The Crime of the Century: Big Pharma and the American Overdose Crisis | October 5, 2021

February 09, 2022

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The Crime of the Century, a two-part documentary, is a searing indictment of Big Pharma and the political operatives and government regulations that enable over-production, reckless distribution, and misuse of synthetic opiates. Exploring the origins, extent, and fallout of one of the most devastating public health tragedies of our time, with half a million deaths from overdoses this century alone, the film reveals that America’s opioid epidemic is not a public health crisis that came out of nowhere. Known for his cinematic, gripping, and deeply insightful documentaries, filmmaker and director of Crime of the Century, Alex Gibney, has won the Academy Award®, multiple Emmy Awards, the Grammy Award, and several other accolades. Patrick Radden Keefe is an award-winning staff writer at The New Yorker magazine and the author of the New York Times bestsellers Empire of Pain: The Secret History of the Sackler Dynasty.

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00:00Afternoon everyone, my name is David
00:03Fiellin I'm I'm the director of the
00:06Yale program in diction medicine,
00:08and I want to welcome you to today's
00:10talk in our finding solutions to
00:12the opioid crisis speaker series in
00:14collaboration with the Sandgaard Foundation.
00:18We are joined today by Alex
00:20Gibney and Patrick Radden Keefe,
00:23who will speak on the topic.
00:24The crime of the century,
00:26Big Pharma and the American overdose crisis.
00:29Before we get started.
00:31Just wondered if receive a few
00:33housekeeping items on the following slides.
00:37First, we encourage you to stay
00:39up to date with the latest in the
00:41finding solution series in the Yale
00:43Program in Addiction Medicine.
00:45By visiting our website following
00:46us up on on Twitter and joining
00:49our program listserv.
00:55Here are some instructions about
00:57hashtags you can use for today's talk.
00:59Second, as a reminder,
01:02coming coming up in this series
01:04will be welcoming Gary Mendell,
01:06who's the founder and CEO of
01:09the Shatterproof Foundation,
01:10who speak to us on October
01:1226th on the topic of stigma
01:14and substance use disorder,
01:16the silent killer.
01:24Here's some instructions on how you might
01:26be able to participate in today's talk.
01:29You can use the chat box to share comments
01:31and observations with your fellow attendees.
01:34You can post your questions in
01:36the Q&A box and it would if you'd
01:38like to unmute to ask a question.
01:40You can use the word raise hand function.
01:43We'll probably do that in the
01:45second half of this hour.
01:47We are offering CME credit today.
01:50So to receive credit please text the code
02:013064322034429435 and we will place
02:02those instructions in the chat.
02:09Now I'd like to introduce invite
02:11Kyle Henderson, who's the Executive
02:13director of the Sandgaard Foundation,
02:14to say a few words and share about the
02:16mission and work of the foundation, Carl.
02:19Thank you David and thank you
02:21everyone for joining us today.
02:23We've got two extraordinary guest
02:26speakers with Alex crime of the
02:28century and Patrick Empire of Pain.
02:31Huge fan of their work across the board,
02:34so we're honored to have them join us.
02:36Sandgaard Foundation was founded
02:38back in 2018, so we're quite young,
02:41but we are laser focused
02:42on the opioid epidemic,
02:44largely with regard to harm reduction.
02:47So year to date.
02:48Since January 1st,
02:49we've helped to distribute over.
02:50500,000 units of Narcan and
02:52naloxone around 26 states,
02:54mostly to recovery homes.
02:56We just launched our Colorado
02:58Naloxone initiative,
02:59so anyone that's at risk or comes
03:02to a hospital or an ER room.
03:04You know experiencing an overdose
03:06or coming close to are now going
03:09to be going home with Narcan or
03:11naloxone in their hand so they don't
03:13have to fulfill a prescription.
03:14Subsequent and overcome the
03:16stigma associated with that.
03:18And we're also big into entertainment,
03:20so we're working on a film
03:21right now called Junction,
03:22which is also going to focus on the crisis.
03:25We just helped to fund a concert
03:27in Vegas this last week.
03:28Along with mobilized recovery and
03:31the recovery out loud concert.
03:32So doing a lot of things but truly
03:35honored to be working with the
03:37old program in addiction medicine
03:38on this wonderful speaker series.
03:40So we appreciate everyone joining us
03:41and again, thank you, Alex and Patrick.
03:45Thank you, Kyle. Thank you for the support.
03:51OK, so so Alex.
03:54I'll introduce her two speakers,
03:57Alex Gibney and Patrick Radden Keefe,
03:59both of whom I will note.
04:01Or Yale alumni.
04:02So we warmly welcome back
04:04to New Haven virtually.
04:06Alex Gibney is an Academy Award Emmy Award,
04:09Grammy Award, and Peabody Award-winning,
04:11documentary filmmaker,
04:12who directed the HBO and HBO
04:15Max Two part documentary,
04:17THE Crime of the Century.
04:19Which explored the origins,
04:21extent and the fallout of the opioid crisis.
04:24Patrick Raddene Keefe is an award
04:26winning staff writer at The New
04:28Yorker magazine and the author
04:30most recently of the New York
04:32Times Bestseller Empire paint,
04:33the secret history of the Sackler dynasty.
04:37So we thank both of you for joining
04:38us today and appreciate appreciate
04:39the way your work has placed a
04:41spotlight on some of the origins
04:43of this major public health crisis.
04:46Alex, you're gonna take it away.
04:49OK, thank you David.
04:53So it's a pleasure to talk to you all,
04:56and obviously you're in.
04:58You're engaged in some very important work.
05:02And I I feel to some extent a little
05:05bit shy in the sense that I I don't
05:08know that much about medicine,
05:09but I've spent a lot of time
05:12thinking about commerce and crime.
05:14And that's how I entered this story.
05:16You know, like many people,
05:18I was experienced,
05:20many hand wringing moments.
05:23Regarding the opioid crisis and and
05:25tended to think of it like a natural
05:27disaster like a flood or a hurricane.
05:29It's something that just happened.
05:31But it in a meeting with some investigative
05:33journalists at the Washington Post,
05:35I was convinced that I became convinced
05:38that the crisis didn't just happen.
05:41It was manufactured. And.
05:42And that led me to the idea of the
05:44notion of the crime of the century.
05:46That is to say,
05:48in the pursuit of profit surrounding opioids,
05:51a number of companies created
05:55an enormous demand for opiates,
06:00which then, you know, once the.
06:01Once the initial surge of Oxycontin happened,
06:04then many people turned to
06:06heroin after that to fentanyl.
06:08And and and you you have a full blown crisis,
06:12but it was a crisis that was very much
06:14manufactured at start and I think
06:16it was manufactured in many ways.
06:19Fraud, that is to say, companies,
06:22particularly early on Purdue Pharma.
06:27You know, arguing that?
06:31Opioids were not addictive. And that.
06:38What was the slogan The The the one to
06:40start with and the one to stay with?
06:43No dose was too high and and
06:46so that notion led me to.
06:50Really, start the film with with a
06:52with a kind of sense of historical
06:54breadth that this is a problem that
06:57we've been dealing with for some time.
06:59This intersection of crime
07:00and commerce going way back.
07:03To to the Egyptians and then you know,
07:07following up through the Opium War,
07:09you know, organized crime,
07:12then into organize commerce,
07:13which is where we pick up the story.
07:16You know, in the last 20 or
07:1825 years I call it crime.
07:19The century meeting with 21st century.
07:22And it was.
07:25The muscle with which Purdue Pharma
07:29got involved that got involved in
07:32trying to convey the idea that.
07:37That opioids were were not addictive that.
07:42Lead me and and Patrick and we
07:43can talk a little bit about you
07:45know how we work together as a?
07:47He is a print journalist and
07:49myself as a as a filmmaker to
07:52discover some things about.
07:56How Purdue worked with regulators to
07:58assure that their view of how Oxycontin
08:01should be perceived for the maximum
08:04market benefit could be accomplished.
08:06So maybe we might show a clip of
08:09of the the Curtis right sequence.
08:14This is a. This is a clip from
08:16part one of crime in the century.
08:20Alright, thank you, give me
08:22one second to keep that up.
08:34Discussed there was a gentleman named
08:36Curtis Wright who worked at the FDA and
08:39and as the as the document suggests he was.
08:45Involved in helping to draft or
08:48helping to review, he was involved in
08:51inviting executives for Purdue in to
08:54basically review their own application
08:56as part of a process which allowed
08:58Purdue to claim in its package insert.
09:01That is, you know,
09:03Oxycontin was believed not to be addictive,
09:07so it's it's it's kind of
09:08a shocking development.
09:09Of course, a year after or year or
09:12so after Curtis right left the FDA,
09:14he then went to work.
09:15For Purdue and was rather handsomely
09:18compensated, so that was a,
09:20you know one incident of of corruption
09:22I I'm going to show another clip quickly
09:25and I'll I'll set this one up again.
09:27The there were there was tremendous
09:30attention paid to trying to prove
09:32to doctors all over the country that
09:35Oxycontin was not addictive and one
09:38of the most incredible instances
09:41that I discovered.
09:43Was was the use of a uh,
09:46of a gentleman named Gary Blinn,
09:48who was.
09:51Well, let's let's take a look at the
09:52clip and then I'll explain it afterwards.
09:54So let's go to the Gary blend clip.
10:05Offered to give him free samples of Oxy
10:07Contin and then they kept upping the dose.
10:10As you saw he saved that pill bottle
10:12for many, many years 'cause he
10:14thought something was terribly wrong.
10:15But one of the more intriguing things
10:17that happens just after this in in
10:19the film is that Stephanie Kaufman.
