the crime prevention research center will discuss the trump administration's move this week to roll back an obama era backgrounds checks rule and democracy journal contributor chelsea barabus discusses her article on how employers and other entities are using big data and how the relationship between workers and technology is changing. be sure to watch c-span's "washington journal" beginning live at 7:00 a.m. eastern this morning. join the discussion. >> sunday, in depth will feature a live conversation with pulitzer conversation dave barry. during our live discussion from bookstore in karl gables, florida, we'll be taking your calls and emails and facebook questions on his literary career. >> in 1986 i moved to miami and been there ever since and karl and i are going to talk about it but it's a good place if you humor writer is an

excellent place to go. >> dave barry has several books, the greatest hits and best state ever, a florida man defends his homeland. watch in depth live sunday from noon to 3:00 p.m. eastern on book tv on c-span 2. >> next a look at opiod addiction in the u.s. speakers include the director of an addiction medicine clinic in california. from zokolo public square this is an hour. >> and now it's my great pleasure to introduce tonight's moderator, ms. lisa garian, a top news editor for americas aters.

as a former investigator reporter at "the los angeles times" she worked on a series of stories that corrected -- connected drug related deaths to the doctors that with her team that filled them and focused on perdue phrma which failed to include risk factors for addiction as well as evidence of illegal drug trafficking. she's won awards for her expose's on alleged human rights abuses in myanmar and health insurers who rescinded coverage for sick members. please give a warm welcome to miss lisa girian. [applause] >> i want to introduce the rest of our panel.

we're really lucky to have a diverse group who can speak to many aspects of this problem. jill horowitz is a legal scholar at ucla who has done quite a bit of research into the opiod epidemic and efforts to fix it. sam kinones, a fabulous reporter and journalist who i worked for at the paper and had written many books, has since written an amazing chronicle of this epidemic called "dream land." and if you haven't read it, i highly recommend it. it's a really fabulous touching and tragic book. . larissa muni runs an addiction unit at ucla and helps doctors cope with some of the victims of this epidemic and she's also done research

into some medication responses to the epidemic. and ben baron who i also watched in action is federal prosecutor here in the courthouse in l.a. and as an assistant u.s. attorney these prosecuted doctors and drug rings and gangs that move drugs and he's seen quite a bit of the risky and dangerous side this problem and endeavored to try to attack it from that end. i'll start off by saying i first began looking at the opiod epidemic as a prescription drug epidemic in 2010. i joined some colleagues at the paper and began looking at the problem. over the last 15 years, more than 200,000 people have died of drug deaths in this country. most of them on prescription

drugs and prescription opiods but increasingly on heroin and closely linked, as i think sam can tell you about. there are 20 million people currently addicted in this country to both legal and illegal drugs and only about 10% of them manage to get treatment. it's underfunded and just not that available. i wanted to start the conversation by hearing from each of you your perspective on what is really the biggest part of the problem with driving his problem. [inaudible question] >> i think what's gone on with this problem is two things. , it was contin

heavily promoted as virtually nonaddictive in the mid 1990's as sort of a cure-all -- there you go. weird echo there. a cure-all for a lot of pain. the difference between oxycontin and the opiates which have been used before is there was no abuse with it. there was no vicadin or percocet or all these opiates, they have acetaminophen or tylenol and you can't develop an unhealthy bad habit to them without destroying your internal organs. oxycontin had none of that. what it did was because it was so widely prescribed, massively prescribed all across the country, it had the affect of raising people, who got addicted, raising their tolerance to a very high level, level that was really unsustainable because when people had to turn to the

ended up se pills costing a dollar milligram and you're talking people using 200, 300 milligrams a day and is unsustainable. in ther part of the story the late 1970's, a lot of the eroin came from the far east from turkey and thailand and etc., etc., that's what the cases were about and all those cases. that changed in the 1980's. hen all the heroin came from mexico or colombia. it's not like red wine or marijuanaa. it really -- the price depends on how far you have to travel with it and this heroin is coming up from mexico was potent and cheap. the problem was nobody paid attention because heroin wasn't

