>> APPRECIATE THE OPPORTUNITY TO
BE HERE TO TALK TO YOU ALL ABOUT

THE OPIOID CRISIS IN WESTERN
NORTH CAROLINA.

A PARTNER IN CRIME IN ALL OF
THIS IS A GUY NAMED DON TEETER.

HE'S A FAMILY PHYSICIAN THAT'S
BEEN WORKING FOR 30 YEARS IN

HAYWOOD COUNTY IF IN THE LAST 18
YEARS IN ADDICTIONS AND THEN

I'VE BEEN WORKING IN THIS SPACE
FOR ABOUT FIVE YEARS NOW.

SO -- I HAVE NO DISCLOSURES.

THE PHARMACEUTICAL INDUSTRY IS
NOT PAYING ME TO SAY THE THINGS

I'M ABOUT TO SAY.

SO JUST TO GET STARTED, 254,000.

THAT'S THE NUMBER OF PEOPLE THAT
WE'VE LOST IN THE LAST TEN YEARS

TO THE OPIOID CRISIS.

SO THAT'S MORE THAN FOUR TIMES
THE NUMBER OF PEOPLE THAT DIED

IN THE VIETNAM WAR.

THERE WAS A PAPER THAT JUST CAME
OUT LAST YEAR AND IT SAID IF

YOU'RE UNDER 50 YEARS OLD AND
YOU DIE IN THE UNITED STATES,

IT'S NOW THE NUMBER ONE REASON
THAT YOU DIE.

SO GRANTED, MOST PEOPLE DIE IN
THE UNITED STATES IN THEIR 50s ,

70s, 80s, 90s, IT'S RARE
UNDER 50.

IF YOU DO DIE UNDER 50 IN THE
UNITED STATES OPIOID ABUSE IS

THE NUMBER ONE REASON I DIE.

IT TRULY IS AN EPIDEMIC.

WE BEING THE PROVIDERS ARE THE
VECTOR.

IT TOOK ABOUT 30 YEARS TO GET
INTO THIS SITUATION BUT IT

REALLY WAS THE PHARMACEUTICAL
INDUSTRY GIVING US A BILL OF

GOODS AND THE PROVIDERS,
INCLUDING DOCS AND FAMILY DOCS

LIKE MYSELF BUYING ALL THIS.

AND WE'LL TALK ABOUT THAT IN A
SECOND.

SO I AM A FAMILY PHYSICIAN.

I'VE BEEN DOING THIS 19 YEARS.

I DO IN-PATIENT WORK AND OUT-
PATIENT WORK.

I SEE PREGNANT WOMEN DELIVER BAY
BABIES ABOUT 30% OF MY PRACTICE

IS KIDS.

AND WHEN I WENT THROUGH
RESIDENCY, AFTER MEDICAL SCHOOL,

THIS IS WHAT I WAS TAUGHT.

OH, YOU HAVE THAT PATIENT THAT
HAS CHRONIC BACK PAIN.

WELL, TRY THESE THREE OR FIVE
MEDICINES OR MODALITIES BUT

EVENTUALLY THAT PATIENT IS GOING
TO BE ON PERCOCET AND OH, YOU

HAVE THIS PATIENT WHO HAS
CHRONIC MIGRAINES.

TRY THESE TWO OR THREE MEDICINES
BUT IF THAT DOESN'T WORK THAT

PATIENT IS EVENTUALLY GOING TO
BE ON VICODIN.

AND THAT'S WHAT I DID.

AND THEN WHEN THEY HIRED ME ON
AS FACULTY, THAT'S WHAT I TAUGHT

OTHER PEOPLE FOR A DOZEN YEARS.

THAT WAS -- THAT WAS ONE WHAT WE
TAUGHT.

I'M HERE TO TELL YOU THAT
THERE'S ACTUALLY NO DATA FOR

USING OPIOIDS FOR CHRONIC NON-
CANCER PAIN.

THERE'S ACTUALLY NO DATA
WHATSOEVER FOR WHAT WE'VE BEEN

DOING FOR THESE LAST 30 YEARS.

BUT I DO HAVE DATA IF YOU START
SOMEBODY ON OPIOIDS AND IT GETS

UP TO A CERTAIN DOSE CALLED 50
MORPHINE MILI EQUIVALENTS A DAY

OR A HIGHER DOSE, YOU INCREASE
FALLS, OVERDOSE AND DEATH.

SO I CAN TELL YOU THAT IT'S
HARMFUL, BUT I CAN'T TELL YOU

THAT IT'S HAPPY HELPFUL FOR
CHRONIC NON-CEABS PAIN.

THESE ARE OUR GOALS TODAY.

STRIVE THE THE IMPACT OF THE
OPIOID CRISIS.

I KNOW YOU KNOW A LOT ABOUT IT
BUT I I THINK I CAN GIVE YOU ONE

OR TWO MORE COUNTS.

FOR ALL OF YOU WORKING IN PUBLIC
HEALTH OR WORKING WITH GROUPS

THAT HAVE PROVIDERS I'M GOING TO
TELL AWE LITTLE BIT ABOUT THE CD

C GUIDELINES FOR ACUTE AND
CHRONIC PAIN JUST SO YOU KNOW

WHAT WE'RE TEACHING THIS NEXT
GENERATION OF DOCS AND WE'RE

HONESTLY HAVING TO GO OUT AND
RETRAIN THE DOCS THAT WENT

THROUGH RESIDENCY YEARS AGO LIKE
MYSELF.

AND THEN DESCRIBE THE -- ITS
IMPACT ON OUR PATIENTS AND YOUR

ALL'S CLIENTS OUT THERE.

SO OPIOIDS IS THE BIG TERM.

IT'S ALL OF THEM.

AND OPIATES ARE IF IT COMES FROM
OR DERIVED FROM THE POPPY.

AND THEN THERE'S OTHERS THAT ARE
LIKE SYNTHETICS LIKE FENTANYL.

THESE ARE JUST SOME EXAMPLES UP
HERE BUT I WANTED TO GO THROUGH

A FEW OF THEM.

ONE, CODEINE, SO IT'S FOR COUGH
SYRUP OR

[ NO AUDIO ]
NOW THE FOOD AND DRUG

ADMINISTRATION HAS COME OUT AND
THEY'VE SAID WELL DON'T -- DON'T

PRESCRIBE CODEINE TO KIDS UNDER
18.

AND THEN THEY CAME OUT AND SAID
WELL, DON'T PRESCRIBE CODEINE

FOR PREGNANT WOMEN?

OR IF THEIR BREAST-FEEDING.

SO NOW WHAT WE'RE TEACHING IS,
DON'T PRESCRIBE CODEINE AT ALL

FOR ANYONE BECAUSE KIDS ARE
GETTING AHOLD OF THIS AND

THEY'RE USING THIS TO GET HIGH.

AND THEY'RE ACTUALLY EVEN USING
IT IN SCHOOL DURING THE DAY.

AND THE REASON THAT THEY CAN GET
AWAY WITH IT IS THE NUMBER ONE

THING YOU LOOK LIKE WHEN YOU'RE
HIGH ON OPIATES IS NORMAL.

NOW, IF YOU'VE BEEN ON OPIATES
FOR A LONG TIME OR WHRA -- WHAT

HAVE YOU, YOU TEND TO HAVE SOME
OF THE STIGMATA LATER.

THE KIDS THAT ARE USING THIS,
IT'S REALLY HARD FOR THE PARENTS

AND THE TEACHERS HONESTLY TO
PICK UP ON THIS.

YOU SEE SOME OF THE OTHER ONES
UP THERE, BUT THE BIG PROBLEM

THAT WE'RE HAVING NOW IS THAT AS
WE GOT INTO THIS CRISIS WITH

OPIATE PILLS, NOW WE'VE MOVED ON
TO HEROINE AND WHAT THEY CALL

SYNTHETICS BUT THAT'S FENTANYL
AND ITS DERIVATIVES AND WE'LL

TALK ABOUT THAT A LITTLE MORE IN
A SECOND.

THE UNITED STATES IS 4.6% OF THE
WORLD'S POPULATION, BUT WE

CONSUME 80% OF ALL THE OPIOID
PILLS PRESCRIBED IN THE WHOLE

WORLD.

80%.

THERE'S NO OTHER COUNTRY THAT'S
EVEN CLOSE TO WHAT WE'RE DOING.

THE ONLY ONE THAT'S EVEN A
FRACTION OF WHAT WE'RE DOING IS

CANADA.

I FEEL REALLY BAD FOR THEM.

THEY JUST HAVE REALLY LONGBOARD
ER WITH US, I THINK

IT'S KIND OF A BLEEDOVER EFFECT.

83% OF THE WORLD HAS NO ACCESS
TO OPIATES.

THINK ABOUT THAT.

83% OF THE WORLD HAS NO ACCESS
TO OPIATES.

AND I'M GOING TO BE A LITTLE
FLIPPANT HERE, BUT THEY'RE

GETTING BY.

YOU KNOW?

AND THEY'RE GETTING BY THE WAY
THAT WE USED TO PRACTICE.

FOR THOSE IN THE BACK, I'M GOING
TO KIND OF GO THROUGH THIS ON

THE LEFT SIDE IS 1986.

ON THE RIGHT SIDE IS 2015.

SO THIS IS A 30-YEAR PERIOD.

AND YOU CAN LOOK AT ALL THE
DIFFERENT COLORS OF THE

DIFFERENT TYPES OF OPIATES, BUT
REALLY THE RED LINE IS THE

ADDITIVE OR ACCUMULATION EFFECT
OF ALL OF THE OPIATES THAT WE

PRESCRIBED AND DISPENSED IN THE
UNITED STATES.

AND IF YOU GO OVER TO THE LEFT
THEN N THE 70s AND EARLY '80S

WE WERE PRESCRIBING IN A LOW
RATE THE WAY THAT WESTERN EUROPE

IS STILL PRESCRIBING.

AND REALLY, BACK IN THE '70S AND
'80S, THERE WAS TWO REASONS THAT

YOU WOULD GET AN OPIATE.

IF YOU WERE IN THE LAST SIX
MONTHS OF LIFE, ON HOSPICE CARE,

THEY WOULD GIVE US AN OPIATE.