10:24You know when she uses Gary Blan
10:26effectively as a marketing tool to
10:28show doctors that no dose is too high
10:32and he was getting a staggeringly
10:34high dose of Oxycontin and and
10:36he was a former heroin addict.
10:37So we developed quite a high
10:40tolerance for opioids.
10:42Her supervisors at Purdue didn't
10:44admonish her, didn't punish her,
10:46promoted her to be a sales trainer,
10:50which gives you some sense of
10:53of how rapaciously they were.
10:55You know that the folks at
10:57Purdue were really pursuing the
10:59exploitation of what they called
11:01inside the company hillbilly heroin.
11:03Alright, so a lot of what goes on
11:05here in in the broad scope of of
11:08the two part series that I do is.
11:10Is about the corruption of medicine
11:13and also how the government to
11:15some extent and the regulators
11:16are bought off in the process.
11:18But the Purdue model then gets kind
11:22of ramped up by some other rather
11:25unethical companies who who who who
11:27did stuff that was so unethical.
11:29They were finally prosecuted and
11:30this was a company called insist
11:33that had a fentanyl spray called
11:35Subsys and I'm going to show you a
11:37brief clip of a of a salesperson for.
11:42Insist. And how, in in his corrupt scream
11:47he would literally categorize doctors.
11:50So he knew just the ones to target
11:53for maximum impact when he would
11:55shower them with bribes for buying
11:58greater and greater for essentially
12:01rewarding them for prescribing
12:03greater and greater doses of Subsys.
12:06So let's take a look at the.
12:09Four colors clip.
12:22Vice President insists.
12:23Kind of the head of sales,
12:25and it's rare that you get somebody
12:28who talks to you with a kind of
12:31candor that Alec Burlakoff did.
12:33Now, at the time he had
12:34already been convicted,
12:35he had decided to plead guilty to
12:40a number of federal crimes and,
12:43and in exchange for testimony
12:44on behalf of the state,
12:46they were giving him a deal and and.
12:48And in fact,
12:49there was a prosecutor in the room,
12:50the federal prosecutor in the room
12:52while we were conducting the interview.
12:53But remarkably, Alec Burlakoff,
12:56after you know, sort of routinized,
13:01confessions of regret,
13:02managed to take himself back
13:05to the period when he was,
13:09you know,
13:10really running sales at incest
13:12and communicate his methodology
13:14and the extreme enthusiasm with
13:16which he puts so many people
13:18at risk and and basically.
13:22You know corrupted doctors for a living.
13:25So that gives some broad sense of
13:27of of of of how I approach this
13:30notion of the crime of the century.
13:33Looking at the way that companies.
13:37Use the hunger for opioids to
13:42to create products and to market
13:45them in ways that were fraudulent.
13:48To try to convince people that they
13:50were not addictive and to convince
13:52doctors that it was either in their
13:55economic interest to sell as much as
13:57possible despite the danger to the patients,
14:00or to try to convince people that
14:02that their product had somehow found
14:05this kind of magic zone where.
14:07You know the the these these medicines
14:10could cure pain and also not be addictive.
14:14That again,
14:15this intersection of you know when you're
14:18making up when I'm making a film like this,
14:19I tend not to focus so
14:21much on on on on victims,
14:23even though we we make manifest
14:26in in the film how devastating
14:30this crisis has been and show,
14:33you know,
14:34a task force in San Diego who is routinely.
14:39Pursuing fentanyl overdoses
14:41and trying to find,
14:43you know the the culprits responsible
14:46for providing illegal fentanyl to people
14:49who are overdosing in large numbers,
14:51but we focus on the perps.
14:54I focus on the perks because
14:56my my view is that.
14:59If you want to prevent crime in the future.
15:02Have to figure out how those crimes
15:04are committed and that takes you to
15:06the perps and and an understanding of
15:08how the crimes were committed in that.
15:11I I was very lucky along the way,
15:14not only to work with a number of
15:17investigative reporters at at the
15:19Washington Post, but you know,
15:22but but I learned that Patrick was
15:24working on a book about the Sacklers,
15:26and I have enormous respect for Patrick,
15:28who is not only a wonderful
15:30investigative journalist,
15:31but a magnificent writer.
15:32We had intersected on a project on
15:35Northern Ireland where I was doing
15:37something kind of similar to two.
15:40Some of the themes that that he was
15:41investigating in a book he did about
15:43Northern Ireland called say Nothing,
15:44which is a magnificent book.
15:46And when I learned he was doing,
15:48you know first, The New Yorker piece
15:49and then a book about the Sacklers.
15:51I was like maybe there's some way
15:53we can work together because I had
15:55such enormous respect for him and
15:57and I knew that we shared this
16:00interest in the intersection of.
16:03Commerce and crime and and how in
16:05in in some ways if you look at at at
16:09criminal drug cartels you see some of
16:11the same economic mechanisms and models
16:13that are used by a legitimate businesses,
16:16the so-called legitimate businesses
16:18and and that provided an interesting
16:20focus and and so we ended up
16:22working together to some extent.
16:24I mean Patrick was working on his own on
16:26his book and doing his thing and I was
16:28working on the film and doing my thing.
16:30But whenever we had opportunities we
16:32shared testimony with each other.
16:34That we would get from people we found
16:36each of us found different documents
16:38that we would share with each other and
16:40it ended up being a very powerful and
16:42important collaboration which I I do a lot.
16:45Honestly with journalists I have
16:47tremendous respect for print journalists
16:48and investigative journalists.
16:49And Patrick, you know,
16:52I have enormous respect for I
16:53having worked with them before.
16:55So with that I'm going to throw over to.
16:57Patrick will give you some sense of
16:58how he came at it and and while I was
17:01telling him a kind of a broader story,
17:03Patrick was much more focused.
17:04On in his book,
17:06Empire Pain on the Sacklers themselves,
17:08both going deeper into the past
17:09with the Sacklers,
17:10and then also focusing on
17:12the story of Purdue.
17:13So with that over to you,
17:15Patrick.
17:17Unmute myself. Hi there.
17:20I'm Patrick Radden Keefe and it's a
17:23real pleasure to be with you today.
17:24Thanks for tuning in and thank
17:27you Alex for joining me for this.
17:31Yeah, so I I was excited to have
17:33this conversation because it is
17:34this sort of interesting thing
17:35where Alex and I have been working.
17:37Kind of in parallel with points
17:39of convergence along the way,
17:41but on two projects that approach.
17:45This massive an urgent issue from
17:50slightly different vantage points.
17:53Alex takes a pretty wide angle lens and
17:57actually manages in this amazing two
17:59part film which if you haven't seen,
18:01I really would encourage you
18:02to take the time.
18:03I mean,
18:03I think you gotta taste from those clips,
18:05but it's well worth watching the whole thing.
18:09To take in the full scope of this
18:11this incredibly complex public health
18:13crisis that has killed more than half a
18:16million people over the last 25 years.
18:17And there are different phases of that.
18:19So he looks closely at the early days
18:22with Oxycontin and prescription opioids,
18:24but also at the later days with fentanyl,
18:28both prescription fentanyl,
18:29which you have in the case of Insys,
18:32but then also at the black market,
18:34which is a huge issue today,
18:36and so he's able to kind of
18:38capture the ways in which.
18:40What we're talking about when we talk
18:42about the opioid crisis is actually
18:43kind of a shifting picture, right?
18:45And it's today it's really not a
18:48prescription pill problem in quite the
18:50same way that it was in the early years.
18:53So I came to it from a slightly
18:54different angle.
18:55As Alex mentioned,
18:56I've always been interested in in crime
18:58and commerce myself and I had been
19:01very interested in drugs and the sort
19:04of permeable boundary between what is
19:06legal and illicit and illegal and illicit.
19:10And I had a particular interest
19:11in the Mexican drug cartels.
19:13I wrote a big cover story for the
19:15New York Times magazine in 2012,
19:16which I joked at the time it was sort of
19:19a Harvard Business School case study of
19:21a Mexican drug trafficking organization.
19:23Really trying to look at it as a business,
19:25and the way in which functioned
19:27and where this project started
19:30for me was looking at the sudden
19:33increase in around the year 2010.
19:37In the volumes of heroin that were
19:39being shipped across the border
19:41from Mexico into the United States.
19:43These cartels, the big ones,
19:46are exquisitely sensitive to consumer demand,
19:49and so when they sense that
19:50there's a market for a new drug,
19:52I mean it.
19:53Actually, it had happened previously
19:55with methamphetamine as well.
19:56I mean,
19:57they they will quickly kind of rejigger
19:59their business to up production
20:00of a product line that they think
20:03is going to have ready buyers.
20:04And then we'll intensify the
20:07export of those products.
20:09So the question was,
20:10why is this country suddenly awash
20:12in Mexican heroin in a way that?
20:13It hadn't necessarily been 10 years before,
20:16and the answer many of you will already
20:19realize is the opioid crisis is that
20:22you had a generation of consumers
20:24who were people who in many cases I
20:26think probably wouldn't have gone out.
20:29They wouldn't have sort of started
20:30from zero and gone out and bought
20:32drugs on the street.
20:33They had an on ramp,
20:34which was prescription pills either.
20:38Instances of iatrogenic addiction where
20:40they were prescribed pills by a doctor
20:43for pain and then found that they.
20:47Were becoming dependent and addicted
20:49and and starting to abuse the drugs.
20:52Or you know for that matter.
20:53I've interviewed many many people
20:54and I'm sure many of you have
20:56spoken with people who you know the
20:58first oxy they took was at a party.