a problem and we only grew to recognize how big a deal it was, this geographic switch that happened. the heroin from mexico and colombia outcompeted the heroin in the far east when we began to create more opiate addicts with the massive prescribing of pills, pills for every kind of pain and wisdom tooth extraction and not just a few but 60 vicadin and 0 oxycontin and huge amounts of these pills and what you get is a huge number of addicts and looking for an alternative to very expensive pills and the heroin coming from mexico or the colombia heroin provides that alternative. it's potent and cheap and extraordinarily mortal. and deadly. and that is what we're seeing

across the country. the combination of those two historic kind of changes that created the heroin issue we have today all over the country and where it's hitting most is in white families, families in communities that are not used to this, families not prepared for this and really didn't believe they did anything to deserve this and it's in the heartland and suburbs and rural areas and is a very different thing and deadlier than any epidemic we've ever had. >> so i think that the heroin is a good -- and the pills, can ou talk a bit about what the law enforcement is doing about this and what role you're playing now and how you're trying to attack this, whether it's gangs or doctors or harmacies?

>> i'll answer your first question about scope of the problem and how law enforcement fits into it. the reason the problem is so big and hard to tackle is it is a multifaceted issue and there's so many heads you have to cut off and there's the corruption of medical practitioners, ignorance of the public about what these drugs are, that strike continue and oxy co-doan are alopted -- allotted and heroin and the fact you can stop doctors from prescribing these drugs but you have a black market of heroin addicts to deal with and why as we plateaued the abuse of the prescription drugs over the last three or four years, heroin abuse has skyrocketed exponentially and you have the public safety issue of fentanyl and imported from china

you can have superlabs import it and it's 50 times more powerful than heroin and leading to mass amounts of death and there are analogs of are more powerful and causing the massive deaths we're seeing when cut as heroin and counterfeited as pills in west virginia and new hampshire. we have a lot of different people involved and where law enforcement comes into play is obviously deterring corruption and doctors and a corrupt doctor with a prescription pad can sell as much heroin in the pill form as any gang and pose as a massive part of this problem. we also, obviously, are involved in the interdiction and prosecution of the heroin importation and the fentanyl importation problem and cooperate very closely with regulators involved in deterring negligence among medical practitioners and taking licenses or disciplining

here that needs to happen. >> i tried to follow up a bit on what sam was saying. i started out by saying there have been 200,000 deaths attributed to opiods, believe it or not, over the past 15 years. but sam makes a good point, kind of the genesis of this or it's closely linked in time to changes in medicine and new drugs like coxy coten coming on he market in the late 1990's with oxycontin coming on the market in the late 1990's. there were approximate 4,000 drug deaths every year when they hit the mark and had been very flat. now there's north of 36,000 a year. and in define as my colleagues and i reported, drug deaths

surpassed car accidents in 2009 as a source of mortality in this country. and in an industrialized moderate country one of the huge goals is to drive down preventative deaths and why we have seat belts and speed limits and childproof pill caps, right? and it's really unusual as i think jill noticed from a public health perspective to look at mortality charts and see everything going down, cancer, heart disease, everything we can do and we're all invested in that and all of a sudden we see something going up sharply and very clearly that is a byproduct of medicine and therapies, right? most of the -- i need it again? most of the drug deaths are actually involved prescription

medications but increasingly they're involving heroin. with that, i think -- it's a big attempt to talk to jill. jill has studied, one of the as it s to this crisis snuck up on everybody was for estates to -- some of them were very old -- we'll go back to the 1930's but others have within started recently to set up things called prescription drug monitoring programs and the idea is that if you're a doctor writing one of these dangerous prescriptions to a patient who has -- is recovering from surgery or car accident and has really bad pain, you want to make sure that person isn't getting the same prescription from three different doctors and is either addicted and selling them to a public health problem. so i think in most of the states -- and jill can tell us more about it. in most of the states the idea

is that the pharmacy sends a record of a prescription that's dispensed to a state agency, oftentimes the attorney general, and the doctor has access to that through a web interface and is supposed to check to see what you're up to before he or she prescribes. jill will tell us how that's working. jill: one of the things interesting about this epidemic is that the states are on to it pretty early and there was a ton of activity. my colleagues published in "the new england journal of medicine" and worked with a group, is sounds like the beginning of a joke, a doctor, a economist, a librarian and me, a lawyer, and we worked on the paper to cover the facets of it and in the period we studied from 2006-2012 there were 81 separate state laws passed to deal with opiod