AND WE HAVE VERY GOOD DATA THAT
SAYS THAT IT HELPS WITH QUALITY

OF LIFE.

HELPS TO TAKE AWAY THE WANE SO
YOU CAN -- PAIN SO YOU CAN SPEND

TIME WITH YOUR FAMILY BUT IT
DOESN'T HELP WITH QUALITY OF

LIFE T. OTHER WAY YOU GOT AN
OPIATE IS ACUTE SEVERE PAIN.

SO IF YOU'RE IN A CAR WRECK AND
THE BONE IN YOUR LEG IS STICKING

OUT OF YOUR SKIN, YOU GOT AN
OPIATE.

BUT THE THIS WHOLE BUSINESS OF
GIVING OPIATES FOR CHRONIC NON-

CANCER PAIN JUST REALLY
WASN'T HAPPENING BACK THEN.

AND THEN TWO ARTICLES CAME OUT
IN THE MID '80S, AND I'M GOING

THE TALK TO YOU A LITTLE BIT
ABOUT THE ARTICLE, IT WAS PICKED

UP BY THE TENS OF THOUSANDS OF
DRUG REPS WHO THEN SPREAD OUT

INTO THE COUNTRY AND STARTED
TALKING TO THE PROVIDERS AND

THEY SAID HEY, THERE'S THIS
ARTICLE IN THE "NEW ENGLAND

JOURNAL OF MEDICINE" AND IT SAYS
OPIATES ARE REALLY SAFE, LESS

THAN 1% OF PEOPLE WILL EVER GET
ADDICTED AND YOU SHOULD BE USING

THESE MEDICINES FOR CHRONIC PAIN
AND IF YOU LOOK, THE LINE STARTS

TO GO UP BECAUSE THEY STARTLING
THE PROVIDERS THIS OVER AND OVER

AND OVER AGAIN.

INTERESTINGLY, IF YOU GO BACK
AND LOOK AT THAT ARTICLE, IT

REALLY WAS IN THIS ESTEEMED
JOURNAL CALLED THE "NEW ENGLAND

JOURNAL OF MEDICINE" BUT IT
WASN'T A RANDOMIZED CONTROLLED

TRIAL AND DIDN'T HAVE ANY AGE
MATCH CONTROLLED, WASN'T

RETROSPECTIVE OR PROSPECTIVE.

IT WAS JUST A LETTER TO THE
EDITOR.

IT WAS SEVEN LINES AND THE GUY
SAID HEY, I HAD SOME PATIENTS IN

THE HOSPITAL
[ NO AUDIO ]

AND NONE OF THEM GOT A ADDICTED.

HE DIDN'T EVEN CALL THEM AFTER
THEY LEFT THE HOSPITAL TO SEE IF

THEY WERE STILL ON OPIATES OR
STILL HAVING TROUBLE WITH OPIATE

USE DISORDER.

THAT'S NOT WHAT THE
PHARMACEUTICAL INDUSTRY SAID.

THEY SAID HEY, WE HAVE THIS
ARTICLE IN THE "NEW ENGLAND

JOURNAL OF MEDICINE" THAT SAYS
THESE MEDICINES ARE SAFE AND YOU

SHOULD START USING THEM.

SO WE START PRESCRIBING AND IT
STARTS GOING UP.

THEN YOU SEE IN 1996 THERE'S
THIS INFLEXION POINT, RIGHT?

AND IT STARTS GOING WAY, WAY UP
AND WE START PRESCRIBING LIKE

CRAZY.

SO WHAT HAPPENED?

IN 1996 THE AMERICAN PAIN
SOCIETY GOT TOGETHER AND THEY

HAD A BIG EXPERT PANEL AND THIS
IS WHAT THEY SAID.

HEY, YOU PRIMARY CARE DOCS,
THAT'S ME, YOU GUYS ARE ALL

DIRTY ROTTEN ROBBERS.

YOU'RE WAY UNDERTREATING PAIN
AND WE HAVE SOME GREAT

MEDICATIONS TO TREAT IT.

OPIATES.

DOES ANYBODY KNOW WHAT OPIATE
WAS DEBUTED IN 1996?

OXYCONTIN.

WE HAVE SOME GREAT MEDICINES
LIKE OXYCONTIN AND URKD BE USING

THEM.

THEY'RE REALLY SAFE.

LESS THAN 1% OF PEOPLE EVER GET
ADDICTED.

AND WE AS PRIMARY CARE DOCS SAID
OH, MY GOSH, THESE ARE OUR

EXPERTS IN PAIN, CHRONIC PAIN,
AND THEY'RE TELLING US WE'RE

DOING THIS WRONG.

THE GLOVES ARE OFF.

WE'RE GOING TO START TREATING
PAIN LIKE THE EXPERTS SAY.

AND YOU CAN SIGH THE LINE GOES
CRAZY, GOES UP.

INTERESTINGLY THAT GROUP GOT
TOGETHER IN TWOZ 18 BECAUSE OF

OUR NEW ETHICS LAWS IN MEDICINE,
THEY WOULD HAVE TO DISCLOSE IF

THEY WERE GETTING PAID BY THE
PHARMACEUTICAL INDUSTRY AND

ALMOST ALL OF THEM WERE.

BUT THEY DIDN'T TELL US THAT
BACK THEN.

SO FROM 1986 TO 2015 THIS 30-
YEAR PERIOD, 600% INCREASE IN

THE NUMBER OF OPIATES THAT WE
ARE PRESCRIBING AND DISPENSING

IN THE UNITED STATES WHILE NO
OTHER COUNTRY IN THE WORLD IS

DOING THE SAME THING.

SO EVERYTHING WE KNOW ABOUT
CHRONIC NON-CANCER PAIN AND

USING OPIATES HAS BEEN
PROGRAMMED BY THE PHARMACEUTICAL

INDUSTRY.

THAT'S MY OPINION.

I DO KNOW THIS FOR A FACT.

THERE'S NO DATA THAT SAYS USING
OPIATES FOR CHRONIC PAIN IS

BENEFICIAL BUT I DO HAVE DATA
THAT SAYS IT'S HARMFUL.

AND THIS IS THE BEST THE
PHARMACEUTICAL INDUSTRY CAN DO.

THAT IS LOT OF WORDS BUT I WANT
TO READ IT FROM TO YOU.

FROM THE AMERICAN CANCER P
SOCIETY.

OPEN YACHT MEDICATIONS IN THE
CLASS OF MORPHINE ARE DESIGNATED

TO HAVE A LEGITIMATE MEDICAL USE
THAT'S TRUE.

AND ARE INDICATED FOR THE
MEDICAL MANAGEMENT OF PAIN,

ESPECIALLY IF THE PAIN IS SEVERE
THAT'S TRUE AS WELL.

THE F.D.A. MAKES IT SO.

SO LOOK AT THIS NEXT LINE THOUGH
ALTHOUGH THEIR USE FOR THE

RELIEF OF A VARIETY OF CHRONIC
NON-CANCER PAIN CONDITIONS

CONTINUES TO EVOLVE.

WHAT DID THEY SAY?

THEY DIDN'T SAY ANYTHING.

READ THAT AGAIN.

READY?

ALTHOUGH THEIR USE FOR THE
RELIEF OF A VARIETY OF CHRONIC

NON-CANCER PAIN CONDITIONS
CONDITIONS TO EVOLVE AND

EVIDENCE OF EFFECTIVENESS OF
THESE CONDITIONS IS DERIVED

LARGELY FROM CLINICAL EXPERIENCE
SO THEY DON'T HAVE A RANDOMIZED

CONTROL TRIAL OR THEY DON'T HAVE
A RETROSPECTIVE OR PROSPECTIVE

TRIAL.

WHAT THEY DO IS COME AND FIND
DOCS LIKE ME AND SAY HEY, DO YOU

HAVE ANYBODY WITH LOW BACK PAIN?

I SAY YEAH.

DO YOU GIVE THEM OPIATES?

YEAH.

DO YOU THINK IT WORKS?

IF I SAY IT YES, THEY PUT A
CHECK DOWN, IT WORKS.

THAT'S ALL THEY'VE GOT.

THERE SEEMS TO BE A GENERAL
AGREEMENT THAT SOME PATIENTS

WITH SUCH PAIN CAN BE PROPERLY
TREATED WITH OPIATE THERAPY.

THAT'S IT.

THAT'S THE BEST THE INDUSTRY HAS
AND THE INDUSTRY TOLD US TWO

THINGS.

THEY TOLD US WE'RE GOING TO
DECREASE PAIN AND INCREASE

FUNCTION DURING THIS TIME PERIOD
THIS IS A 20-YEAR STUDY ACROSS

THE BOTTOM IS LOW BACK PAIN,
MUSCULOSKELETAL PAIN, NECK PAIN

AND OSTEOARTHRITIS IS PAIN IN
THE HIP OR KNEE.

SO YOU CAN SEE THAT PAIN WENT UP
IN ADULTS IN THE UNITED STATES.

BUT WITH A 600% INCREASE IN
OPIATES, YOU WOULD THINK THAT IT

WOULD AT LEAST STAY THE SAME OR
GO DOWN.

BUT IT DIDN'T, IT WENT UP.

BUT THE SECOND THING THEY SAID
IS BUT WE'RE GOING TO INCREASE

FUNCTION.

AND SO DOCS THAT I WORK WITH
THAT CAN REMEMBER BACK IN THE

'80S, THEY MIGHT HAVE HAD A
LITTLE BIT MORE GRAY HAIR THAN I

DO, THEY SAID THEY COULD
REMEMBER DRUG REPS SAYING HEY

YOUR PATIENT THAT FELL OFF THE
LADDER AND BROKE HIS BACK, DON'T

YOU WANT HIM TO GO BACK TO WORK?

AND THE DOCS P LIKE YEAH, I WANT
HIM TO GO BACK TO WORK.

THEY'D SAY HEY, YOU SHOULD USE
OPIATES TO HELP.

BUT DO YOU KNOW THE NUMBER OF
DAYS THAT YOU NEED TO BE ON AN

OPIATE TO DOUBLE YOUR RISK OF
GOING OUT ON PERMANENT

DISABILITY?