21:00They started out using
21:02these drugs recreationally,
21:03but the knowledge that the drugs were
21:05FDA approved and that you stole it out
21:08of your parents medicine cabinet did
21:10make it seem on the front end like a
21:12less threatening proposition than going
21:14out and buying heroin on the street.
21:18But what really fascinated me as
21:20I started looking into this was
21:22that there was this one company,
21:23Purdue Pharma, that I think there was
21:26there was a fair amount of agreement,
21:27had played a very special role in
21:30helping precipitate the crisis,
21:32so that's not to say that Purdue
21:34was the only company to blame.
21:35There are obviously other companies
21:38marketing and selling opioids.
21:39There are many other bad actors
21:41in this story.
21:42I think there's plenty of blame to go around,
21:44but in the words of 1 employee who
21:46worked on Oxy Contin, who I interviewed.
21:49Uh.
21:50Purdue and Oxycontin were the
21:51tip of the spear.
21:53There was a very conscious decision at
21:55high levels of that company to change the
21:58way in which American physicians prescribed,
22:00and you see,
22:01some of that campaign and
22:02what Alex was talking about.
22:03And we can certainly talk more about
22:05the ways in which that happened.
22:06What interested me was that that
22:09much of the story was known.
22:11In 2007, Purdue had pled guilty
22:13to federal criminal charges.
22:14There have been many,
22:16many lawsuits against the company.
22:18But the company was owned by this family,
22:20the Sacklers.
22:21And I was familiar with the
22:23Sackler name in a very,
22:24very different context.
22:25I grew up in Boston.
22:27I worked for a year after high school
22:29and before college at the American
22:30Repertory Theater in Harvard Square,
22:32and there's the Sackler Museum at Harvard.
22:35I moved to New York City,
22:36went to Columbia,
22:37where the Sackler name is all over the place.
22:39On the weekends,
22:40I would go to the Met to
22:41the Sackler wing of the Met.
22:43I ended up going to law school at Yale,
22:45and, as you may know,
22:47Yale has been a big recipient until fairly
22:50recent years of lots and lots of money.
22:52From the Sackler family,
22:54including the Yale School of Medicine.
22:56So what I knew was the imprimatur of this
23:00philanthropic dynasty who were known
23:03really chiefly for their generosity.
23:05They were thought of as these
23:07kind of benevolent,
23:08rich people who were very closely associated
23:11with academic prestige at elite universities,
23:15and with the art world.
23:17And.
23:18This seemed really strange to me,
23:20particularly because it wasn't actually
23:21a secret that they owned the company.
23:23It had been written about by
23:25Barry Meyer and a New York Times
23:27reporter as far back as 2001.
23:28Sam Quinones wrote a great
23:30book called Dreamland,
23:31which many of you have probably read,
23:33which came out in 2015 and had a couple
23:35of chapters about the Sacklers and.
23:37I was just sort of puzzled that
23:40this history had not caught up with
23:42them and I was fascinated by the
23:44idea that there was this family
23:46that had made billions
23:47and billions of dollars.
23:49You know, while in the background
23:52the downstream consequences of
23:53their own decisions had led to
23:55so much death and destruction,
23:58and so initially I wrote a
23:59piece in The New Yorker in 2017
24:02which was all about the family,
24:03and I think there's something
24:05Alex mentioned about victims,
24:06and I think it's something I want
24:07to get to in a minute and then
24:09maybe talk about with him, but.
24:10You know any of us?
24:12If you're making a film,
24:13if you're if you're writing a piece,
24:14if you're writing a book.
24:16You sort of decide what your
24:17aperture is going to be and
24:19where you're going to focus,
24:20and I notice that in the
24:23literature of the opioid crisis.
24:25There was a tendency,
24:26particularly in the books,
24:28to tell a kind of multi strand
24:30story in which you have multiple
24:32characters and themes that you're
24:34servicing and you kind of cut back
24:36and forth between chapters and so
24:38you know you might have a doctor and
24:40then you have a you meet the high
24:42school athlete who then gets injured
24:44and then is prescribed Oxycontin
24:46and then starts developing problems
24:47and you're going back and forth
24:49and back and forth and the Sacklers
24:52would occasionally feature as kind
24:53of 1 strand in the tapestry like that.
24:55This was the case with
24:57with Barry Meyers book.
24:58It was the case with Sam Quinones
25:00book with some of the press
25:01coverage in which the family had
25:03featured they were always there,
25:05but sort of there in the margins
25:07and what I wanted to do was just
25:09put a spotlight right on them
25:11and and focus very closely on the
25:13family and not cut away too much
25:15and and see you know how they held
25:18up under that kind of scrutiny.
25:21You know I would.
25:22I would posit to you that they
25:23don't hold up too well that the the
25:25conversation when it comes to the Sacklers,
25:27and certainly the legal conversations
25:29have often involved questions
25:31about how to what extent were
25:33they really managing the company.
25:35Was the company just kind of chugging
25:37along autonomously and and just sort of?
25:40You know,
25:40sending off billions of dollars that
25:42landed in the family's bank accounts?
25:44Or was this more of a kind of command
25:47and control situation in which
25:49the family was really exercising
25:51strategic vision and leadership
25:52and direction at the company?
25:54And my research indicated it
25:56was very much the latter,
25:57which raises questions of,
25:59you know,
25:59both of legal liability but also
26:01just a moral culpability,
26:03and so that was a question I
26:04wanted to explore.
26:05As I deepened my research beyond
26:07the piece and wrote this book,
26:09which was published in April,
26:11what was really fascinating to me is that.
26:14The story goes further back
26:16that that the original 3 Sackler
26:18brothers were three physicians.
26:20They were psychiatrists who
26:21came of age really against the
26:23backdrop of the Great Depression
26:25and made their fortune in
26:27the pharmaceutical business.
26:28But actually, the first big
26:29fortune was made in pharmaceutical
26:31marketing and advertising,
26:33and there are these incredible
26:34stories about Arthur Sackler.
26:35Some of these stories,
26:36Alex tells in his film as well,
26:37but the oldest of these three brothers,
26:39who was kind of the Don Draper of
26:42medical advertising in the 1950s.
26:44Made his first great fortune
26:46by marketing Valium.
26:47Another potentially quite addictive
26:49substance that made him very very
26:52wealthy and owned a pharmaceutical
26:54marketing firm and really pioneered
26:57a lot of the developments that we
26:59see even today and so from the idea
27:02of sending out an army of sales
27:05reps to enlisting doctors to be the
27:08kind of pitchmen for your product
27:12to dramatically overplaying the.
27:14Range of therapeutic benefits from
27:17a drug to dramatically underplaying
27:19the range of side effects.
27:21A kind of fun little piece of
27:23trivia is that the the term.
27:26Broad spectrum.
27:29As applied to to drugs,
27:31was actually coined by Arthur's
27:33firm was it was it was a term
27:35invented by marketing people right?
27:36And so part of what was really
27:38fascinating to me is that Arthur Sackler,
27:40this brother, who dies in 1987.
27:43But in the 40s fifties 60s,
27:44he really kind of creates the world in
27:46which Oxycontin would eventually do it.
27:48It did.
27:49He creates the world in which you
27:51know that that marketing campaign
27:53that Alex described is able to
27:55be as effective as it was in
27:57changing the way in which American
28:00physicians prescribed these drugs,
28:02and therefore in giving
28:05rise to the opioid crisis.
28:08You know,
28:09if if the if the crisis is as you know,
28:12this staggeringly complex.
28:14Phenomenon you know about which
28:19many books have been written
28:20and many more will be written.
28:22What I wanted to do is in some ways
28:24tell us somewhat simpler story which
28:25which was kind of an origin story.
28:27I wanted to go back and see
28:29how did this thing begin,
28:30and so in that sense,
28:32my book isn't even really an
28:33opioid crisis book per say.
28:34It's more of a kind of
28:36multigenerational family saga.
28:37But this theme that runs all the
28:40way through it is that there was
28:42a kind of mania in this family for
28:45collapsing the boundaries between.
28:47Medicine and commerce.
28:48You know,
28:49finding some way for the market
28:52to create a wedge between a
28:54patient and his or her physician.
28:59And I think I'll leave it at that,
29:01but I I will say that the you know the the.
29:04The collaboration with Alex
29:06was was really fun for me.
29:08Frankly,
29:09I think you know print journalists
29:11can often take a somewhat
29:130 sum view of the world,
29:15and if they find out that anybody
29:17else is working on a project
29:19that is in the same wheelhouse.
29:22They get very proprietary and defensive,
29:25and in this case Alex and I
29:27collaborated in the past.
29:28I had the highest regard for his
29:30work and I think we both took a view
29:33that the the whole could be greater
29:34than the sum of its parts in this case.
29:37And so you know I ended up
29:39doing an interview for the film,
29:40but also as Alex said,
29:41we went back and forth and.
29:44You know, I don't know what the
29:45analogy would be in the kind of
29:47medicine that that you all practice,
29:49but these kinds of deep investigative
29:52projects can often be quite lonely
29:55because you're sort of there just digging
29:57away in the mineshaft by yourself and
29:59a lot of the time you don't even know.
30:01I mean, it's sort of a joke that my wife,
30:05when I come to dinner at the end of the day,
30:07and I want to talk about whatever The
30:08thing is that that has been troubling me.
30:10It's I'm so in the weeds that
30:12it's very hard to.
30:14To convey to another person who's not been
30:17in there doing this bad work with me.
30:19So it was a huge thrill.
30:20I mean,
30:21there were a number of mysteries
30:23that Alex and I were were kind
30:25of confronting and and it was
30:26a great thrill to be able to.
30:28Who you know literally?