prescriptions and abuse. and the one that gets all the attention, these pdmp's and also things like tamper resistant prescription pads. it used to be fairly easy to steal a pad and fake prescriptions, now there are special pads that say void if they et heat on them or have certain number of signatures and the states passed laws that would make it hard to do. and we studied people who were permanently disabled and on medicare though they were under 65 because they were disabled and could no longer work. and among that population which is a relatively small population of the u.s., about 2% to 3%, maybe a little over 3% now, they accounted for about 50% of the opiod deaths. it's a population that's very hard hit. and when we looked at the

passage of these laws, we were thinking we were going to find something because if you just look at when the laws were passed in average and then you ook at the trends in prescription abuse, all these things, what you find is a slight slowdown in 2010. but when you look at the states that passed the laws when they passed the laws and you compare it to states that didn't we found no affect for any one of hese interventions at all. the lesson we could have is we had a tough population but we have to be careful. the results weren't welcomedly the c.d.c. and wrote a letter saying we did lousy research and we wrote a letter saying you have to take the bad news, too, because you have to learn from this. we'll keep trying and looking at different populations but

this is not good news. >> that research is important but from the perspective of law enforcement and regulators, pmdp information is essential difference in taking pharmacies and doctors in the market. >> tell people how you use that data tell people how you use that data. >> in drug trafficking, we don't know when they sell drugs but with pdmp you know every time a doctor has prescribed drugs that have been filled at a pharmacy in california and we know the dosages so if the doctor is prescribing the same drugs or mass of dosages and we know if the patients are living miles away or the cage reduce cocktails of sedatives are being prescribed together and it's essential not just for board ions but medical

regulators in taking care of the problem and every time we get a conviction and the l.a. times reports on it, it sends a message to doctors as well so i have to imagine it has had a effect even for negligence. i want to emphasize how important the data is. >> the pdmp is not a pdmp. states do it differently and statesman date cross border checks of these and makes a dig difference. not so much in california, it's a big state and not so easy to get. but in states where we have a big problem, new england is particularly hard hit, it's not so easy -- or not so hard as i learned growing up in massachusetts to drive to new hampshire to get the things the parents didn't want you to have. states are right next to each other there so it could be working in some places and not in others.

>> on the topic of imperfect solutions this would be a good opportunity, dr. muni, for you to talk about treatment options. i know i have spoken to way too many families who exhausted their retirement funds and mortgaged their homes and, you know, sent a family member into treatment numerous times only to have them relapse, overdose, recover a and in many cases then finally die. so what's out there? nd how well is it working? >> in terms of treatment, i view the most important element of treatment for this population, even more so than for other addictions is prevention of overdose deaths because nobody can be engaged in rehabilitation and recovery f their illness caused their

death. the gold standard for treatment for opiod addiction based on evidence emerging from research is medication treatment. that doesn't mean it's the only type of treatment in effect, often a comprehensive approach is very beneficial. we have different types of treatment and behavioral therapies and skills that are important to learn. but the f.d.a. approved medications available to treat opiod addiction are considered the gold standard and we have methadone and now trexdone and i can go into the differences of these medications but bufanofene and methadone, some can be aware are opiods. bufanorphine has partial activity and acts differently than some of the other opiods we've been talking about. and methadone is a long-acting

-- both of them are long-acting adam: oid -- opiod substitution therapies. what it means is you're giving a medication that can take the place of and really break the cycle of intoxication, withdrawal, and chasing the high and then trying to recover from the low. it's a vicious cycle of addiction and these medications can stay in the system for more than 24 hours at a very steady level and really can be lifesavers for many people. they can allow individuals of opiod addiction to improve their functioning and quality of life, get their lives back. now, trexone is an opiod blocker and there is a monthly injectable form that's long acting that seems to be a better option for people with opiod addiction and basically if you're on trexone and use an

