself, and
• 32:26
  Speaker 1: had I written a story about it in the Washington Post,
• 32:29
  Speaker 1: that maybe it would have made some small difference, or.
• 32:32
  Speaker 6: Even a book about it, or.
• 32:35
  Speaker 1: Even a book about it. I didn't do any of
• 32:43
  Speaker 1: those things. In the nineteen thirties, the rest of America
• 32:46
  Speaker 1: dismissed what Paul Madden was saying because they thought Paul
• 32:49
  Speaker 1: Madden was overbearing and hysterical. In the nineteen nineties. I
• 32:55
  Speaker 1: dismissed what sid Wolf was saying because we thought sid
• 32:58
  Speaker 1: Wolf was overbearing and hysterical. We violated all of us
• 33:02
  Speaker 1: the first rule of learning from experiments, which is to
• 33:06
  Speaker 1: judge the message, not the messenger.
• 33:10
  Speaker 9: Once you've found the right doctor and have told him
• 33:13
  Speaker 9: or her about your pain, don't be afraid to take
• 33:16
  Speaker 9: what they give you.
• 33:19
  Speaker 1: Sidwolf said the sky was falling back in nineteen ninety one,
• 33:23
  Speaker 1: and guess what the sky fell. Revisionist History is produced
• 33:32
  Speaker 1: by Elvis Linton, Leeman Gesteu, and Jacob Smith, with Taly
• 33:36
  Speaker 1: Emlin and Harrison VJ. Choi. Our editor is Julia Barton.
• 33:41
  Speaker 1: Our executive producer is mie La Belle. Original scoring by
• 33:45
  Speaker 1: Luis Kira, mastering by Flon Williams, and engineering by Nina Lawrence.
• 33:49
  Speaker 1: Fact checking by Keishaw Williams. Our voice actor was David Glover.
• 33:55
  Speaker 1: I'm Malcolm Glava. Well, thank you so much. This has
• 34:03
  Speaker 1: been so much fun and interesting. I think I can
• 34:08
  Speaker 1: find that memory serves. I think I read at least
• 34:12
  Speaker 1: part of your monograph from the art I can say.
• 34:14
  Speaker 6: The only thing I downloaded it. It's in one PDF
• 34:18
  Speaker 6: which i'll send you. Do I have your email address