30:29In some of these instances,
30:31it's like what happened behind closed
30:33doors at the Justice Department in
30:35one particular week in the year 2006.
30:38Or maybe it was early 2007,
30:40where they decided not to pursue
30:42felony charges against individual
30:44executives at Purdue Pharma.
30:46You know I could talk about that
30:47till the cows come home and there
30:49are not many people who would be
30:50particularly interested in doing that.
30:51But fortunately I I found one in Alex
30:54and so it was a really thrilling.
30:57Collaboration in that respect
30:58and I I feel very fortunate,
31:01I think what we're going to do,
31:02if it makes sense to you all is we'll
31:04just talk a little bit back and forth,
31:06'cause I have a question or two for Alex.
31:07And then maybe we'll open it up to others.
31:09But Alex mentioned victims and this
31:12is something I thought a lot about.
31:15And you know,
31:16I think it's actually a great sign of
31:19progress that we talk about people who
31:22struggle with addiction as victims.
31:25Many of you will probably be
31:26familiar that there's a.
31:27You know there's there's a critique,
31:28and I think a very sound one that talks
31:31about the racial violence here where
31:33there is a more compassionate language
31:35we use when we talk about the opioid crisis,
31:38people wonder where was this
31:40concern for victims during the
31:42crack epidemic back in the 80s?
31:44But I think it's a great sign of progress,
31:45and obviously I think a lot more
31:48destigmatization has to happen.
31:50But both Alex and I separately,
31:53I think, made a decision.
31:55Not that you would ignore the experience
31:57of people struggling with addiction
31:59as one of those clips made clear.
32:01I mean Alex did interview these
32:03people and incorporate their stories.
32:06But that there would be a kind
32:09of prosecutorial focus
32:10on the bad actors. And, you know,
32:12I had my own reasons for doing that.
32:14Alex, but I wondered if maybe
32:15you could talk a bit about about
32:17yours and sort of the status of
32:19victims in a project like this.
32:21Well, I mean the status of victims
32:24always has to be in the mind because
32:27after all they are the casualties
32:29of this crisis is, as you said,
32:31early on Patrick I mean 500,000 people.
32:34More than 500,000 people dead.
32:38And and there is a poignancy to
32:41their struggle, but I think that.
32:44For so long there had been a tendency,
32:47even on the part of the of the malefactors,
32:51to blame the victims, that is to say,
32:53to to to effectively say this
32:55was a lack of strong character.
32:57They were just, you know, weak people,
33:00because they got addicted.
33:01That's not our problem,
33:03and and and to turn the lens
33:05in a different direction,
33:06was really to show how.
33:10A different kind of
33:11psychological process worked,
33:12which is a psychological process
33:14that's always interested me, which is.
33:18With the police call noble cause corruption.
33:21The idea that when you think you
33:23have a noble cause and in this
33:25case it was the IT was the notion
33:27that you could cure pain and the
33:29pain had become the 5th vital sign,
33:31and that that that that end justifies
33:36any any amount of ignoble means
33:38in order to get there until you
33:41get to a place where you know.
33:43You can't even see the lines
33:46that you've crossed,
33:47because they're all wrapped in this kind of.
33:52Sort of facade of nobility.
33:53You know the the cops use the term
33:56because it's it's part of you.
33:58Know what happens when you know a
34:00cop in the street is frustrated.
34:02He's not getting the the drug kingpin.
34:06And instead of doing it the right
34:07way ends up, you know,
34:09planting drugs in in his car,
34:11something like that,
34:11and and feeling good about it
34:13till the next thing.
34:14You know that that corruption
34:16is really ramped up.
34:17So so that focus I thought was very
34:20important because you had to see the
34:22crisis from a different perspective
34:24and and I you know I talked early
34:26on about crime and commerce and
34:28and and Patrick came into this.
34:29From that, you know, Patrick,
34:31you came into this from that too,
34:32but I think you've properly
34:34reframed in the sense that.
34:35It's how the commerce of medicine ended
34:39up corrupting the nobility of the.
34:43Uh,
34:43of so many and and that really is a problem,
34:46because who do you trust more
34:48than anybody is your doctor?
34:49And if your doctor has become corrupted?
34:53Through the blandishments by people
34:55like insists or or or Purdue,
34:58then you've got a real problem and
34:59and and then you have a corruption
35:01at a very deep level.
35:02And then of course you depend on
35:04regulators to help solve the problem,
35:05but the regulators end up being bought
35:08off through campaign contributions
35:09and and I I you know I document
35:12that at some length and Patrick and
35:14I did spend a tremendous amount of
35:16time talking about how influence
35:18at a very high level prevented
35:20felony charges from being brought
35:22against executives at Purdue.
35:24Which might have led if they were
35:26to have flipped to, you know,
35:28prosecutions of the Sacklers
35:30themselves and and that that was,
35:33you know,
35:34corrupt because that's something
35:35as a matter of public policy.
35:38You can really begin to address once you
35:41understand you know how the crime works,
35:43how the corruption works,
35:45then you can hopefully try to steer
35:48against it and and and it seems like
35:51that's the best way of serving.
35:54The victims, that's that.
35:55That would be my view.
35:57Yeah, I mean, it's fascinating hearing.
35:59I should say just just a little program note.
36:01I think there are various.
36:02If you look in the chat box,
36:03there are various ways in which
36:05people can submit questions,
36:07so I'd encourage you all to do so.
36:11There should be instructions,
36:11I think at the top of the chat box
36:13about about how to do that, but the.
36:15It's fascinating hearing you talk
36:16about the noble cause corruption idea,
36:19because one thing that I became really
36:21fixated on and I think for the physicians
36:24and medical students joining us today.
36:28This may be an interesting dynamic.
36:30In one you're probably familiar with, but.
36:35Arthur Sackler, you know,
36:37from whose mind I think so
36:39much of of where we are today,
36:41sprung how to view, essentially,
36:43that the physicians cannot be corrupted.
36:46He had a notion of physicians as
36:49kind of possessed of a nobility
36:51where they were incorruptible.
36:52They were kind of unimpeachable.
36:55But he would talk about how we
36:58don't need to worry about medical
37:00advertising and pharmaceutical
37:02advertising because nothing could get
37:05between the physician and the dictates
37:07of the best care for the patient.
37:09And this was really striking to me.
37:11I mean, first of all, it's hypocrisy, right?
37:12Because because Arthur Sackler for
37:14decades ran a medical advertising firm
37:16which made lots and lots of money by
37:18advertising for doctors and changing
37:20the ways in which they prescribed.
37:22That was the whole point.
37:25But also because I think there's a kind of,
37:27I actually think that in that
37:29very notion of Unimpeached ability
37:31lies the danger of corruption.
37:33I mean,
37:34I've interviewed and talked
37:35to just socially any number of
37:38physicians who've said to me.
37:39Of course,
37:40we realize that the pharma companies
37:43are always pursuing this kind of full
37:45court press trying to influence us,
37:47but I personally would never be
37:48influenced by that sort of thing.
37:50You know, there's this sense of,
37:51yes,
37:52I I kind of register the clamor of
37:54them trying to change the way I behave.
37:57But I'm immune to that clamor and
37:58it's funny because when you when
38:00you really get into the statistics
38:01and you look at the history at
38:03a company like Purdue Pharma,
38:04you know there's a statistic I
38:07cite in the book where some years
38:10Purdue would spend $9 million
38:11just buying food for doctors,
38:14and I can't tell you how many doctors
38:17I've talked to who say, come on,
38:19you think you buy me a steak dinner
38:21and it'll change the way I prescribe.
38:22You know, they're kind of insulted
38:24by the very suggestion,
38:25but the thing about Purdue?
38:27Then the Sacklers and Richard Sackler,
38:29who you know was running the company
38:30for some of these years in particular,
38:32is the real sticklers for
38:33detail and and for spending,
38:35and they knew exactly,
38:37you know,
38:38down to the dollar what the return on
38:40investment was on that kind of spend.
38:42And I actually strangely think
38:44that this kind of the in our
38:47cultural iconography of the doctor,
38:50our notion of the physician,
38:52as this priest like figure.
38:54I actually think some of the seeds
38:55of the corruption are right in there.
38:56What I think about it,
38:57I grew up in Boston.
38:58And I grew up in a extended
39:01Catholic family in Boston,
39:04and I think if you look at what
39:07happened with the sex abuse.
39:09Crisis in the Catholic archdiocese.
39:11There part of the problem was that
39:14periodically when word would sort of
39:16dribble out that there were something
39:18bad was happening and some of these
39:20priests were doing terrible things.
39:22There were people you know,
39:23frankly,
39:23like relatives of mine who would say,
39:25well, not priests.
39:26You know, like I could,
39:28I couldn't believe that priests
39:30would do such a thing and so borne
39:32along by that misperception that that
39:35you know some professional tribes
39:38among us are immune to to corruption
39:41or or to that kind of wrongdoing.
39:45I actually think that you end up
39:48insulating and perpetuating that behavior,
39:50and I think it was a very
39:51similar thing that happened with
39:52the opioid crisis in which.
39:53Our kind of faith in the unimpeached
39:56ability of doctors are sense
39:57that they they might not suffer
39:59from the same human temptations
40:01of people in other lines of work
40:03actually contributed to the problem.
40:06Yeah, you know, just picking up on that.
40:08I mean, there's this this whole
40:09notion of noble cause corruption
40:11has so many facets to it.
40:13There's another aspect in the
40:14opioid crisis that I think is
40:16really interesting, which is that.
40:17The nobility was very much used as a tool
40:21of corruption and very often it wasn't.
40:24You know, for for some doctors it wasn't.