opiod, the effects are blocked. so these are the medications that are available. another important issue to narcan, a aloxone, medication that rapidly can reverse opiod overdose and has been used by medical personnel, e.r. set fogs a long time and now there's a public health movement for lay people to have access to naloxone so anybody at risk for an overdose, physicians are encouraged to provide naloxone so a family member or loved one could use it in the case of a suspected overdose because the benefits ar outweigh the risks. >> i have a question for you, sam but want to throw out another fact i found interesting. several years ago when we were really digging into the deaths, the mortality statistics again and what was really interesting

for us was that the population at greatest risk of death, where the greateth death rates were, it wasn't kids as you might imagine, you know, seeking a thrill but it was people in their 40's and 50's and that's the hardest hit population in terms of mortality from open oids and gives you a little sense of what we're dealing with. one of the solutions they've talked about lately, especially in the presidential campaign, is stopping the heroin coming from mexico and building a wall. tell us a little bit -- i'd like to hear you explain as i heard you before how the heroin kind of got into the midwest and what effect a wall might

ave on that. >> we absolutely need to do something about the heroin coming from mexico. it's an outrage, honestly. and i think the fact that most of the heroin comes from mexico had a lot to do with why donald trump won very key states that were key to his victory, ohio being one, pennsylvania another, people in that area know where the heroin is coming from and not too happy with it and i think the openities played a big part in that. -- opiates played a great part in that. it's a great trafficker's drug because it's easy to steal and not because marijuanaa or cocaine is very bulky, you don't need a lot of space in which to traffic heroin. and therefore what really most

likely needs to happen is not a wall. you have a lot of walls on the border. tijuana and san diego, we have two walls and one that starts 50 yards in the ocean and goes for 14 miles until it hits a big mountain. but we have a lot of walls around the border. we don't have walls everywhere. but heroin -- walls i don't believe will stop heroin. they will and have stopped people in fact but won't stop heroin. particularly when you have the size of demapped we've created since the mid 1990's across the united states, what will stop flow of heroin is a mexico that starts to change in fundamental ways. mexico faces -- i lived two years in mexico and wrote two books about the country. it seems to me what we really need to do with regard to mexico is not alienate it but

also not value its friendship above all things. we need to be in conversation with mexico and we need to be relating to mexico as one of our most important foreign relations. but we need to be pushing them to do the kind of changes and what will make that country as a place people are not dying to leave which literally is the case. when mexico begins to change and develops the kind of law enforcement capacity that, say, canada has, will we begin to see kind of a modern partner. the way we get there, i believe, anyway, is not by alienating and insulting and inflaming really what trump has done really more than anything is inflame and allow the elites of mexico to distract the population with his inflammatory rhetoric while they do nothing really to change what is an essential

component of a bilateral relationship which is a next we which has better law enforcement, a criminal justice system so that cops here can call down to areas where they are growing heroin and be kind partners with their mexican counterparts. it does not exist -- it exists to some degree but not the degree it ought to. the problem with heroin is a perfect example because we probably can stop a lot of the marijuanaa or cocaine. heroin is so condenseable, so small, a pound of very potent heroin can be smuggled across the border very easily and cut into -- stuffed down five times and is still extraordinarily potent. we need to understand in order for that to change, mexico needs -- we need to treat them as neighbors and not as some kind of dysfunctional family, that kind of thing.

and that focus on the wall has inflamed that and done really, i don't believe, anything positive in that regard. >> so we've talked to a lot of doctors obviously in our reporting on this issue and many doctors who are trained up until very recently, they all told me they were trained when ey went to medical school be really careful tripping opiods and they're addictive and you have to weigh the risk of addiction to what your patients are facing. and until the mid 1990's, doctors really were loathed to prescribe opiods for anything but people in terminal pain and with cancer. and in those cases the calculus was they're either going to die so addiction is not a problem or they're not humane to let people suffer with cancer.