SEVEN DAYS.

THAT'S IT.

AND EVERY DAY AFTER THAT THAT
YOU'RE ON AN OPIATE INCREASES

YOUR RISK EVEN MORE OF GOING OUT
ON PERMANENT DISABILITY.

AND WHEN I HEARD THAT, I HAD
BEEN WORKING IN THIS OPIATE

SPACE FOR ABOUT A YEAR, I HAD 12
PATIENTS THAT HAD CHRONIC PAIN

THAT I WAS WRITING OPIATES FOR
THEM, EVERY THREE MONTHS I WOULD

SEE THEM.

I WENT BACK AND LOOKED AT THEIR
CHARTS.

11 OUT OF 12 OF MY PATIENTS WERE
ON PERMANENT DISABILITY.

SO THE PHARMACEUTICAL INDUSTRY
SAID WE'RE GOING TO DECREASE

PAIN AND INCREASE FUNCTION, BUT
IT DID THE OPPOSITE.

AND IF THAT'S KIND OF LIKE NOT
DAMNING ENOUGH, THIS IS THE

GREEN LINE IS ALL OF THE OPIATES
PRESCRIBED -- DISPENSED BY ALL

THE PHARMACEUTICAL COMPANIES IN
THE UNITED STATES, THE SECOND

LINE IS OPIATE DEATHS DURING
THAT TIME FRAME.

AND THE THIRD LINE IS PEOPLE
GOING INTO INPATIENT TREATMENT

FOR OPIATE USE DISORDER, THE NEW
TERM FOR OPIATE ADDICTION.

TO BRING IT HOME TO NORTH
CAROLINA THEN, SO THIS -- THIS

SLIDE IS FROM THE NORTH CAROLINA
DEPARTMENT OF HEALTH AND HUMAN

SERVICES AND THE TOP LINE THERE
IS NUMBER OF OPIATE DEATHS FROM

PILLS.

THEN THE SECOND LINE DOWN, THE
FIVE -- 7, 9, IS OPIATE DEATHS

FROM SYNTHETICS AND WE'LL JUST
CALL THEM FENTANYL FROM NOW ON.

THE 538 IS OPIATE DEATHS ARE
HEROINE.

SO THE STORY HERE IS THAT THIS
STARTED OFF AS A PILL PROBLEM.

AND IT STILL IS A PILL PROBLEM.

BUT NOW IT'S A HEROINE AND
FENTANYL PROBLEM.

WHEN WE FINALLY GET THE DATA
FROM 2017A LITTLE OVER 1,500

NORTH CAROLINIANS WILL HAVE DIED
FROM OPIATE DEATHS IN THE YEAR

2017.

ON AVERAGE FOUR PEOPLE DIE EVERY
DAY.

AND THIS IS HOW WE'VE GOTTEN
INTO THIS PROBLEM NOW, IS THAT

WE STARTED WITH PILLS BUT NOW
IT'S -- IT'S REALLY GOTTEN INTO

HEROINE AND FENTANYL.

SO THE FIRST BOTTLE THERE IS
SUPPOSEDLY A GRAM OF HEROINE.

AND DEPENDING UPON A PATIENT'S
OR A PERSON'S POLL RANS, IF YOU

SHOOT A GRAM YOU CAN OVERDOSE
AND DIE.

BUT THE SECOND BOTTLE THERE IS
FENTANYL, AND IT'S 50 TO 100

TIMES MORE POTENT THAN THE
HEROINE THAT'S OUT THERE ON THE

STREET RIGHT NOW.

THAT'S JUST 50 GRAINS.

AND IF YOU SHOOT THAT, YOU CAN
OVERDOSE AND DIE.

AND THEN THE LAST ONE, HAVE YOU
HEARD OF THIS?

THIS CAR FENTANYL BUSINESS?

IT'S AN ELEPHANT TRANQUILIZER.

IT'S 5,000 TIMES MORE POTENT
THAN THAT HEROINE THAT'S ON THE

STREET AND THERE'S JUST THREE
GAINS.

THERE'S A REASON YOU CAN'T SEE
MUCH IN THAT BOTTLE BECAUSE

THERE'S ONLY THREE GRAINS IN
THERE.

IF YOU SHOOT THAT, YOU OVERDOSE
AND DIE.

SO YOU CAN IMAGINE AS THE END
USER IF THEY CUT THE CARFENTANYL

INTO THE HEROINE AND YOU SHOOT
THE SAME AMOUNT OF TIME YOU DID

LAST TIME AND YOU DON'T KNOW IT,
YOU DON'T KNOW WHAT'S IN IT, YOU

CAN OVERDOSE AND DIE.

AND THAT'S WHAT WE'RE FEELING
OUT THERE.

WHEN YOU TALK TO THE POLICE, THE
FIRE -- FOLKS IN FIRE AND THE E.

M.S. AND SAY HEY, I HEAR
YOU'VE REALLY GOT A HEROINE

PROBLEM NOW, THEY'LL CORRECT YOU
AND SAY IT'S A FENTANYL PROBLEM.

AND THE REASON THAT THEY'RE
CUTTING THE FENTANYL IN THERE IS

BECAUSE IT'S MORE POWERFUL,
PEOPLE ARE SEEKING THAT, AND

IT'S LESS EXPENSIVE.

AND IT'S BEEN LESS EXPENSIVE
EVERY YEAR FOR THE LAST THREE OR

FOUR YEARS.

SO THIS IS UNINTENTIONED
MEDICATION AND DRUG OVERDOSE

DEATHS BY COUNTY.

AND YOU CAN SEE THAT THE
[ NO AUDIO ]

AND THE DARKER COLOR IS WORSE.

SO IF YOU KIND OF LOOK AT
WESTERN NORTH CAROLINA THERE, WE

HAVE A LOT OF COUNTIES THAT HAVE
THAT DARK COLOR.

[ NO AUDIO ]
IN APPALACHIA, NOT JUST NORTH

CAROLINA, EASTERN TENNESSEE,
WEST VIRGINIA, EASTERN OHIO, YOU

GO UP THE APPALACHIAN CHAIN EVEN
UP INTO PENNSYLVANIA, AND WE

HAVE FOR THE SAME AMOUNT OF DRUG
PROBLEMS, PEOPLE WITH THEIR

OPIATE USE DISORDER, WE HAVE IN
APPALACHIA 55% INCREASE IN OVER

DOSE DEATHS COMPARED TO THE
REST OF THE COUNTRY.

SO SOMETHING IS GOING ON HERE IN
APPALACHIA.

AND THIS IS NORTH CAROLINA
OPIATE OVERDOSE DEATHS -- OVER

DOSES THAT THE EMERGENCY
DEPARTMENT IS SEEING.

YOU CAN SEE IT WAS KIND OF
STEADY IN 2016 AND THIS IS JUST

THE DATA WE HAVE THROUGH 2017.

AND THEN IT ACTUALLY WENT UP
QUITE A BIT, AND THEN NOW IT

SEEMS TO BE COMING DOWN.

INTERESTINGLY THOUGH WE THINK
THERE'S MORE REVERSALS BUT WE'RE

NOT SEEING AS MUCH IN THE
EMERGENCY DEPARTMENT.

SO WHAT'S HAPPENING?

BECAUSE OF A LOT OF EFFORTS OF
YOU ALL, WE'RE GETTING MORE

NARCAN OUT INTO THE COMMUNITIES
AND THE REVERSALS ARE ACTUALLY

HAPPENING IN THE FIELD.

SO A LOT MORE POLICE DEPARTMENTS
AND FIRE DEPARTMENTS, E.M.S. ARE

CARRYING IT.

BUT ALSO THERE'S A LOT OF PEOPLE
THAT ARE ALT -- AT HIGH RISK

THAT ACTUALLY HAVE NARCAN, OR
THEIR LOVED ONES DO IN THE LOCK

ZONE AND ABLE TO REVERSE A
PATIENT OR PERSON THAT'S

OVERDOSED IN THE FIELD.

SO WE'RE SEEING A FLATTENEDING
IN THE EMERGENCY DEPARTMENT AT

THE SAME TIME WE BELIEVE THERE'S
MORE AND MORE OVERDOSES THAT ARE

HAPPENING.

AND THEN FOLKS, SOMETIMES THEY
TAKE THE PILLS BUT OFTENTIMES

WHEN YOU'RE IN YOUR USE DISORDER
YOU'RE EITHER SNORTING OR

SHOOTING.

THERE'S A LOT OF EFFORT OUT
THERE TO TRY TO HELP WITH FOLKS

THAT ARE I.V. DRUG USERS.

BUT WE ARE SEEING THE EFFECTS OF
THIS.

AND SO ALL OF YOU THAT ARE OUT
THERE TRYING TO HELP TO GET

CLEAN NEEDLES TO THESE FOLKS AND
THEN ALSO JUST BEING THERE FOR

THE TIME THAT THEY'RE READY TO
SAY I'M -- I'M READY TO DO

SOMETHING ELSE.

I WANT HELP.

I REALLY PRAISE Y'ALL AND
APPRECIATE WHAT YOU'RE DOING.

BUT THIS IS WHAT WE'RE SEEING.

SO HEPATITIS.

>> CR IN NORTH CAROLINA, 500%
INCREASE IN THIS SEVEN-YEAR

PERIOD.

AND HERE'S INFECTIONS THAT ARE
IN THE BLOODSTREAM.

OFTENTIMES THEY CAN GET
INFECTIONS FROM DIRTY NEEDLES

AND GET A PUS POCKET OR ABSCESS
IN THE SKIN.

SOMETIMES THAT WILL GET INTO THE
BLOODSTREAM AND THAT'S INCREASED

FOUR TIMES OVER.

AND THEN SOMETIMES THIS -- THE
BACTERIA WILL GO UP TO THE HEART

AND WILL ATTACH TO THE HEART
VALVES.

AND WE'VE SEEN A 13.5 TIMES
INCREASE.

AND I KNOW I'M E PREACHING TO
THE CHOIR, JUST TO TELL YOU THIS

PUBLIC HEALTH STORY THEN, SO IT
COSTS ROUGHLY $7 FOR 100 CLEAN

NEEDLES.