40:28You know, just give me a lot of money and
40:30I'll prescribe a lot of your drugs for some.
40:34And I I checked with the number you
40:36know with the with the tennis palmen
40:37who said it was a doctor in New Jersey,
40:39you know he recalls being besieged
40:42by Purdue sales people,
40:44all of whom really laid on him a very
40:46heavy guilt trip about his patience.
40:49I IE the victims the the people who
40:51had back pain and so forth and so on.
40:52It's like what's the matter, don't you care?
40:55Don't you care about their pain
40:57and to internalize?
40:59That that that that forced empathy was
41:03something that really made many doctors,
41:05I think,
41:06vulnerable to prescribing something
41:09that they might not otherwise do.
41:12And and and frankly,
41:15corruption usually doesn't work when.
41:18It's when someone comes along and says,
41:21I'll give you a lot of money to do
41:23something that you don't want to do.
41:26It's usually much more
41:28effective as Jack Abramoff,
41:29the disgraced lobbyist, once told me.
41:32He said he could buy a congressman
41:34for a stereo and proved he was right,
41:36that it's much easier to get a
41:38Congress person to go along if there's
41:41something they sort of want to do.
41:42You know, and all it requires
41:44is a is a slight adjustment.
41:47That's really where the corruption happens.
41:49It's not, you know which is what
41:51I found so interesting about
41:53that that that's why they would.
41:55You know, Purdue.
41:55Could use people like Gary Blend
41:57and others to to convince doctors
41:59that it was that that that they
42:01were really doing the right thing.
42:05At that point, Alex.
42:05I was wondering if you could speak or
42:07Patrick speak a little bit about a character.
42:10J. David haddox. In the way that.
42:13He has an authoritative physician messenger.
42:17Prior to joining Purdue created this
42:20whole new pseudo diagnosis based on
42:23pseudoscience of pseudo addiction
42:25that was used to justify many of
42:29the things that you're describing.
42:31Alex, which is we.
42:32We should feel better about
42:33helping people with chronic pain.
42:38You wanna take that Alex?
42:39Should you take that you take that Patrick?
42:41I mean I, I could follow up
42:42with Lynn Webster if you like,
42:43but but why don't you take haddox?
42:45Yeah, I mean in Curtis.
42:48Wait?
42:51I do think that this was a.
42:53This was a little bit of a perfect storm
42:56in the sense that there was a movement.
43:01Really, in the 1980s and 1990s,
43:03to re examine the way pain was
43:07treated and pain was taught.
43:09In the the medical establishment here in
43:11the US and in other countries as well,
43:13and a sense that people had
43:15been suffering needlessly,
43:16particularly from chronic pain that
43:18was under treated and then many,
43:21many physicians sort of went from that too.
43:24The reason for this was a was a kind of
43:27hysterical stigma that had been attached
43:29to opioids and the dangers of opioids,
43:32and there were a bunch of doctors,
43:34very influential doctors who who I think,
43:38believed that very earnestly some of
43:40them have since recanted and said
43:43that they were they were wrong,
43:45others have not. But the.
43:49I think Alex is exactly right.
43:51It's it's strangely not a situation
43:53of a conflict of interest.
43:55It's more sort of confluence of interest
43:56in which you had some real true believers,
43:59and then you had the industry which
44:02was happy to kind of come in and.
44:05Turbo charge that message and
44:08underwrite research,
44:09and do conferences and set up.
44:11I mean Purdue.
44:12Set up a speakers Bureau with thousands
44:14of doctors getting paid to go out
44:16and give speeches to other doctors
44:18and so you can have this incredible
44:21amplification of a particular message.
44:24Now I should say I think the
44:26critique was not entirely wrong.
44:29I think pain probably was under treated.
44:32It was also very much the case,
44:34for instance, that.
44:35Pain had not been a mainstay of
44:37medical education up to that point,
44:40and that pain was often treated
44:41just as a symptom and not too kind.
44:44Not something to explore more deeply.
44:47The challenge is that you had a whole
44:49generation of physicians, many of them.
44:52I would.
44:53I would agree with Alex.
44:54I think people who really all
44:55they wanted to do was treat their
44:58patients and relieve their pain.
45:00Who who got their their first dose
45:03of education on pain management
45:05and on opioids essentially from
45:08the Pharmaceutical industry.
45:09So the critique was was a correct one that
45:11there was a there was a bit of a vacuum,
45:13but into the vacuum rushed
45:16the industry and you know,
45:17the interesting thing is,
45:19as Alex said,
45:20you know,
45:21produce initial marketing tagline
45:22for Oxycontin was it's the one to
45:24start with and the one to stay with.
45:26So implicit in that is this is not some.
45:30Serious remedy that you keep on
45:32the top shelf and you do use it,
45:35but you use it when you've kind
45:37of graduated from other remedies
45:39that may not be effective.
45:40It's the first thing you reach for.
45:43And then you know there's no ceiling dose,
45:45as Gary Blenkin tell us,
45:47you can just use more and more and more.
45:49Both the company itself and its
45:52pharmaceutical representatives
45:52were incentivized in the sense
45:54that you know you're going to.
45:55Everybody is going to make more
45:57money on 160 milligram pill
45:58and on an 80 milligram pill.
45:59And if you can do
46:0125 or I don't know how many
46:03100 and 60s it was a day,
46:05this is very good for business
46:06and so you have this kind of thing
46:09where the therapeutic advice that
46:10they have happens to dovetail
46:12precisely with the profit motive.
46:14And I think even today we are seeing
46:18you know the the the after effects
46:20of this in the sense that for many
46:24many doctors the education in
46:25opioids came in terms of how do you?
46:28How do you onramp somebody onto these drugs?
46:30And there was no consideration whatsoever
46:32for how long should somebody take them?
46:35When should somebody come off?
46:36What does that look like?
46:37How do you taper?
46:39Somebody could.
46:39Could you be tapering somebody too fast?
46:41What happens if you're cutting
46:42off the supply and so?
46:44You end up now in this
46:46kind of crazy situation,
46:47in which I would argue that the
46:49interests of legitimate pain
46:51patients were kind of cynically
46:53exploited in the first instance.
46:55Back in the 90s by the industry,
46:58many of those same patients today feel
47:00kind of left out in the cold because
47:03the pendulum is swinging back the other way.
47:06A lot of doctors,
47:07I think you know,
47:08having having sort of gotten the education
47:10on how to get people on these drugs
47:12and then not really how to responsibly.
47:14Get them off or sort of figure out when
47:16or how long people should be on them.
47:18Essentially say,
47:18alright, well,
47:19I don't wanna I don't wanna prescribe them
47:21at all now or I want to cut people off.
47:23Which, paradoxically,
47:25is actually going to fuel the crisis.
47:28You know itself,
47:29and so I think it's a very
47:31complicated thing in which you've got.
47:37Some people who were quite sincere in
47:38their critique in their belief that
47:40there should be a reevaluation of the
47:42way we treated pain and then this just
47:44flood of industry money and influence,
47:47which I think kind of corrupted
47:52the whole situation and created
47:54a scenario that's that's.
47:57That's very hard to unwind at this point.
48:01And that's why I sense we should
48:04probably get the questions soon,
48:06but I just wanted to follow up
48:08on what Patrick was saying with
48:09one other notion I remember.
48:12It's this subtle effects
48:14of economic incentives that I think happened
48:17without people really realizing them.
48:19A former head of Medicare once told
48:21me that he called it the MRI problem.
48:23Like if you're a practice of doctors and
48:27together you buy a few MRI machines,
48:30you may not notice it.
48:31But in all likelihood your prescriptions
48:33for MRI exams are probably going to go
48:35up and you don't think it's a bad thing.
48:37I mean, after all,
48:39an MRI is a good diagnostic tool,
48:41but in in a.
48:42In a world where the cost of
48:44health care is a problem,
48:46you know the the greater and greater
48:48use of MRI machines is is is,
48:50is is is contributing to a larger
48:53problem and so this economic incentive
48:55is kind of built in and it's mixed with
48:59a sense of nobility which gets you to
49:02to back to this noble cause corruption.
49:04I you know I got lucky along the way.
49:07My producers Svetlana Zill was able to get
49:09one of these key influencers not addicts.
49:13I was able to get a guy named Lynn
49:14Webster to sit down for a long
49:16interview and one of the things that
49:18was staggering to me was despite.
49:21You know the huge number of
49:23deaths at his clinic,
49:24how much of a true believer he
49:27maintained and continued to be,
49:29you know.
49:29And and and and denied that that the the
49:31enormous amount of economic incentives he
49:33is getting for all these pharmaceutical
49:35companies had anything to do with it.
49:37And then I remember asking him a question,
49:40thinking that he would deny it.
49:41And you know, there's an old
49:44journalist trick where you you,
49:45you,
49:46you ask about a higher number and
49:48then the person corrects you with
49:49a lower number which is actually.
49:51Quite a high number and and so I said,
49:53well,
49:54you know I I heard it as as many
49:57as 100 people died in your clinic
49:59and and I was expecting to say no.
50:01No,
50:01it's not nearly that it was
50:03only 70 but he said no.
50:04Is 100 a high number?
50:06I thought really 100 people
50:08dead in your clinic and you're
50:10wondering if that's a high number.
50:12I mean that is really staggering
50:15evidence of a kind of a deep
50:18seated psychological noble
50:19cause corruption that that.
50:21Is is the thing that I think we have
50:24to look out for and then examine the
50:26kind of economic incentives that
50:28plays into human psychology that
50:31allows that kind of thing to take place.
50:37They cut a couple of the questions I think
50:39you've addressed them and thank you.