the humanity idea was expanded to include a much broader range of pain. d the doctors prescribeing tendencies shifted. ut nowadays -- it got to the point where doctors were prescribing opiods quite frequently for all kind of pain cluding dental extractions and short-term pain and all kinds of pain. doctor, do you have ideas how the transformation went from stay away from opiods, they're very dangerous and you don't want to get your patient addicted to oh, you're going to have a tooth pulled, i'll write you a prescription for an opiod. >> i'm not sure of all the

historical and political reasons behind. i think sam could comment on that a little more. but i do recall in medical school exactly when that transformation occurred. it was pretty dramatic. it was suddenly a fifth vital sign, doctors are undertreating pain, we need to be more aggressive. i'm not a pain management doctor but in med school we were hearing exactly what was supposed to be done. and i think the pendulum completely swung the other way and fortunately now it's swinging back. and based on all the problems that emerged. doctors were told actually that opiods for pain are both effective if minimal risk of addiction in patients with pain. so we're learning that is not

true. and much of the research is showing that opiods, they're actually very -- opiods are valuable medications and highly effective for acute pain. we need these medications. if you have a surgery or have an injury for acute pain, it's highly effective. but the efficacy for chronic pain and long-term use in the management of chronic pain is now being questioned. nd the risks are very clear. now there are new guidelines shifting back to we need new approaches to manage pain and please consider nonopiod therapy and nonopiod medication and physical carpe and cognitive behavioral therapy to cope with pain so hopefully we'll see a return of more comprehensive pain clinics to manage these problems. >> i think a lot of it had to do with us. i thought when i was starting my book i was writing a book

about drug traffickers and drug trafficking and really it became a book about america and who we become. particularly after the end of the cold war, 1990's and so on, we became a country that loved to -- that loved to kind of exalt the private sector, we became a country where people were applauded for making lots of money even though the way they made their money didn't do much for the community. we kind of savaged government and exalted the private -- and we became a country that above all wanted comfort and veents nd a lack of pain. we have padded playgrounds because god for bid our kids skin their knees. we have trophies for everybody

because god forbid somebody should feel left out. we don't want our kids to feel pain and now in college they're asking for trigger warnings so that when a professor is going to deal with an issue that might be painful. so we go from protection of physical pain to protection from emotional pain. and patient would come to him and say doctor, i can't have any pain and people came to believe we can't suffer any pain at all and that's when we began to not just prescribe these pills for some kind of ailment but prescribe massive doses and began to believe they were virtually nonadictative. so what happened with acute pain, i had my appendix out, i had vicadin and i had pain that would last three days, i got 30 days of dope. we became a country that went

indoors and isolated ourselves. this is a story about isolation, the end of community and isolation in america. it's about the hallmark of the crack epidemic was the crack house, a public house, usually a place that had been taken over, a rental or what have you and people covered this when i was a crime reporter in stockton early in my career. the hallmark to this epidemic is the private bedroom, this bedroom that's the hallmark of the sign of our great prosperity as a country, the place where every mother wishes her child should be, don't be outside, there are child molesters and somebody will hurt you outside, no, stay indoors. it's in those private bedrooms kids are hiding their dope, shooting up and dying. and doctors i believe picked up on this and began to see this insistence with which we wanted to have no pain at all. doctors were the selectors for

this whole problem but my feeling is really what started this is all of our health consumers, americans in general believing we'd won the cold war and it was time to kick back and huge amounts, huge cars and houses and huge halloween candy, you see what the halloween candy looks like now, it's massive because kids can't possibly not have -- they would be unhappy if they didn't get a full snickers bar every house they went to. i think this is all part of what this -- the story honestly and why doctors felt such pressure. and all of a sudden they're getting pain specialists telling them yes, we now know that open outs from the opium poppy, the oldest medicine we know of, we now know those drugs are nonaddictive when you treat pain so go right away. and that's what they did, they went right ahead. it was our wanting to be nonaccountable for our own consumer choices and our own

choices, a variety of sorts that pushed them and i think that's kind of what led us to where we are today. this is not a story about dope but a story about who we are as a country or who we are as americans and what we think will lead thousand happiness. i think one of the things we haven't heard us discuss yet is some of the systemic drivers of why doctors prescribe in this amount and these kinds of drugs. we have to look at what our insurance system is and how octors get reimbursed. it's very hard to get reimbursed an adequate amount of your time to do the kind of slow, careful, intervention to do alternative treatments for ain. even though some of them have been effective. the insurance system tells our