AND SO -- TO REPLACE SOMEONE'S
VALVE THAT'S BEEN DAMAGED TBI

BACTERIA ON THERE IS ROUGHLY $2
50,000.

SO IF WE CAN KEEP TELLING THIS
STORY, AND I APPRECIATE AGAIN

ALL Y'ALL OUT THERE THAT ARE
WORKING IN THIS SPACE AND TRYING

TO HELP, BUT WE HAVE TO GET
CLEAN NEEDLES TO THE FOLKS TO

HELP THEM TO NOT HAVE THESE
INFECTIONS.

H.I.V. IS ON THE RISE AS WELL.

TO TRY TO NOT HAVE THESE
INFECTIONS AND THEN BE THERE FOR

THEM WHEN THEY'RE COMING TO
EXCHANGE THEIR NEEDLES AND WHEN

THEY'RE READY TO SEEK CHANGE IN
THEIR LIVES, THEN WE'RE THERE

FOR THEM, AND WE NEED TO BE
DOING THAT.

AND IT'S GOT TO BE A GOOD USE OF
OUR RESOURCES.

SO THEN HERE IS SOME DEMOGRAPHIC
S.

IT'S URBAN AND RURAL AND WHITE
AND BLACK.

THIS STARTED OFF AND THIS WAS A
WHITE PHENOMENON AND

PARTICULARLY IN RURAL AREAS.

BUT IT REALLY HAS BECOME A RACE
AND CLASS -- IT'S LIKE EVERYBODY

IT'S AFFECTING EVERYBODY NOW.

IT DOESN'T MATTER IF YOU'RE
WHITE, BROWN, OR BLACK.

IT DOESN'T MATTER IF YOU'RE RICH
OR POOR.

I ACTUALLY THINK IN MY PRACTICE,
SO I DO WRITE A MEDICATION

CALLED SEBOXONE TO HELP PEOPLE
STABILIZE THEIR LIVES SO THEY

CAN GET TO THEIR THERAPY, IF
THEY HAVE OPIATE USE DISORDER.

BUT IT ALMOST SEEMS LIKE IF YOU
HAVE MORE MONEY YOU'RE MORE

LIKELY TO BE ABLE TO BE ABLE TO
BUY THESE DRUGS AND GET INTO

THIS PROBLEM.

SO IT REALLY CUTS ACROSS ALL
SOCIOECONOMIC BOUNDS.

AND AGAIN, THE LAST ONE SHOWS
APPALACHIA.

WE HAVE A HIGHER RATE OF DRUG
OVERDOSE MORTALITY THAN THE REST

OF THE COUNTRY.

AND THEN JUST PUTTING A FEW OF
THE COUNTIES OUT THERE, I KNOW

SOME OF YOU ARE FROM GRAHAM
COUNTY RIGHT NOW AND THEY'RE

REALLY GETTING BROADSIDED WITH
THIS.

THIS WAS DATA FROM AROUND 2011
TO 2013, I THINK.

SO SWITCHING GEARS, I WANT TO
TALK A LITTLE BIT ABOUT

[INAUDIBLE].

THERE'S ACUTE PAIN AND CHRONIC
PAIN.

THIS IS ONE OF OUR PROBLEMS.

[ NO AUDIO ]
GETTING INTO THE MEDICAL SCHOOLS

, NURSE PRACTITIONER, P.

A. SCHOOLS, DENTAL SCHOOLS,
AND WE'RE TRYING TO TEACH THIS.

IF YOU BELIEVE CHRONIC PAIN IS
JUST ACCUSE PAIN THAT LASTS A

LITTLE LONGER THEN YOU'RE GOING
TO SAY OPIATES HELP IF YOUR BONE

IS STICKING OUT OF YOUR SKIN SO
IT MUST HELP IN CHRONIC PAIN.

BUT CHRONIC PAIN IS A TOTALLY
DIFFERENT KETTLE OF FISH AND

THAT'S WHY THOSE TWO MEDICINES
DON'T WORK IN THE SAME

SITUATIONS.

HERE IS ACUTE PAIN.

YOU HAMMER YOUR TOE AND YOU HIT
IT SO HARD YOU SPLIT THE SKIN

OPEN.

ALL RIGHT?

YOU'RE TO HAVE A LOT OF TISSUE
INPUT.

YOU MIGHT EVEN THINK ABOUT SAY
AGO BAD WORD.

I KNOW YOU WOULDN'T.

BUT THERE ARE THOUGHTS AND
EMOTIONS THAT GO INTO THAT ACUTE

PAIN.

RIGHT?

AND NOW LOOK AT CHRONIC PAIN.

SO LIKE MY PATIENT, I'VE BEEN
SEEING FOR ALMOST TEN YEARS AND

HE HAD THREE BACK SURGEONS AND
THE SURGEON SAID I CANNOT

SURGEONIZE YOU ANYMORE.

GO SEE YOUR DOCTOR, THAT'S ME.

I'VE BEEN SEEING HIM TEN YEARS
AND WRITING HIS OPIATES.

AND HE'S STILL GETTING SOME
TISSUE INPUT FROM THE PAIN IN

HIS BACK.

BUT CHRONIC PAIN REWIRES THE
BRAIN.

AND IF YOU HAVE CHRONIC PAIN AND
YOU'RE ON OPIATES, IT REWIRES

THE BRAIN EVEN MORE.

AND SO THERE'S A LOT OF THOUGHTS
AND EMOTIONS THAT ARE GOING INTO

THE PAIN THIS GENTLEMAN HAS.

AND I'M NOT SAYING IT'S ALL IN
HIS HEAD, BUT IT'S ALL IN HIS

HEAD AND THAT HE REALLY IS
EXPERIENCING -- IF HE SAYS I'M

HAVING 7 OUT OF 10 PAIN, IT'S
THAT WAY ALL THE TIME.

HE REALLY IS EXPERIENCING IT
THAT WAY BECAUSE THE BRAIN HAS

REWIRED.

BECAUSE HE'S GETTING THE OPIATES
ON TOP OF IT.

SO REALLY WHAT WE'RE TRYING TO
TEACH ALL THE NEW PROVIDERS THAT

ARE COMING OUT OF THEIR PROGRAMS
IS THERE IS THIS NEUROPATHIC

PAIN, THERE'S OPIATE WITHDRAWAL
PAIN.

SO YOU ACTUALLY CAN GET MORE
PAIN FROM BEING ON OPIATES.

ISN'T THAT CRAZY?

IT'S CALLED OPIATE HYPER ALGESIA
PROBABLY TAKES MONTHS TO YEARS

FOR THAT TO HAPPEN, BUT
SOMETIMES WE ARE WEANING PEOPLE

DOWN ON THEIR OPIATES AND THEIR
PAIN GETS BETTER AND THEY START

FEELING BETTER.

AND THEN WHAT I WAS JUST TALKING
ABOUT WAS THIS CENTRAL

SENSITIZATION.

SO THEY'RE HAVING THIS CHRONIC
PAIN AND THEN IF THEY GET

OPIATES ON TOP OF IT, IT'S
CHANGING THEIR BRAIN.

AND THEN THERE'S ALSO THE NOASH
OWE SEPTIC PAIN, YOU HAMMER YOU.

SO IN LIFE WHEN THEY LOOK AT US
AS A SPECIES, IT'S DOPAMINE THAT

MAKES US DO EVERYTHING WE DO.

WHY YOU WAKE UP IN THE MORNING,
YOU MAKE MONEY, EAT, DRINK, THE

WHOLE SHOOTING MATCH, RIGHT?

AND THERE'S ACTUALLY ONLY TWO
THINGS THAT DUMP INTO DOPAMINE.

AND THAT'S ENDORPHINS AND
OPIATES.

INTERESTINGLY.

SO WHAT HAPPENS IF YOU HAVE
SOMEBODY THAT SAYS I'VE NEVER

TAKEN AN OPIATE BEFORE, AND THEY
START TO TAKE AN OPIATE FOR THE

FIRST TIME?

SO WHY DO WE HAVE OPIATE
RECEPTORS?

AND MOST PROVIDERS WOULD SAY
IT'S TO DECREASE PAIN.

AND THAT'S TRUE, BUT THAT'S
ACTUALLY THE SECOND REASON.

SO IF YOU GET INTO THE PRIMARY
CARE LITERATURE ON WHY AS A

SPECIES WE HAVE OPIATE RECEPTORS
, IT'S TO ACHIEVE A

SHORT-TERM GOAL.

IT'S FASCINATING NOW.

THINK ABOUT THAT WHEN I SHOW YOU
EVERYTHING ELSE THAT LIGHTS UP

AS THIS PERSON IS TAKING
PERCOCET SAY FOR THEIR BROKEN

ANKLE.

IT DEYESES PAIN, GREAT, THAT'S
WHY I GAVE YOU THIS MEDICINE,

RIGHT?

BUT IT ALSO INCREASES MOTIVATION
, IT INCREASES

CONFIDENCE, IT INCREASES THE
REWARD SYSTEM, AND IT REDUCES

DEPRESSION AND ANXIETY.

IT MAY ONLY BE FOR 30 MINUTES OR
AN HOUR AND A HALF, IT'S REALLY

SHORT TERM, BUT WHEN YOU FIRST
START TAKING THAT, THAT CAN

HAPPEN SOMETIMES.

SO THINK ABOUT THAT PATIENT
MAYBE THAT'S BEEN SEEING ME FOR

FIVE YEARS AND THEY HAVE
DEPRESSION, I'VE TRIED FIVE OR

SIX DIFFERENT MEDICINES, TRIED
TO GET THEM INTO THERAPY, AND

IT'S JUST NEVER GOTTEN TAKEN
CARE OF.

AND THEY GO TO THE E.R. WITH A
BROKEN WRIST AND THEY GET

PERCOCET AND THEY TAKE IT AND
THEIR DEPRESSION TOTALLY GOES

AWAY.

DO YOU THINK THEY'RE GOING TO
FINISH THAT PERCOCET RATHER --

WHETHER IT'S 6 PILLS, 12 PILLS
OR 30?

FOR SURE.

THAT'S THE BEST THEY'VE FELT IN
FIVE YEARS.