50:41There was a comment and a question
50:44about some recent information and
50:47data from the CDC indicating that
50:50the number of prescription opioid
50:52overdose deaths is that as if we could
50:56measure those accurately in 2016,
50:58was erroneous and resulting from
51:01miscoding deaths involving illicitly
51:04manufactured fentanyl and those were
51:07ascribed to prescription opioids.
51:09And the the question is,
51:10what do you make of this new data and
51:12how a myopic focus on prescription
51:15opioids may be contributing to more harm,
51:17particularly among individuals
51:19with intractable pain?
51:22I'm going to take part one of that and
51:23then I'm gonna throw it to Patrick,
51:25but I I think this is 1 area and and this is
51:28a question that's come up for both of us.
51:30I think quite a bit. You know,
51:32it's like you guys are saying that that
51:34prescription opioids are really the problem.
51:36When actually it's illicit fentanyl,
51:39it's really the problem today.
51:40But if you look at at the crisis
51:43from a different perspective,
51:44that is to say, if you look at
51:45it in the context of economics,
51:47you look at in the context
51:49of supply and demand,
51:50and an overabundance of supply
51:52of prescription opioids.
51:54Early on, created an enormous
51:56demand and at a certain point,
51:58that demand had to be sated by illicit means.
52:02And you know,
52:03we profiled one person in our in in,
52:05in in part two of our documentary,
52:07A guy named Caleb Lanier,
52:09who is a guy who you know had a very
52:11you know he had an auto accident.
52:14Terrible back entry started
52:15taking Oxycontin for it.
52:16At some point one of his doctors
52:18became a little nervous about
52:20prescribing more and more Oxycontin
52:22and it was getting to be expensive.
52:24So he turned to heroin.
52:26And then when that proved
52:27to be too expensive,
52:28he turned to fentanyl and became a fentanyl
52:31dealer and and ultimately was prosecuted.
52:33Now you could say, well,
52:35what is the fentanyl have to do
52:36with the prescribed Oxycontin?
52:38Well, you can see the the the
52:41supply and demand issues.
52:43You know where we're a victim in
52:45this case actually went to become,
52:47you know, a dealer,
52:48but but I think that that that really is
52:51the the broader answer to that question,
52:54you know?
52:56It's it's it's not so simple.
52:57Also,
52:58once you have economic incentives beyond.
53:03Prescription opioids that are
53:04being misused by doctors.
53:06You create situations where the
53:07big pharmaceutical companies not
53:09only the manufacturers like Purdue,
53:11but distributors like Cardinal Health
53:14and AmerisourceBergen and McKesson
53:16you know are shipping to pharmacies
53:19who are knowingly making money by.
53:22Giving phony prescriptions to people
53:24who are just using these drugs for
53:27recreational purposes and they
53:29know very well what they're doing.
53:32They're prescription opioids,
53:33but they're not properly prescribed.
53:35They're pill mills,
53:36so there's a whole host of things that
53:38I think you have to take into account here,
53:40but one of the big ones I think has
53:42to do with this economic issue.
53:44I don't know if I covered that sufficiently,
53:46but Patrick,
53:46maybe you want to pick up on that.
53:49Yeah, I would agree with that.
53:50I mean I, I think that the look this is a.
53:52This is a hugely complex issue and I think
53:55particularly when you when you're talking.
53:58Uh. I think you have kind of different.
54:02You have different equities here and you
54:04have different interest groups and and I you
54:06know I hate to call them interest groups.
54:08It sounds cynical, but like I get emails
54:10every week from pain patients who say.
54:15You know you shouldn't
54:16write about the Sacklers.
54:17You shouldn't write about Purdue,
54:20you're you know the very notion that
54:23you're like telling this story might help.
54:26Hurt my access to opioids and that I'm very,
54:29very sympathetic with people who you know
54:32are chronic pain patients who who rely on
54:34these drugs and who worry about access.
54:36I am not a,
54:38you know there are some people,
54:39maybe some people on this zoom today
54:42who really question the sort of the
54:45fundamental long term efficacy of
54:47opioids as a treatment for pain.
54:49I don't need to get to that,
54:50that's like that's that's a hard therapeutic
54:52question that I don't need to get too.
54:54I'm looking at one company
54:56which has twice pled guilty to.
54:57Criminal charges.
55:00And so I you know,
55:02I'm very sympathetic to people who
55:04feel kind of left behind in that way,
55:07and as though the the kind of the
55:09way in which society has corrected
55:11for overreacting before,
55:13and getting too liberal with pain medicine,
55:16is to overreact in the other direction
55:18and get too conservative with it.
55:20I'm sympathetic with that.
55:22Where I begin to become a little skeptical.
55:26Is that a lot of these people will then say,
55:29you know,
55:30really the problem is these black
55:32market like addicts and junkies and
55:35people who can't control themselves
55:37and I can control myself and you know,
55:39there's there's this kind of dichotomy
55:41right between the like the legitimate
55:43pain patient who responsibly uses
55:45the medicines and never has a
55:46problem and should have access.
55:48And then, on the other hand,
55:49reckless junkies who can't control
55:51themselves. And there I get.
55:54I get pretty skeptical in part because.
55:57You know, for me,
55:58I'm not trying to stigmatize
56:00anybody in this equation,
56:01and I think the notion that you
56:03would try and diminish the stigma
56:05of one group by re stigmatizing
56:07another is not necessarily helpful.
56:09This also happens to be a talking point
56:11that the Sacklers and Purdue put out there,
56:13as did others in the industry
56:14from very early on right.
56:15It's essentially guns.
56:17Don't kill people, people kill people.
56:20You have these.
56:21Reckless pill poppers who are ruining
56:24it for the legitimate pain patients.
56:26And you know this is a false dichotomy
56:29so it is certainly true that when you
56:32look at the overdose problem today,
56:34it's not a problem.
56:36By and large of prescription overdoses.
56:39But as Alex said,
56:41you have this enormous market that
56:44was created by the over promotion
56:46of opioids in the 1990s.
56:47In the early aughts which eventually
56:49graduated to other things I could
56:51give you a whole bunch of statistics,
56:52but let me just give you 2 quickly.
56:54So. Part of the problem here is
56:58that you know even when you get what
57:02looked like common sense solutions.
57:04They can have perverse outcomes.
57:07So in 2010, Purdue Pharma Reformulates
57:10Oxycontin to make it harder to crush,
57:13so harder to crush,
57:14harder to snort, harder to shoot.
57:17And there's a whole story I tell
57:19in my book about the interesting
57:21coincidental timing of the fact
57:22that the the patents on the original
57:24Oxycontin were about to run out,
57:26and so this was a really excellent.
57:29Strategy for evergreening the patent.
57:31But in any case they roll out this
57:33new version of the drug and I think
57:35this would generally be something
57:36that most people from the outside
57:37would celebrate and you would look
57:39at it and say this is this is great.
57:40You're making it harder to abuse,
57:42and that is a good thing,
57:43and they invested money to do that.
57:46So in 2010.
57:49After the reformulation sales
57:51nationwide of at the time,
57:54the biggest dose of Oxycontin 80
57:56milligram Oxycontin pills plummeted by 25%.
58:00And it's interesting, right?
58:00'cause you can look at that.
58:01On the one hand,
58:02you can say isn't it great that they
58:04reformulated on the other hand you
58:05realized that you know 25% of their
58:07market up to that point was people
58:08who presumably were abusing the pill,
58:10who then are going to leave and
58:12potentially go to the black market?
58:13It might have been safer for them
58:16to continue abusing Oxycontin,
58:17so you get,
58:18I think,
58:18when you get into the incentives and
58:20what the right policy fixes are,
58:21you get into into very kind of
58:24treacherous terrain.
58:25And I'm pretty skeptical of anybody
58:28who looks at this.
58:30In terms that are too black and white,
58:31the last thing I'll say is on the
58:33black and white thing.
58:34You know this dichotomy.
58:35You have pain patients,
58:37and then you have abusers.
58:39You know the Sackler less so Purdue,
58:41but the Sackler,
58:43certainly through their representatives
58:45in interactions with me and and.
58:47And you know,
58:48and my lawyer fairly recently we're
58:51arguing that instances of biotronik
58:53addiction to Oxycontin are vanishingly rare.
58:56That it almost never happens that
58:58if you take the pill as prescribed
59:00by a doctor for pain,
59:02and you take it as directed.
59:05You'll get addicted.
59:07They essentially say doesn't happen.
59:09You know, maybe once in a blue moon,
59:11but generally speaking doesn't happen so.
59:14I found this amazing filing in
59:16the Purdue bankruptcy from United
59:17Health one insurer a big one,
59:19but one insurer which had run a study.
59:23It wasn't even for 10 years.
59:24It was something like 8 years
59:26looking at United Health people
59:28who have United Health policies
59:30and what they were looking for
59:33was people who were prescribed.
59:36An opioid and then subsequently
59:38diagnosed with an opioid use disorder.
59:41So I should say this is going to
59:43be under inclusive number for sure,
59:44but it's people who were prescribed an
59:47opioid subsequently diagnosed on one
59:49health insurance company in a single
59:52digit number of years and their estimate
59:55was that what they came back with was
59:58numbers in the hundreds of thousands.
01:00:00So you know the idea that
01:00:02I think on the one hand,
01:00:03we can say absolutely the overdose
01:00:05crisis today is more of a heroin
01:00:07and fentanyl crisis than it is
01:00:08a prescription pill crisis.
01:00:10But at the same time,
01:00:11just suggest that we don't have even
01:00:14today a prescription painkiller problem
01:00:17of dependence, addiction, abuse.