doctors through reimbursement to write the prescription. furthermore it tells the doctor to write the prescription for a lot of pills because you don't do so well if the patient keeps coming back. it takes a lot of time. i think there are mixes we easily could put in where you set up a system you get a certain number of pills and call in to get a certain number more. it wouldn't solve the problem but slow down some things. there are some systemic changes we can make. i'm not sure i agree but about the candy bars and all. but i do agree about some of the cultural drivers of this. so there are practice patterns in medicine that have shown up in all kinds of treatment. if you look a cross the country, there are different levels of prescription and really different kinds of treatments for the same illnesses and that has to do with the culture of practice. ironically this is a problem, the prescription drug problem is a problem of white america. i think it's one of the few ways in which racism actually helped minority groups because

doctors won't prescribe these big prescriptions to people of color. so in some respects they've been saved from some of this. those cultural -- the cultural causes of in some of this problem need to be looked at from the doctor or patient or from the community and then i think probably larissa is the person that can speak most directly about this. we need to think as a culture as what happens in our society that makes an 18-year-old take her grandmother's pills from the medicine cabinet, what's happening at this point in time that someone does that when they wouldn't otherwise do that? i know a large part of the problem is people get addicted when they have pain and they get treated and are on this stuff. what about all these young people in which some states people are being harder hit than in others but what makes people so desperate they think ok, between this and that, i

choose reaching for this pill? >> one element of lack of perceived risk. now this problem is getting a lot of media attention and it's starting to talk about it but there was a perception that this was a medicine prescribed by a doctor and is not a treat drug and therefore must be safer. that's one component but for sure a lot of experimenting with the pills, people do seek -- people do experiment with drugs and seek a high and recreational use of all sorts of substances and experimentation is very common in young people. but certainly there were years when in high school students, the use of prescription opiod pills for recreational drug use was rising exponentially.

in one element there's a lack of perceived risk. i can just get a buzz and feel good and what do opiods do? they block pain and analgesic and cause euphoria and make you feel really good and the memory there, the talk of the lonely person and people struggling with depression and anxiety, stress, the memory associated with taking that pill and the immediate relief, we're a society and want instant gratification and that's a very powerful memory. when you look at the neurological changes in the brain that happen over the course of addiction and across addictions, there's a big component of this, what do the opiods and other substances do to the award system, they're very reinforcing and you feel really good and you form these memories and the next time you're feeling bad and stressed and depressed, the temptation is to quickly obliterate that

feeling. that can drive to drug craving and over time leads to addiction. >> can i say i think on a lot of school campuses what has driven this is football. football is a gateway to heroin addiction in america today because that's how we learned to treat pain is by throwing pills at it. and most places, many high schools, i think football players are kind of like the cool guys, the ones kind of -- and people watch football players, also lacrosse, wrestling, baseball, mainly football. what i was finding is an enormous number of football players getting addicted to these pills because there's a pressure to get back on the field and this is how you treat chronic pain with a lot of dope and there's lot of spillover. you go in for a surgery, everyone on your people knows you'll get the pills and soon the pills you got prescribed are in four or five guys' other

lockers. all across america this is happening, i think. and football players being kind of like the popular leaders on campuses i think frequently set that standard as well. it's a hunch. i don't have any evidence or study to show this but i was running into it a lot during my research of my book. >> i completely corroborate what you said about football and wrestling. usually was in the homes of people who had lost someone to an addiction through overdose and when it was younger kids, you know, in their teens and early 20's, almost every case they had a football injury, a wrestling injury, a ski accident, motocross, car accident. and they are 16, 17 years old and put on opiods which is probably the right response in the hospital and immediately

after a surgery but then there's no -- there was no follow-up, there was no care, right? you go from the surgeon and the hospital to your family practitioner and your rehab. and nobody is paying attention to how many refills you've gotten and it doesn't take that long. >> if you had put it in those terms, parents would say oh, really, ok. let's go easy on this. but nobody ever got that talk. that i talked to anyway. >> the other thing you reminded me of, jill, was i spent quite a bit of time out at the betty ford center and has a long history of treating all types of addiction, alcoholism in this country, and you really can kind of chart the history of addiction in america at the