THAT CAN ACTUALLY HAPPEN.

THAT INCREASES THE PLEASURE IN
THE CURRENT ACTIVITY.

BUT WHAT HAPPENS IF YOU TAKE
OPIATES CHRONICALLY?

OKAY?

SO AT LEAST MONTHS BUT PROBABLY
YEARS.

AND SO IT DECREASES DOPAMINE
PRODUCTION.

THAT'S WHY WE LIVE.

IT'S DECREASES THE NORMAL REWARD
SYSTEM.

IT DOWNREGULATES OPIATE
RECEPTORS AND INCREASES

ENDORPHINS.

THE ONLY TWO THINGS THAT DUMP
INTO DOPAMINE.

IT DECREASES MOTIVATION AND LONG
TERM IT INCREASES DEPRESSION.

GREAT MED, HUH?

SO THIS IS THE YELLOW BRICK ROAD
, RIGHT, WIZARD OF OZ, AND

THEY WERE SKIPPING AND SINGING
THROUGH THE POPPIES.

THAT'S RIGHT.

THAT'S RIGHT.

SO THIS IS AN ILLUSTRATION OF
THE POPPIES SOMETIMES CAN MAKE

YOU FEEL REALLY GOOD AT THE
BEGINNING, BUT DOES ANYBODY

REMEMBER, THEY DIDN'T QUITE MAKE
IT TO THE EMERALD CITY?

THEY FELL ASLEEP, RIGHT.

AND IRONIC FORESHADOWING FOR
EVERYTHING THAT'S HAPPENING WITH

THIS OPIATE CRISIS NOW IS YOU
GET TOO MUCH OF THE OPIATES AND

YOU CAN FALL ASLEEP FOR SURE.

SO THIS IS THE C.D.C. GUIDELINES
THAT CAME OUT MARCH OF 2016 FOR

ACUTE AND CHRONIC PAIN.

AND WE'RE GOING TO START TALKING
ABOUT ACUTE PAIN FIRST.

SO THE C.D.C. CAME OUT MARCH OF
2016 AND THEY SAID TO PROVIDERS,

IF YOU'RE GOING TO PRESCRIBE
OPIATES, PRESCRIBE THREE DAYS OR

LESS AND NO MORE THAN SEVEN IS
RARELY NEEDED.

AND THIS WAS A RADICAL CHANGE.

NOT ONLY FOR PROVIDERS BUT FOR
PATIENTS AS WELL.

BUT AGAIN, WE'RE DOING THIS
TOTALLY DIFFERENT THAN OTHER

PLACES.

SO IN THE COUNTRY OF GERMANY,
THEY TAKE OUT ORGANS AND WHEN

YOU LEAVE THE HOSPITAL YOU'RE ON
TILE TYLENOL AND IBUPROFEN.

AND THAT JUST DOESN'T COMPUTE
WITH US OVER HERE.

OF COURSE THAT'S REALLY SEVERE
PAIN.

I MUST NEED PERCOCET OR VICODIN,
RIGHT?

THAT'S HOW THEY DO IT.

IT'S NOT LIKE IN ONE HOSPITAL IN
GERMANY T. COUNTRY OF GERMANY.

YOU GET A HYSTERECTOMY, THEY
TAKE CARE OF NEW THE HOSPITAL

AND WHEN YOU GO HOME YOU'RE ON
TYLENOL AND IBUPROFEN.

WE ARE TRYING TO BACK UP AND
FIND OUT WHAT WE SHOULD BE DOING

IT SAYS COUNSEL YOUR PATIENTS ON
SAFE STORAGE AND DISPOSAL OF

OPIOIDS.

I HAVE TO SAY PRIOR TO WREADING
THAT I DISPENSED A LOT OF

VICODIN AND PERCOCET AND I NEVER
DID THAT.

BUT I DO NOW AND TEACH IT.

THIS IS WHAT THE C.D.C. IS
SAYING AND I APPRECIATE ALL

Y'ALL THAT ARE OUT THERE AND
GETTING THESE LOCKBOXES TO

PEOPLE AND REAL LIVE -- REALLY
TALKING TO THEM ABOUT IT.

BUT WE NEED TO TALK TO EVERYONE,
OUR CLIENTS, PATIENTS, AND

ANYONE THAT WILL LISTEN IN OUR
FAMILY.

THE C.D.C. IS SAYING IF YOU HAVE
AN OPIATE YOU NEED TO HAVE IT

LOCKED UP.

AND IF YOU DON'T USE IT ALL, YOU
NEED TO GET RID OF IT.

YOU NEED TO GET IT OUT OF YOUR
HOUSE.

THERE'S THREE WAYS TO DO IT.

YOU CAN GOOGLE WHERE YOUR
PERMANENT DROPBOX IS IN YOUR

COMMUNITY AND TAKE IT THERE AND
DROP IT OFF.

IF YOU CAN'T DO THAT YOU CAN ADD
COFFEE GROUNDS TO IT OR KITTY

LITTER, WATER, YOU SHAKE IT UP
AND MAKE A SLURRY AND THROW IT

AWAY.

IT WILL RUIN IT.

OR IF YOU CAN'T DO ONE OF THOSE
FIRST TWO, THEY SAY YOU SHOULD

FLUSH IT.

I'M JUST SAYING, FLUSHING IT
FEELS NOT GOOD TO ME.

FLUSHING THIS INTO OUR, YOU KNOT
SEEMS LIKE YOU SHOULD BE ABLE TO

DO ONE OF THE FIRST TWO.

IF I ONLY HAD THAT OPTION, WOULD
I RATHER DO THAT THAN HAVE MY

14-YEAR-OLD BECOME ADDICTED TO
OPIATES?

YEAH, I WOULD DO IT.

BUT THIS IS WHAT THE C.D.C. IS
SAYING WE SHOULD DO.

SO A STORY ABOUT THAT, ONE OF
THE FOLKS I WORK WITH, SHE HAD A

SOFA DELIVERED AT HER HOUSE AND
ONE OF THE GUYS DELIVERING IT

SAID HEY, CAN I USE YOUR
RESTROOM?

SHE SAID YEAH.

THEN AFTER THEY LEFT SHE SAID
HUH, HE SURE SPENT A LOT OF TIME

IN THERE.

SHE WENT INTO HER BATHROOM AND
ALL OF HER PERCOCET WERE GONE.

AND DO YOU THINK EVERY TIME THAT
HE DELIVERS A PIECE OF FURNITURE

THAT HE ASKS TO USE THE RESTROOM
I BET HE DOES, DON'T YOU?

AND IF WAS -- IT WAS THAT EASY
FOR THAT GUY, THINK ABOUT IT.

HOW EASY IS IT FOR OUR KIDS, OUR
KIDS' FRIENDS, OUR GRANDKIDS TO

GET TO IT?

THERE ARE LITERALLY HUNDREDS OF
MILLIONS OF UNUSED OPIATES IN

UNLOCKED CABINETS IN OUR HOMES.

WE GOT TO GET THEM OUT OF THERE,
AND WE HAVE TO TELL OUR PATIENTS

AND CLIENTS TO DO THE SAME THING
SO WHERE DID THIS COME FROM?

THE C.D.C. COMES OUT AND SAYS
HEY, REALLY YOU SHOULD JUST GIVE

THREE DAYS.

BUT IF YOU HAVE TO, SEVEN DAYS
BUT NOT MORE THAN SEVEN.

SO THIS IS A TEN-YEAR STUDY OF
ADULTS IN THE UNITED STATES.

OKAY?

AND THEY WERE OPIATE NAIVE.

THEY HAD NEVER HAD AN OPIATE
BEFORE AND THEY GET A LEGITIMATE

PRESCRIPTION FROM THEIR PROVIDER
LEGITIMATE PRESCRIPTION FROM

THEIR DOCTOR FOR A LEGITIMATE
REASON.

THEY SAY WHAT'S THE CHANCE
YOU'RE STILL ON OPIATES AT A

YEAR AND AT THREE YEARS?

SO I JUST WANT TO SHOW YOU HERE.

IF YOU'LL FOCUS IN AT THE 30
DAYS.

SO IF YOU GOT A 30-DAY
PRESCRIPTION, NEVER HAD AN

OPIATE IN YOUR LIFE, ONE YEAR
LATER, 30% OF PEOPLE ARE STILL

ON AN OPIATE.

THREE YEARS LATER, 15, ALMOST 20
% OF PEOPLE ARE STILL ON AN

OPIATE.

THAT IS NOT LESS THAN 1% OF
PEOPLE WHO EVER GET DEPENDENT

OSH ADDICTED TO THESE.

THESE ARE REALLY SAFE MEDICINES,
IS IT?

FROM ONE 30-DAY PRESCRIPTION, 15
TO 20% OF PEOPLE THREE YEARS

LATER ARE STILL TAKING AN OPIATE
NOW, THEY DIDN'T BREAK IT OUT IN

THAT DATASET.

PROBABLY THE MAJORITY OF THEM
ARE STILL IN PAIN AND SEEING

THEIR PROVIDER AND GETTING A
MEDICATION FOR THAT.

BUT MAYBE SOME OF THEM ARE
GETTING THEM FROM FAMILY AND

FRIENDS, MAYBE SOME OF THEM ARE
SLOOTING HEROINE.

THEY JUST SAID HAD YOU ON AN
OPIATE ONE YEAR AND THREE YEARS

LATER AND WHERE THAT DATASET
STARTS TO GO UP IS RIGHT HERE AT

THREE DAYS.

AND WHY WE IN NORTH CAROLINA
PASSED THE NORTH CAROLINA STOP

ACT THAT NOW SAYS FOR ACUTE PAIN
THAT YOU CAN ONLY PRESCRIBE FIVE

DAYS WORTH OR AFTER SURGERY
SEVEN TO TRY TO REDUCE THE

CHANCE THAT FOLKS WILL STILL BE
ON OPIATES AT A YEAR.

THEN THIS DATASET IS FROM THIS
SAME STUDY WHERE THEY SAID WHAT

ABOUT THIS REFILL BUSINESS?