01:00:19I think is reductive and doesn't
01:00:22sit well with the facts.
01:00:28Very helpful, I want to move the
01:00:30conversation briefly to another
01:00:31area and you've sort of highlighted
01:00:33the way in which profit mode.
01:00:35If pharmaceutical distributors
01:00:37and the like their incentives may
01:00:40be misaligned with public health
01:00:43over the last five to 10 years.
01:00:45What I've seen is an attempt
01:00:50through philanthropic means
01:00:52for pharmaceutical companies.
01:00:56Distributors to sort of get ahead
01:00:58of the story and start to fund
01:01:01programs that are designed to address
01:01:04problems associated with opioids,
01:01:06and so that that is one set of issues.
01:01:12And then there's the issues that
01:01:14the medications that we use
01:01:16to treat opioid use disorder,
01:01:18so buprenorphine, naltrexone,
01:01:20and the companies that are behind those.
01:01:25Medications have engaged in practices
01:01:29that we wouldn't necessarily
01:01:30want to align ourselves with,
01:01:33and so now as clinicians,
01:01:35we're in this this ethical dilemma
01:01:37where you know we want to provide
01:01:39the best care to our patients.
01:01:41We want to do it based on the evidence,
01:01:43and so we we support the provision of
01:01:46medications for opioid use disorder.
01:01:49But we may need to develop programs
01:01:52and fund programs where we have the
01:01:55opportunity to do that from sources
01:01:57that we don't feel comfortable with,
01:01:59and we don't want to be aligned with.
01:02:01So how?
01:02:01What are you thoughts about that
01:02:04and how does this play into?
01:02:06How do we spend the the money
01:02:08from the opioid settlement?
01:02:14I'd have to say that that those
01:02:17are hugely important questions.
01:02:19And no, I'm not sure they're I'm
01:02:23qualified to to provide answers.
01:02:26I mean, I, I just I,
01:02:28I think I think they're great questions,
01:02:30and particularly in terms of.
01:02:33Of how treatment is is rendered
01:02:34I think is is hugely important.
01:02:37I the the only broad thing I would
01:02:38say and I'll toss it over to Patrick.
01:02:41I'm sure this is something more
01:02:43interesting to say is that.
01:02:45You know, I think one of the things that
01:02:48that I didn't really fully appreciate.
01:02:51Uhm?
01:02:53When I started this story is that I
01:02:56started a story about you know the
01:02:58opioid crisis or the opioid crime,
01:03:00depending on how you want to define it,
01:03:02but then realized you know by the time
01:03:05I got to the end that what I was really
01:03:08talking about was the problem with.
01:03:10For profit healthcare in
01:03:12this country and and and,
01:03:14and it's very difficult to separate
01:03:16the two or or to figure out how you
01:03:19can fix the opioid problem without
01:03:23also addressing that larger issue
01:03:26which gets into this notion of you
01:03:28know what happens when pharmaceutical
01:03:30firms are funding research and
01:03:33then funneling that research.
01:03:35You know in in,
01:03:36into into treatment modalities,
01:03:38and so forth and so on.
01:03:42Yeah, I mean a couple of
01:03:44quick quick thoughts, the.
01:03:49You know on the on in a way,
01:03:51on the on the second thing you mentioned
01:03:53the idea that these same companies
01:03:55produce the drugs that that may.
01:03:58Hopefully help us start to find
01:04:01our way out of this crisis.
01:04:03I just got back from a 10 day trip in Europe
01:04:06because my book was coming out over there.
01:04:08And I would get these questions
01:04:10everywhere I went about Big Pharma
01:04:13and American Big Pharma and and.
01:04:17Poor and LAX regulation of
01:04:19Big Pharma as it applies to.
01:04:23COVID vaccines and it put me in
01:04:26this quite awkward situation.
01:04:27You know, I the in the first
01:04:29section of my book I talk about.
01:04:32Now an instance back in the
01:04:351950s when Pfizer bribed the
01:04:37head of antibiotics at the FDA.
01:04:39It was a big scandal at the time,
01:04:41and I published the book after
01:04:44getting my first jab of Pfizer and
01:04:47before getting the second one.
01:04:49I think that you know we we kind
01:04:52of have to live with the reality
01:04:55of this industry and understand
01:04:57the the that that it it.
01:05:00It's it's complicated, right?
01:05:01I mean these companies are
01:05:03capable of amazing.
01:05:05Our innovations and and and life saving
01:05:09work and we should celebrate that and
01:05:12and take advantage of it wherever we can.
01:05:14At the same time I think.
01:05:16We should be mindful of the
01:05:18fact that they are.
01:05:20Driven by an overwhelming profit
01:05:22motive that they've become very,
01:05:25very sophisticated.
01:05:27You know, in in how to leverage influence
01:05:30and that they have essentially. You know?
01:05:34Bottomless resources with which.
01:05:38To do that so.
01:05:42The more proximate issue in my mind,
01:05:44for a place like Yale.
01:05:46Would be the ways in which.
01:05:49Yeah.
01:05:50Educational institutions can be
01:05:53enlisted and Co opted in these types
01:05:57of efforts and that seems to me in
01:05:59some ways to be a kind of an easier
01:06:01and more immediate thing that you
01:06:03all and your colleagues could be mindful of.
01:06:06And just on the lookout for,
01:06:10I don't have any tally of all
01:06:12the money that the Sacklers have
01:06:15given to Yale in recent years,
01:06:17but it's a lot and it's
01:06:20the bad Sacklers you know,
01:06:21like if you think of a kind of a.
01:06:23If you think of a like a target
01:06:26in which you get rings concentric
01:06:29circles of culpability.
01:06:32Richard Sackler has given
01:06:33a lot of money to Yale,
01:06:35and he's right there at the bullseye.
01:06:38I think it would be worth probably
01:06:40looking at that money and where it went,
01:06:42and you know how it's being spent today.
01:06:45If it's being spent and I, you know I I,
01:06:48I haven't done any kind of an audit myself,
01:06:50but I think it would be an interesting
01:06:52project for people at Yale to wonder.
01:06:53Kind of.
01:06:54What are the tentacles of that influence?
01:06:57Are there people at Yale who have
01:07:01been kind of standard bearers?
01:07:03You know,
01:07:03for the family and for the company
01:07:06and for its interests and so.
01:07:11You know, on the one hand,
01:07:12I think a lot of these come.
01:07:15These companies probably now that
01:07:17they're in huge legal trouble,
01:07:18are going to claim that
01:07:19they've they've sort of.
01:07:21They've found God and they wanna,
01:07:22they wanna make amends?
01:07:24But I do think a healthy skepticism.
01:07:28About the the the altar.
01:07:31Real dangers of getting him
01:07:32listed in a reputation laundering
01:07:34campaign is probably a good thing
01:07:38for you and your colleagues,
01:07:40and anyone at any kind of elite
01:07:43medical or educational institution
01:07:45that might lend its name too.
01:07:48You know people with nefarious purposes.
01:07:52And I think I just wanna elevate that
01:07:55you know the the point that you know.
01:07:58Especially for for the trainees
01:08:00on this call and and folks who
01:08:03are here learning the the healthy
01:08:04skepticism across the board, right?
01:08:06And and I think you mentioned
01:08:08earlier a real lack of medical
01:08:11education with regard to.
01:08:15You know? Opioid medications
01:08:18and things like that, but how? How
01:08:20do we treat chronic pain?
01:08:21How do we identify and treat addiction?
01:08:23How do we talk to patients
01:08:25about these things?
01:08:26And I think these are really
01:08:28important points that can be
01:08:29gleaned from this conversation.
01:08:35There was another question in the chat.
01:08:37I just was sort of along those lines.
01:08:41Specifically, around balancing access to
01:08:45medication with being critical of companies,
01:08:49and so you know, I think we touched
01:08:50on this a little bit earlier,
01:08:52but I'd be interested to hear you know the
01:08:55the person who asked the question said,
01:08:58have you found that big Pharma executives
01:09:00have Co opted the language of health
01:09:03care access trying to push Oxycontin or
01:09:05oxycodone through everyone deserves?
01:09:07To easily obtain medication messaging and how
01:09:10can we balance that with ensuring access?
01:09:12And I just think that's an interesting point.
01:09:14I'd love to hear your comments on.
01:09:16I mean, I, I do think that the balance is
01:09:19hugely important and going back to you know
01:09:21what we talked about at the beginning.
01:09:23I mean, pain is not a joke and and and
01:09:27people deserve good treatment for pain.
01:09:30And properly prescribed,
01:09:32even something like Oxycontin
01:09:33can be a terribly valuable drug.
01:09:37So so, so I think the balance
01:09:40has to be maintained, but but,
01:09:41but that's why you have to constantly
01:09:43re examine what's going on,
01:09:45what the trends are and and and whether
01:09:47or not the incentives are wrong.
01:09:49Whether or not you know drugs are being.
01:09:56Use for purposes for which they were
01:09:58not really properly designed or tested,
01:10:00and indeed that the testing
01:10:03and the and the termination,
01:10:05even by regulators like the FDA,
01:10:07was corrupted to give people a
01:10:09false view of what their dangers
01:10:11were along with their values.
01:10:16Yeah, I mean I I would.
01:10:16I would say that that language of access
01:10:20absolutely was Co opted and that there was a.
01:10:23You know it's ironic because now you
01:10:25have a lot of doctors who are fearful of
01:10:29the consequences if they are perceived
01:10:32to be to freely dispensing opioids,
01:10:35but I've certainly interviewed many,
01:10:38many physicians who in the late 1990s
01:10:42and particularly the early aughts.
01:10:46Concern was the opposite, right?