betty ford center. there's heroin, valium, cocaine. d by the early part, 2003, 005, almost opiods, oxycontin, hydrocodone, vicadin, percocet, that's what's bringing the cases to them. so i was out in the office of one of tease administrators. and he talked about the practice culture and is he, you know, i was at the dentist and had a emergency tooth pull and writes me a prescription for something like vicadin, one of these drugs, it was 30 days. i said what are you doing? you know what i do for a living. and the dentist said you don't have to fill it or take it but i don't want the call in the middle of the night that you're in pain. so there you go. >> that explains an enormous -- that right there explains the

enormous supply store. i used to believe when i lived in mexico all dug problems begin with demand and this book changed my mind completely. it was a supply story. it starts with supply and the supply is doctors prescribing like that or the guy who gave me 60 vicadin for my two or three days' worth of appendix operation pain and if you multiply that by millions of doctor visits and millions of surgeries over 20-year period, that's what creates this massive supply of opiates that then of course transitions to eroin. >> could you talk about how easy it is to obtain the market availability of bills in los angeles and how you've seen that evolve over time? >> to the extent thankfully

l.a. does not have the same level of opiate problem you're seeing in west virginia and ohio and new hampshire. not to say we don't have a drug problem but fentanyl deaths, for example, is rampant in those areas and according to at ast the l.a. coroner data is relatively hard here but we're seeing the fentanyl deaths spread east to west and sacramento had a space of two dozen overdoses in a matter of weeks and had to do with counterfeiting, right? you have this incredible power of opiate, two milligrams and the fraction of a penny it takes to kill someone, and they're being imported and counterfeit pills created out of it and you go to a party and take whatever you get, you think you're getting a vicadin and it's not being manufactured by perdue phrma but a drug manufacturer in his basement and you don't know how strong

or safe it is. the ignorance of not only what prescription drugs are or with a the drug someone hands you are, they're filling a lot of deaths. i'm not sure it answered your question but it was an interesting point i wanted to make. i wanted to make one other ., the insurance industry was brought up and the public health insurance industry not intentionally and not because of anything medicare or medicaid is doing wrong is fueling the black market for these drugs. and that should really outrage everybody here. again, not because they're doing anything wrong but, you know, you have a cottage industry of people in los angeles and other areas who are not drug traffickers and they're not doctors. their sole involvement is to recruit medicare, medicaid patients to go to doctors, drug as icts, steal the identities of these ell elderly people and an exchange of a $100 kickback

and they get a prescription that they fill and usually these are drug addicts using the drug for their own habits. what we're starting to are larger and more complex schemes that involves these protruders, the beneficiaries, doctors conspiring with pharmacies to divert just mind-blowing amounts of these pills, hundreds of thousands of these pills to the street. just two weeks ago we convicted a doctor whose prescriptions were the number one cause of billings to medicare in the state by porn double the next doctor for schedule 2 trucks. you should be outraged because this is your taxpayer money going towards this. it's just so tragic. and of course creates all sorts of other issues even for the recruited people. and just responsible for so many of the drugs being spread. >> when i first started looking at this problem, there hadn't been that many prosecutions of doctors for drug dealings.

one of the explanations is it is nearly impossible to convict someone in a white coat of drug dealing and that drug dealing was the only law in the books, at you had to go after that. has that changed at all? benjamin: it absolutely has. when i did trainings on these cases, i tell people who might be afraid of charging a doctor with drug dealing. these are some of the easiest cases we prosecute because a paper trail exists left and right. you have the pdpa, bank records, billing records. who runs a cash business? you have it all over the place. number two, there is a very narrow range of conduct that is consistent with legitimate practice. that narrow range of conduct is not consistent with what a corrupt doctor is going to do to profit from these drugs.