SO I'VE HAD THIS PATIENT
I WAS

16 YEARS OLD, BROKE MY BACK IN
THREE PLACES AND MY DOCTOR GAVE

ME PERCOCET FOR A MONTH AND
REFILLED IT SIX TIMES OVER THE

PHONE AND THEN SAID GO SEE YOUR
REGULAR DOCTOR.

I CAN'T DO THIS ANYMORE.

AND SHE FOUND THAT SHE STARTED
TO WITHDRAW AND SHE -- SHE HATED

THAT.

SO SHE STARTED BUYING PILLS AT
SCHOOL AND THEN BY 20 WAS

SHOOTING HEROINE AND ROLLED IN
TO SEE ME WHEN ONE OF HER

FRIENDS OVERDOSED AND DIED AND
SAID I DON'T WANT TO DO THIS

ANYMORE.

I DON'T WANT TO DIE.

AND WHAT HAPPENS IF YOU GET A
PRESCRIPTION AND THEN YOU REFILL

IT SIX TIMES?

WELL, THERE'S A 60% CHANCE THAT
YOU'LL STILL BE ON OPIATES AT A

YEAR AND A 40% CHANCE YOU'RE
STILL ON OPIATES AT THREE YEARS.

THIS IS NOT LESS THAN 1% OF THE
PEOPLE.

SO FOR CHRONIC PAIN, THIS WAS
VERY CONTROVERSIAL, TOO.

IT SAID IN GENERAL DO NOT
PRESCRIBE OPIATES AS FIRST LINE

TREATMENT FOR KRON CHRONIC PAIN
AND THEN RIGHT UNDERNEATH IT IF

YOU GO TO THE C.D.C. WEBSITE,
DO NOT PRESCRIBE OPIATES FOR LOW

BACK PAIN, FINE BRO --
FIBROMYALGIA AND HEADACHES.

I HAVE DONE THAT OVER MY
PRACTICE.

AND THIS IS A HARD THING TO SAY
BUT I LOOK AT MY PATIENTS AND I

BELIEVE I ADDICTED SOME OF THEM.

DOCTORS WERE TRYING TO HELP
PEOPLE, WE CERTAINLY WEREN'T

TRYING TO HURT THEM BUT THIS IS
WHAT WE DID.

WE BOUGHT THIS BILL OF GOODS
THAT THESE MEDICINES ARE SAFE

AND THEY'RE REALLY NOT.

CHRONIC PAIN, LOW BACK PAIN ON
OPIATES AND THERE'S BEEN LOTS OF

STUDIES ABOUT HOW THESE FOLKS
HAVE DONE AND FOUND FOUR HIGH-

QUALITY STUDIES AND DO THIS
THING CALLED A META-ANALYSIS.

AND THE QUESTION IS WHAT'S THE
CHANCE IF YOU HAVE CHRONIC LOW

BACK PAIN AND OPIATE YOU'LL HAVE
A SUBSTANCE ABUSE DISORDER IN

YOUR LIFETIME?

LOOK AT THAT 36 TO 56% OF PEOPLE
WILL HAVE A SUBSTANCE ABUSE DIS

ORDER IF THEY'RE ON OPIATES
FOR CHRONIC BACK PAIN.

THAT'S NOT LESS THAN 1%, RIGHT?

AND THIS IS AN ARTICLE FROM JAMA
, JUST IN 2018 AND THEY SAID

, OKAY, YOU HAVE CHRONIC
BACK PAIN AND YOU'RE EITHER ON

AN OPIATE OR NOT.

HOW DO YOU DO?

AND THIS IS WHAT THEY FOUND OUT.

THERE'S NO SIGNIFICANT
DIFFERENCE IN THE TWO GROUPS IN

TERMS OF THEIR PAIN RELATED
FUNCTION AT 12 MONTHS BUT THE

PAIN INTENSITY WAS SIGNIFICANTLY
BETTER IN THE NON-OPIATE GROUP.

SO YOU ACTUALLY FELT BETTER IF
YOU WEREN'T GETTING OPIATES FOR

YOUR CHRONIC BACK PAIN.

AND THE OPIATE GROUP HAD
SIGNIFICANTLY MORE MEDICATION

SIDE EFFECTS LIKE FALLS, OVER
DOSE, AND DEATH IN SOME OF THEM.

WHAT ABOUT KIDS?

THE NEXT COUPLE OF SLIDES, THE
STORY IS THE BRAIN UNDER 25

SHOULD NOT BE TOUCHING THIS
STUFF IF AT ALL POSSIBLE.

SO THEY DID THIS STUDY, IT'S IN
PEDIATRICS, IT'S AN ES SCHEME --

ESTEEMED JOURNAL BEEN THE
PEDIATRIC GRIEWBING, 2015.

AND THEY SAID WHAT'S THE CHANCE
YOU'LL HAVE A SUBSTANCE ABUSE

DISORDER IN YOUR EARLY ADULTHOOD
IF YOU GET ONE LEGITIMATE

PRESCRIPTION OF AN OPIATE BEFORE
12th GRADE?

WHAT THEY FOUND OUT IS IT
INCREASING YOUR CHANCE 33%.

SO I DIDN'T SAY IF YOU TAKE 100
KIDS AND GIVE THEM AN OPIATE FOR

THEIR BROKEN WRIST THAT 33 WILL
GET ADDICTED.

I DIDN'T SAY THAT.

BUT IF YOUR CHANCE WAS 1% OR 2%
OR 6%, IT BUMPS IT 33% MORE FROM

ONE PRESCRIPTION.

AND THAT ACTUALLY REALLY
CONCERNED THE RESEARCHERS A LOT.

THEY SAID WHAT ABOUT KIDS THAT
HAVE A LOW CHANCE OF EVER HAVING

A SUBSTANCE USE DISORDER?

THEY DIDN'T USE ACE SCORES OR
ADVERSE CHILDHOOD EXPERIENCES

BUT IT WAS SIMILAR TO THAT.

IF YOUR ACE SCORE WAS LOW, A 0
OR 1, THIS SHOULD BE SOMEBODY

WHO HAS A LOW CHANCE OF HAVING A
SUBSTANCE ABUSE DISORDER IN

THEIR ADULT ONE, ONE LEGITIMATE
PRESCRIPTION INCREASED THAT KIDS

' CHANCE 300%.

IF YOU WERE A 1%, NOW YOU'RE A 3
%.

SO IF YOU'RE A 3% CHANCE, YOU
NOW ARE A 9% CHANCE.

JUST FROM ONE LEGITIMATE
PRESCRIPTION.

BUT THERE IS HOPE.

IVE BEEN HANGING A LOT OF CREPE
AS THEY SAY HERE IN THE SOUTH SO

FAR.

BUT IF YOU TALK TO KIDS ABOUT
DRUGS, 50% REDUCTION IN STARTING

AND USING ILLICIT DRUGS.

THAT'S AMAZING, RIGHT?

AND WE NEED TO BE DOING THAT,
BECAUSE LOOK AT THAT TIME

STATISTIC ABOVE THAT.

90% OF PEOPLE THAT ARE ADULTS
THAT HAVE A SUBSTANCE USE

DISORDER STARTED BEFORE THE AGE
OF 18.

50% STARTED BEFORE 15.

SO WE DO NEED TO BE DOING THIS.

WE NEED TO TALK TO OUR KIDS, OUR
GRANDKIDS, ANYBODY THAT WILL

LISTEN, AND WE NEED TO BE
TALKING TO ALL OF OUR PATIENTS

AND TELLING THEM TO TALK TO
THEIR KIDS.

50% REDUCTION IN STARTING DRUGS
OR USING DRUGS.

BUT INTERESTINGLY, SO THEN THEY
GO AND TALK TO THOSE KIDS AND

THEY SAY HEY, DID SOMEONE TALK
TO YOU ABOUT DRUGS?

YEAH, YOU KNOW, MY MOM DID.

AND THEY SAY WELL WHAT DID SHE
SAY?

AND THEY SAY WELL, SHE TALKED TO
ME ABOUT COCAINE AND METH AND

HEROINE.

ALMOST NEVER DO WE TALK TO THEM
ABOUT PRESCRIPTION DRUGS.

BUT YET THAT IS THE MOST COMMON
WAY THAT YOU GET TO HEROINE.

AND I GET IT, RIGHT?

SOMEBODY WITH A WHITE COAT ON
WROTE THE PRESCRIPTION AND

HANDED IT TO YOU AND YOU WENT
AND PICKED IT UP FROM SOMEBODY

IN A WHITE COAT AT A PHARMACY.

IT MUST BE SAFE.

BUT IT'S NOT.

RIGHT?

SO WE REALLY NEED TO TALK TO OUR
KIDS ABOUT DRUGS, BUT WE NEED TO

SPECIFICALLY TALK TO THEM ABOUT
PRESCRIPTION DRUGS.

NOT USING THEM OR ABUSING THEM
WHEN THEY GO TO THESE PARTIES OR

BUYING THEM FROM OTHERS.

SO WHAT ARE SOME OF THE
ALTERNATIVES?

WHAT CAN WE DO?

TALK ABOUT ACUTE PAIN, THERE'S A
SIT MINH FIN, IBUPROFEN,

OPIATES FOR ACUTE PAIN.

YOU MIGHT GATHER I'M A LITTLE
DOWN ON THEM.

THERE'S TOPICAL ACTS AND THIS
REALLY DOES WORK WHEN YOU HAVE

ACUTE PAIN, ICE, HEAT, PHYSICAL
THERAPY.

THEY WORK.

ALL RIGHT?

SO WHAT ARE THE SIDE EFFECTS?

YOU HAVE SOMEBODY THAT'S TAKING
SOME TYLENOL AND SOMETIMES IF

YOU DON'T TAKE IT RIGHT
[ NO AUDIO ]

WHAT ABOUT THESE NSAIDS,
IBUPROFEN, ALEVE, MOTRIN?

WELL, IT CAN CAUSE YOU TO HAVE A
LITTLE BIT OF BLEEDING IN YOUR

GUT.

THAT SOUNDS BAD.

AND IT CAN AFFECT YOUR KIDNEY IF
YOU HAVE KIDNEY PROBLEMS AND IT

CAN MAKE YOUR BLOOD PRESSURE GO
UP.