01:10:47That there that there were fears of what
01:10:49the consequences for you would be if
01:10:51there was a perception that you were.
01:10:53You were under treating pain
01:10:54or not taking it seriously,
01:10:56or not prescribing pain medication.
01:10:59So again, I think it's it's difficult to
01:11:02calibrate what the right approach is.
01:11:04I don't envy those of you who have to
01:11:07figure it out on a day to day basis,
01:11:09but one thing I know for sure is that.
01:11:13As clinicians. You should.
01:11:17You should not be taking
01:11:19your cues from industry.
01:11:22You know, I think again.
01:11:25Hard questions, difficult answers,
01:11:26but I think that to take
01:11:29the low hanging fruit.
01:11:30The drug makers should
01:11:32not be the ones you know.
01:11:34Writing the guidebook on this.
01:11:38One last question, before we finish up. This
01:11:43is from Liz Trelow who talks about
01:11:45focusing on the supply side and the
01:11:48Sackler role in the supply side.
01:11:51Arguing that it's it's more of a
01:11:53demand side issue that a lot of the
01:11:55issues of chronic pain and maybe even
01:11:57addiction or associated with social
01:12:00determinants of health and so does.
01:12:04Focusing on single villain
01:12:06detract from demand,
01:12:08side perspectives and does doing
01:12:10so limit our understandings of
01:12:12the root causes of the crisis?
01:12:14And how should this impact our solutions?
01:12:18I mean, I, I'd be interested to
01:12:19hear Alex's thoughts on this.
01:12:20Let me let me just quickly
01:12:22take it from my perspective.
01:12:23The you know, it's often the case.
01:12:25I'll spend a few years writing a book.
01:12:28Or a big article and.
01:12:32And the reaction will be OK.
01:12:34Well, all of that is true,
01:12:35but there's also all this other stuff.
01:12:37It's complicated.
01:12:38Why did you make those particular choices?
01:12:40And I have to say,
01:12:42I mean as a writer and a journalist,
01:12:44I don't feel particularly
01:12:46constrained to this is not a textbook
01:12:49on the opioid crisis, right?
01:12:51It's a third of the book takes
01:12:53place in the 1950s and 60s.
01:12:57B and I was looking at this family so
01:13:00so I feel as though in this instance I
01:13:05picked a particular subject to look at.
01:13:06I do think that the Sacklers and
01:13:09Purdue play a really significant
01:13:12role in shaping this story.
01:13:16And I would also argue that you know,
01:13:18I'm very.
01:13:20I'm very attuned to questions
01:13:22of supply and demand.
01:13:23I thought about them a lot,
01:13:24also in terms of how we,
01:13:25you know how we cover Mexican
01:13:27drug cartels and illicit drugs.
01:13:29But I think in the in the specific
01:13:31case of the opioid crisis.
01:13:35You know opioids had been around previously.
01:13:38I do think that something happened
01:13:41in terms of the kind of manufacturer
01:13:43of demand that you actually had.
01:13:46This supply side kind of creating demand,
01:13:49and that's a story I try and
01:13:50tell at length in the book.
01:13:51Having said that,
01:13:52as I make very very clear,
01:13:54if you read the book.
01:13:58The Sacklers are not the
01:13:59only bad actors here.
01:14:00Purdue is not the only bad
01:14:02pharma company you know.
01:14:04If you look around at the the
01:14:05litigation environment right now,
01:14:07you obviously have pharmacy chains.
01:14:08You have distributors that are in
01:14:12hot water legally and should be.
01:14:15I would argue, the FDA deserves
01:14:16a great deal of scrutiny.
01:14:18The DEA DOJ you can go on and on.
01:14:22I mean you don't get to a crisis
01:14:24that kills half a million people
01:14:25with one set of bad actors, so.
01:14:27I hope that we can understand that
01:14:30there's you know there is a rich
01:14:32and ongoing literature on this
01:14:34subject and and and my choice to
01:14:36devote a book to one family and one
01:14:39company is by no means an assertion
01:14:42that these other elements are
01:14:44not important or worth studying.
01:14:46It's just I leave it to others to do so.
01:14:50Just picking up on that ever so slightly.
01:14:52I mean, one of the reasons that I
01:14:54did what I did by focusing on the
01:14:56crime was the focus on the crime.
01:14:58And there are many other aspects to this,
01:15:00particularly the medicine of addiction, that
01:15:02that I didn't really go into in the film.
01:15:05I did try to show that you know there
01:15:08wasn't one malefactor, you know,
01:15:10we we, the in in crime of the century.
01:15:13We start with. Purdue,
01:15:16but you know by the time we get to Part 2,
01:15:19we're dealing with a huge consortium
01:15:22of pharmaceutical companies and
01:15:24distributors who knew very well
01:15:25where all of these pills were going.
01:15:27It didn't just happen,
01:15:29they they had very conscious
01:15:30knowledge of what was going on.
01:15:32So in that sense I was focusing on the
01:15:34criminal aspect on the supply side.
01:15:35It's true.
01:15:36One of the purposes of having you know,
01:15:39in part one I did do.
01:15:43A kind of brief, intentionally brief,
01:15:45but also intentionally expansive
01:15:47summary of the history of opium
01:15:50and the history of opium,
01:15:51both consumption and production and
01:15:53and and and and marketing, I mean.
01:15:57It's always been a very popular,
01:15:59you know,
01:16:00opium or opioids have always
01:16:01been very popular and they eat.
01:16:03In the 1840s opium balanced World Trade.
01:16:06There was no more traded commodity
01:16:08in the world than opium.
01:16:10It bounds East West trade.
01:16:11China had everything in the West
01:16:13had nothing that China wanted.
01:16:15The only way to balance that
01:16:16trade was with opium,
01:16:17which testify to a pretty significant demand.
01:16:21So so.
01:16:22But but the question was,
01:16:24what is the downside of that demand,
01:16:26in other words?
01:16:28Is it addictive and is it going to create
01:16:31problems and and a public health problem?
01:16:33And how do you manage that
01:16:36overtime and are the exigencies of.
01:16:39Of industry prized over a larger
01:16:40question of of a public health and
01:16:43how you balance the efficacy of the
01:16:45drug with its potential for addiction.
01:16:48And obviously the.
01:16:51British East India Company was
01:16:54not much thinking about the the
01:16:56public health problem in China.
01:16:58They just wanted to be able to
01:16:59have the right to sell as much
01:17:01of it as they possibly could as
01:17:03fast as they possibly could,
01:17:04and and when trying to resist it,
01:17:06they invaded.
01:17:10So I was incorrect. There is one
01:17:12last question from Doctor Art Vanzee.
01:17:14I think you may know. And it's a fairly
01:17:18crime of the century. For those
01:17:19of you who haven't seen it yet.
01:17:23It's a firewall question.
01:17:25Can we move to make major policy
01:17:27changes so that pharma is simply not
01:17:29able to market controlled medications
01:17:31to the medical profession and
01:17:33that a federal agency can then be
01:17:36responsible for continuing education
01:17:37free of any pharma influence?
01:17:44Alice. I mean, I think we have
01:17:47to move in that direction.
01:17:48I mean, the problem now is we've created
01:17:52a medical system that's so infused with
01:17:55money that regulators become corrupted.
01:17:59Medical education becomes corrupted
01:18:02and and and we're not looking.
01:18:05Enough at the pure scientific
01:18:08evidence as we are at the blank.
01:18:11And so as a result,
01:18:12we we're all susceptible to economic
01:18:17influences that provide very bad
01:18:21incentives sometimes for for,
01:18:23for treatment.
01:18:24And so you know,
01:18:27at every step along the way there,
01:18:29there's a larger systemic,
01:18:30I think solution to this,
01:18:32but I think that that that getting you know.
01:18:40Creating a web of regulations that
01:18:43prevent big Pharma from becoming
01:18:46the engine of education about.
01:18:51Drugs that they sell would
01:18:52be a good first step.
01:18:56Yeah I I couldn't really add anything to
01:18:57that apart from just just my total agreement,
01:18:59and I think that some scenario in which.
01:19:03You know I spent a couple of years digging
01:19:06into this stuff and what's amazing is the
01:19:08hand of industry is often hidden, but if you,
01:19:11if you look enough, you'll find it.
01:19:15So creating some sort of scenario
01:19:17in which you had an opportunity
01:19:19for continuing medical education,
01:19:21particularly on these types of questions that
01:19:24was truly free of that sort of influence,
01:19:27I think, would be a huge contribution.
01:19:29And of course there would be the question.
01:19:30Well, how do we pay for it?
01:19:31But if you look at the
01:19:32cost of the opioid crisis,
01:19:34which is now in the trillions of dollars,
01:19:36I do think that from a preventative POV,
01:19:39making that kind of public
01:19:41expenditure not relying on private
01:19:43sector funding would ultimately.
01:19:46Save a great deal of money and and
01:19:48pain and suffering in the long term.
01:19:53Yeah, I think the danger of thinking
01:19:55about patients as consumers is
01:19:57a terribly dangerous path and
01:20:00and and that philosophically
01:20:02would be something we'd be.
01:20:05We do well to to to to change.
01:20:10I wanna thank you Alex and thank you Patrick.
01:20:13Thank you to Kyle and the Sandgaard
01:20:16Foundation for making this talk possible.
01:20:18We really appreciate the efforts and time
01:20:21that you've put in sort of explicating
01:20:25and shining a spotlight on these areas
01:20:27that we really need to discuss more.
01:20:30So thank you everybody and we look
01:20:32forward to seeing you at our next talk.
01:20:35Thank you, thank you so much delighted. Here.