THOSE ALL SOUND KIND OF SCARY,
RIGHT?

WHAT ARE THE SIDE EFFECTS OF
OPIATES FOR TAKING THEM FOR

ACUTE PAIN?

WELL, THEY'RE MENTALLY IMPAIRING
IT DELAYS RECOVERY.

AND I'M OUT THERE TRYING TO TALK
TO ALL THE SURGEONS ABOUT THIS.

DOW THE SAME SUR JOB ON TWO
GROUPS, ONE YOU GIVE OPIATES

WHEN THEY GO OPEN AND THE OTHERS
YOU DON'T, THE ONES WHO GET THE

OPIATES, THEY HAVE DELAYED
RECOVERY AND DELAY WOUND HEALING

THAT'S CRAZY.

WE DON'T KNOW WHY, BUT IT
HAPPENS.

SO IT INCREASES MEDICAL COSTS
WHEN YOU GIVE THEM OP YACHTS,

THE OPIATE HYPERALGESIA.

YOU CAN START DEVELOPING PAIN
FROM THE MEDICINE.

IT DOUBLES YOUR CHANCE OF GOING
OUT ON PERMANENT DISABILITY IN

AS LITTLE AS SEVEN DAYS.

IT INCREASES FALLS.

IT TREATS DEPRESSION SHORT TERM
BUT MAKES IT WORSE LONG TERM,

RIGHT?

AND THEN THIS BRAIN CHANGING
BUSINESS.

I'VE GOT TO TELL YOU ABOUT THIS.

THERE'S A SURGEON IN TEXAS, HE
DOES A CERTAIN KIND OF NECK

SURGERY.

AND HIS USUAL IS YOU COME OUT OF
SURGERY AND YOU GET ON I.V.

OPIATES AND YOU GET OPIATES BY
MOUTH AND THEN YOU GO HOME AND

BACK THEN HE WOULD GIVE 30 DAYS
OF OPIATES.

AND SO HE HAD HIS USUAL GROUP
AND THEN HE HAD ANOTHER GROUP

THAT WHEN THEY WENT HOME, THEY
DIDN'T GET ANY OPIATES AT ALL.

AND AT 30 DAYS HE SCANNED THEIR
BRAINS AND HE COULD SEE BRAIN

CHANGES IN THE PEOPLE THAT GOT
THE OP YACHTS.

- -- OPIATES.

THAT REALLY SCARED HIM,
CONCERNED HIM.

HE TOOK THEM OFF THEIR OPIATES
AND WAITED SIX MONTHS AND SKEIN

SCANNED THEIR BRAINS AGAIN, AND
THOSE CHANGES WERE STILL THERE.

SO OPIATES CAN CAUSE BRAIN
CHANGES AND SOMETIMES THOSE

BRAIN CHANGES ARE PERMANENT.

AND THEN OPIATES CAN CAUSE
ADDICTION.

SO WHAT CAN WE DO?

WE CAN -- THIS IS A STUDY OF
OVER 40,000 PATIENTS BUT THEY

WEREN'T HEAD-TO-HEAD STUDIES.

THEY WERE INDIVIDUAL ONES.

AND IT WAS ONE HOUR AFTER
SURGERY THEY GAVE ONE OF THE

FOLLOWING MEDICATIONS.

AND IF YOU HAD A 50% REDUCTION
IN YOUR PAIN, THEN THAT WAS

CONSIDERED A WIN.

PEOPLE FELT SATISFIED.

SO YOU GIVE ONE IBUPROFEN OVER
THE COUNTER, 200 MILLIGRAMS.

AND 37 OUT OF ONE HIN PEOPLE,
ONE HOUR AFTER SURGERY SAID I'VE

GOT 50% PAIN RELIEF FROM ONE
IBUPROFEN.

THAT'S PRETTY GOOD.

TYLENOL, IT WAS 28.

THEY INCREASED -- DOUBLED THE
IBUPROFEN AND GOT TO 40.

AND IBUPROFEN 600 AND 800 IT
WENT UP TO ABOUT 41 OR 42.

SO IT DOESN'T GO UP MUCH MORE,
BUT YOU DO START TO PICK UP THE

SIDE EFFECTS SO WE PROBABLY
SHOULD STAY ON THE LOWER END OF

THE IBUPROFEN.

BUT WHAT ABOUT OXYCODONE.

15 MILLIGRAMS, OKAY?

IT HAS F.D.A. APPROVED
[ NO AUDIO ]

LOOK AT THAT.

ONLY 21 OUT OF 100 PEOPLE GOT 50
% PAIN RELIEF OR MORE.

BUT THEN THEY -- PHARMACEUTICAL
INDUSTRY SAID WOW, OUR MEDICINES

NOT WORKING VERY WELL, SO THEY
ADDED TILE NOT TO IT AND MADE

PERCOCET AND GOT BACK UP TO THE
37, RIGHT?

BUT WHAT HAPPENS IF YOU TOOK ONE
TILE TYLENOL AND ONE IBUPROFEN,

AND THIS IS THE KEY, TOGETHER AT
THE SAME TIME ONE HOUR AFTER

SURGE JI -- SURGERY?

IN 62 OUT OF 100 PEOPLE GOT 50%
PAIN RELIEF.

SO DO YOU THINK THIS IS WHAT I'M
TELLING MY PATIENTS TO USE?

YEAH.

IS THIS WHAT I WOULD WANT MY KID
TO GET IF HE WERE INJURED OR

HURT?

FOR SURE.

FOR TWO REASONS.

ONE, IS IT WORKS THE BEST, AND
THE OTHER IS IT'S NOT ADDICTIVE.

SO THIS IS WHAT WE'RE TEACHING
THE NEXT GENERATION OF FOLKS.

THIS IS WHAT AGAIN THE REST OF
THE WORLD IS ACTUALLY USING

INCLUDING EUROPE.

SO THEN WE HAD OUR FIRST
HEAD-TO-HEAD TRIAL IN THE

EMERGENCY DEPARTMENT AND TYLENOL
AND IBUPROFEN DID JUST AS GOOD

AS THE PERK E SET.

AND KIDNEY STONES, I DON'T KNOW
IF ANYBODY HAS EVER HAD A KIDNEY

STONE.

IT'S SUPPOSED TO BE SOME OF THE
MORE INTENSE PAIN THAT YOU CAN

ER EXPERIENCE, AND USING I.V. IN
SEDZ LIKE IBUPROFEN, COUSIN IS

CALLED TORADOL, VERSE -- VERSUS
AN OPIOID THEY HAD EQUAL

EFFICACY AND TREATMENT BUT
OPIOID HAD MORE SIDE EFFECTS.

POSTOP PAIN, INTERESTINGLY THEY
DID THIS STUDY WHERE THEY HAD

THIS MAJOR SURGERY WHERE THEY
SPLIT THE PEOPLE OPEN AND CUT

OUT A PIECE OF THEIR BOWEL.

SO IT'S COLON SURGERY.

IT'S A MAJOR SURGERY.

AND USUALLY THE USUAL CARE IS IS
THAT YOU COME OUT OF SURGERY

AND GET A P-C-A PUMP.

EVERY 15 MINUTES YOU CAN PUSH IT
TO GET OPIATES TO HELP WITH PAIN

WHAT THEY DECIDED TO DO IS WHEN
YOU COME OUT OF SURGERY THEY'RE

GOING TO TRY NOT TO GIVE YOU
OPIATES AT ALL AND TRY THESE

OTHER THINGS.

ONE OF IF THINGS THEY DID IS
THEY TALKED TO THE PATIENTS

BEFORE THE SURGERY FOR UP TO 30
MINUTES ABOUT WHAT THE PAIN WAS

GOING TO BE LIKE WHEN THEY WOKE
UP.

AND THEY SAID
[ NO AUDIO ]

HAVING MAJOR SURGERY.

WHEN YOU WAKE UP YOU'RE GOING TO
HAVE PAIN.

AND WE'RE GOING TO TRY TO DO ALL
THESE THINGS FOR YOU.

AND WE'LL GIVE YOU THIS KIND OF
MEDICINE AND THAT KIND OF

MEDICINE AND GIVE YOU HEATING
PAD.

WE'LL WALK YOU AND DO ALL THESE
OTHER THINGS.

AND 50% OF THE PEOPLE WHEN THEY
WOKE UP, THEY SAID HEY, THE PAIN

IS NOT AS BAD AS I WAS EXPECTING
AND THINK ABOUT THAT, IF YOU'RE

THE NURSE OR THE DOCTOR TRYING
TO TREAT THAT PATIENT AND THEY

THINK HEY, THIS ISN'T AS BAD AS
I WAS EX -- PECTING YOU'RE IN

PRETTY GOOD SHAPE IN TRYING TO
GIVE THEM TYLENOL AND A HEATING

BAD.

IF YOU'RE IN THE OTHER WING,
WHICH IS MOST OF AMERICA, AND

YOU WAKE UP AND GO OH, MY GOD,
THAT IS LOT OF PAIN.

DIDN'T THE DOCTOR OR NURSE TELL
YOU YOU WERE GOING TO BE IN PAIN

NO.

IF YOU'RE EXPECTING 0 OUT OF 10
PAIN YOU'RE GOING TO BE

CALLING FOR THOSE OPIATES OVER
AND OVER AGAIN.

THIS HAS DONE APLAYSING THINGS.

IT'S REDUCED THE AMOUNT OF
OPIATES THEY'RE GIVING FOR

CERTAIN SURGERIES AND WE'RE
DOING THIS AT HOSPITALS IN

WESTERN NORTH CAROLINA.

REDUCED THE NUMBER OF OPIATES BY
30%.

LOOK AT THIS, HALVED THE
COMPLICATIONS, THE PATIENTS ARE

LEAVING THE HOSPITAL TWO DAYS
EARLY AND SAVING $7,000 PER

SURGERY.

SO WE'VE BEEN DOING THIS WRONG
FOR 30 YEARS.

BUT WE'RE TRYING TO GET BACK
INTO IT AND DO IT THE RIGHT WAY.

[ NO AUDIO ]
END OF LIFE, HOSPICE CARE WE

HAVE VERY GOOD DATA THAT SAYS
THESE MEDICATIONS CAN BE HELPFUL

TO HELP WITH PAIN AND AT THE
LAST FEW MOMENTS OF LIFE. THAT

THEY DON'T EX P TEND LIFE.

AND THEN IN ACUTE SEVERE TRAUMA
FOR A SHORT PERIOD OF TIME,

PROBABLY THREE DAYS OR LESS, BUT
DEFINITELY SEVEN DAYS OR LESS.

BUT THERE'S NO DATA THAT SAYS
THESE MEDICATIONS ARE HELPFUL

FOR A CHRONIC NON-CANCER PAIN.

SO WHY DO PEOPLE START ABUSING
OPIATES?

WELL A PERSON CAN BEGIN BY
MISUSING THEM AND PROVIDERS WILL

SEE THIS.

WE'LL HAVE SOMEBODY WHO'S ON
CHRONIC OPIATES AND THEIR

MEDICINE IS SUPPOSED TO LAST 30
DAYS, THAT'S WHY I WRITE IT FOR

30 DAYS AND AT 27 DAYS THEY CALL
AND SAY HEY, I'M OUT OF MY MEDS

AND THAT CAN HAPPEN EVERY ONCE
IN A WHILE, THE DOG ATE IT OR

WHATEVER, THE FOLKS THAT THAT
HAPPENS OVER AND OVER AGAIN.

THEY'RE MISUSING THEIR MEDICINES
THEY ARE TAKING THEIR MEDICINES

FOR WHAT THEY PERCEIVE AS MORE
PAIN OR OTHER REASONS.

THEY CAN USE THE MEDICINES TO
COPE WITH EMOTIONAL ISSUES.

STUDY CAME OUT LAST YEAR, 16% OF
THE ADULTS IN THE UNITED STATES

HAVE DEPRESSION OR ANXIETY.

I FELT WOW, THAT'S A BIG NUMBER
BUT OKAY.

THEY CONSUMED 51% OF ALL THE
OPIATES WE WROTE LAST YEAR.

SO MAYBE THEY ALL HAVE CHRONIC
PAIN, BUT MAYBE THEY'RE USING

THE MEDICATIONS FOR OTHER
REASONS, TO TRY TO HELP COPE

WITH OTHER THINGS THAT ARE GOING
ON.

AND WE HAVE TO ACKNOWLEDGE THAT
AS PROVIDERS AND FOLKS THAT ARE

HELPING PEOPLE OUT THERE.

AND THEN MAYBE THEY'RE
EXPERIMENTING WITH THE OPIATES.

BUT WHY DO THEY CONTINUE?

SO ONCE YOU'RE ON YOUR OPIATES
AND YOU'VE BEEN TAKING THEM FOR

A WHILE, WHETHER YOU'RE TAKING
THEM CORRECTLY AND IT'S BEEN

YEARS OR YOU'RE STARTING TO
MISUSING -- USE THEM AND YOU'RE

TAKING WAY TOO MUCH, WELL, THEY
FEAR WITHDRAWAL.

THEY -- IF THEY'VE EVER BEEN,
SAY, ABUSING OPIATES FOR A WHILE

AND THEN THEY RAN OUT OR THEY
COULDN'T GET ANYMORE, FOR

WHATEVER REASON, THEY'VE BEEN IN
WITHDRAWAL AND THEY FEAR IT.

SO WHAT DOES WITHDRAWAL FEEL
LIKE?

IT REALLY FEELS LIKE THE FLU
TIMES TEN.

AND THEY DON'T WANT TO BE THERE
ANYMORE.

AND THE OTHER THING, THE OTHER
REASON THAT THEY CONTINUE, IS

BECAUSE OF THE CRAVINGS.

AND WHEN WE FREET -- TREAT FOLKS
WITH BEHAVIORAL THERAPY AND WITH

MEDICINES IF THAT'S WHAT THEY
USE FOR THEIR OPIATE USE

DISORDER, WE'VE GOT TO TAKE CARE
OF TWO THINGS.

THEY HAVE TO NOT FEAR WITHDRAWAL
, SO THEY EITHER

HAVING TO GET THROUGH THE
WITHDRAWAL PHASE AND BE DONE

WITH IT OR WE HAVE TO GIVE THEM
MEDICATION SO THEY DON'T

WITHDRAW.

THE OTHER THING YOU HAVE TO TAKE
CARE OF IS THE THE CAVINGS.

I'VE BEEN SITTING IN FRONT OF
SOMEBODY WITH FULL-BLOWN

WITHDRAWAL AND THEIR NOSE IS
RUNNING AND EYES ARE WATERING

AND THEY HAVE NAUSEA, THEIR
MUSCLES HURT, THEIR JOINTS HURT,

AND I'M TRYING TO TALK TO THEM
ABOUT THERAPY AND HOW I THINK

THIS IS GOING TO REALLY HELP
THEM, AND IT'S REALLY HARD FOR

THEM TO ENGAGE.

RIGHT?

SO WE HAVE TO TAKE CARE OF TWO
THINGS.

WE HAVE TO TAKE CARE OF THE
CRAVINGS AND WE HAVE TO TAKE

CARE OF THE WITHDRAWAL SO THEY
CAN DO THE THERAPY, THEY CAN GET

BACK TO WORK, IF THEIR KIDS ARE
IN FOSTER CARE SO THEY CAN GET

THE KIDS BACK.

SO THERE'S REALLY JUST FOUR WAYS
THAT WE TREAT OPIATE USE

DISORDER IN THE UNITED STATE%
DETOX AND ASHES NENS.

IT'S THE NUMBER ONE WAY WE TREAT
IT IN TUSES AND IN NORTH

CAROLINA.

AND THEN THERE'S TWO AGONIST
MEDICINES, AND THEN THERE'S THIS

MEDICINE THAT'S CALL AN
ANTAGONIST MEDICINE, MEL TREKS

ZONE AND YOU CAN TAKE IT BY A
PILL ONCE A DAY OR AN INJECTION

ONCE A MONTH.

HERE'S THE DATA.

THESE WAVY LINES ARE HERE
BECAUSE WE DON'T HAVE ANY

HEAD-TO-HEAD TRIALS.

BUT IF YOU GO THROUGH DETOX AND
ABSTINENCE, WHETHER IT'S

INPATIENT 14 DAYS, 28 DAYS, 90
DAYS.

AT SIX MONTHS TO A YEAR, 90% OF
PEOPLE ARE USING AGAIN.

ALL RIGHT?

BUT YOU CAN SEE WITH THE
MEDICINES AND WHY THE MEDICINES

ARE NOW THE EVIDENCE-BASED
ANSWER TO THE OPIATE USE

DISORDER.

SO I'M AN ALL THE ABOVE GUY.

IF SOMEBODY -- AND I -- I KNOW
PEOPLE THAT HAVE BEEN THROUGH

DETOX AND THAT ARE ON ABSTINENCE
NOW, AND THEY'RE DOING GREAT.

THEY SAY I'VE BEEN CLEAN AND
SOBER FOR SIX MONTHS, FIVE YEARS

ONE GUY I WORK WITH 25 YEARS.

WONDERFUL.

BUT KNOW THAT NINE OUT OF TEN
PEOPLE THAT GO THROUGH THOSE

PROGRAMS ARE USING AGAIN WITHIN
SIX MONTHS TO A YEAR.

SO THE WORLD HEALTH ORGANIZATION
SAYS USING MEDICATION ASSISTED

TREATMENT SO THAT PEOPLE CAN DO
THE THERAPY, GET INTO GROUPS AND

INDIVIDUAL IS -- IS THE WAY TO
GO.

AND 12 ORGANIZATIONS, FED
FEDERAL -- AT THE FEDERAL LEVEL

HAVE ALL AGREED WITH THIS.

THIS IS THE -- THE NEW WAY THAT
WE SHOULD BE TREATING OPIATE USE

DISORDER.

SO IF SOMEONE CAN GO THROUGH
DETOX AND ABSTINENCE AND DO WELL

, GREAT F. THEY'VE GONE
THROUGH IT SEVERAL TIMES AND

THEY'RE STRUGGLING AND THAT IS
REALLY P -- SCARES ME BECAUSE WE

KNOW THAT THERE'S A 40 TIMES
INCREASE OF OVERDOSE AND OVER

DOSE DEATH ONE MONTH AFTER
GETTING OUT OF DETOX IN AND AN

ABSTINENCE PROGRAM N THE FIRST
MONTH.

THEY'VE BEEN THROUGH IT A COUPLT
WORKED I'M FEARFUL THEY'RE GOING

TO OVERDOSE AND DIE BEFORE THEY
CAN GET THROUGH THIS AGAIN.

MAYBE THIS IS WHERE WE SHOULD GO
MAYBE THEY NEED SOME MEDICATIONS

SO TREATING OPIATE USE DISORDER,
IT REALLY IS A LIFE-THREATENING

ILLNESS BECAUSE OF THE CHANCE OF
DEVELOPING OR LOSING YOUR

TOLERANCE AND THEN WHEN YOU
RELAPSE USING AGAIN AND IF YOU

USE THE SAME AMOUNT, THEN YOU
OVERDOSE OR OVERDOSE AND DIE.

SO I HOPE THAT YOU KNOW A LITTLE
BIT MORE ABOUT THE OPIATE CRISIS

AND HOW IT'S AFFECTING NORTH
CAROLINA.

I TALKED TO YOU A LITTLE BIT
ABOUT ACUTE AND CHRONIC "LOVE,

PAIN AND THE WHOLE CRAZY THING"
AND HOW WE'RE USING -- HOW WE'RY

TO THE NEXT GENERATION OF
PROVIDERS IN WESTERN CAROLINA

AND RETEACHING THE DOCTORS AND
PROVIDERS THAT HAVE BEEN OUT

THERE FOR 20 OR 25 YEARS ABOUT
THE -- THE APPROPRIATE WAY TO

USE THESE MEDICATIONS.

AND THEN WE TALKED ABOUT THE
IMPACT OF -- OF THE OPIATE

CRISIS AND OPIATE USE DISORDER
ON OUR PATIENTS.

SO THANK YOU VERY MUCH.

[ APPLAUSE ]