you have to prescribe maximum dosages of the same drugs over and over again in dangerous combinations. why is your pain doctor prescribing maximum strength of xanax to everyone who comes in the door? why are they only doing two-minute examinations? i could list 50 different things you see in these cases over and over again. we have incredible tools to go after these cases, not just as prosecutors, but as regulators, as well. i think that is even more important for combating corruption. one thing we will have to do is combating corruption in pharmacies, which is more difficult to do. with regular drug trafficker, you prosecute whatever drug dealer. with a doctor, you have to be licensed and educated, be willing to commit a crime. as we get better prosecuting in these cases, there are fewer and

fewer doctors doing this. now we have to turn our attention to the pharmacies. we do have an array of criminal tools beyond drug charges, obviously. there is safe handling of drugs, a doctor in l.a. who was convicted of murder. manslaughter for continuing to subscribe despite rampant death. in the last couple of years, we haven't 27 or 25 year sentences of doctors who are murderers and need to be treated as such. we have a lot of tools and our toolkit, we just need to use them. >> we are going to take questions for all of you. there are two of us walking around with microphones. if you would please say our first and last name when you ask your question, this program will

be recorded and rebroadcast on our website. it will also be broadcast by c-span at a later date. we will take your first question. >> my name is todd. there is a trend going on that i suspect will intensify with the recent election about drug testing people on public assistance. it's sort of a two-part question, which is, does that kind of drug testing catch prescription drugs? and second, does it highlight the income disparity with regards to this particular epidemic as opposed to other ones? lisa: it would depend on how sensitive the drug test is. i'm not sure what kind of drug test your talking about, but it

might not be able to distinguish between something illicit and something you are taking legitimately. it's all the same stuff when it gets down to the chemical level. >> but that would only catch people who would go in for public assistance. to what extent is the opioid epidemic affecting people who may be able to not be dependent on public assistance? sam: i would say that this affects white people. just white people. that's in appalachia, where you get some really poor -- if we had paid attention to appalachia, we would not be in the situation. that was like 1998, 2000, those years.

for my book, i was in appalachia, but also in suburban charlotte, one of the wealthiest parts of america. portland, salt lake, indianapolis, you are talking about people doing the best in the run-up since the mid-1990's of economic expansions we have had. the bigger question is why is it only white people? i still don't have a complete answer to why that is. i've been racking my brain, reading things, trying to understand it. part of it does have to do with doctors prescribing, but i don't think -- many black people have received these drugs, and yet, it is not in the black community, the latino community, it is not. i think part of it may have to do with cultural memory. in the 1970's, the latino community in east l.a. was destroyed by heroin. there is a cultural memory of that. that might have something to do with it.

i don't know. they say that addiction is colorblind, but in this case, it is very much not. it is white people and it is all over wherever you find a white person. lisa: the other role public assistance plays in this epidemic, people with medicare and medicaid cards who may be homeless or easily manipulated or maybe ssi, if you have a government card, you can get a prescription filled for a very small co-pay. you are valuable to drug dealers. you become recruited and a straw patient. you are driven in a van. you probably get lunch. taken to a corrupt

doctor and a prescription is written in your name after you pass through the mail. you turn the prescription over to your capper who is driving you around. and you are taken back to the homeless shelter. that's the way i've seen public assistance play out in this particular epidemic. benjamin: and you are paying for drug dealers to get their source and supply. >> and on your left. question on your left. >> thanks for an excellent panel. i have a question for sam in particular. i am writing my dissertation about the opioid epidemic, and your book has been super helpful. thank you for that. i would love it if you could speak a little more to this gray area that exists bridging the highly regulated official market for prescription drugs and the

market for heroin. you have spoken a lot about medicaid and medicare and ssi's, but what bridges that divide in places like suburban charlotte? sam: i'm not sure i heard the question, it's kind of echoing here. basically why is there a market in suburban charlotte for this? >> you've talked about how medicaid, ssi, those kind of things set up this transition between the market for prescription opioids and the market for heroin among people who take that kind of assistance. what about this epidemic cuts across class? sam: they get back to what i was saying about doctors accepting the idea that these pills could not be prescribed with virtually no risk. that was the fundamental change and that's with the pharmaceutical companies did very well.

they set about to convince an entire generation and more of doctors that the pills that everyone knew were addictive were actually not so. it was a magnificent piece of marketing. no, we now know that these drugs are not -- so you have a massive prescribing of these pills in many parts of america. medicaid and medicare were a big part of what happened and continue to happen in various parts of the country. pill mill doctors and scandalous doctors were not the reason this happened. it was an entire generation of doctors buying the idea that these pills could now be prescribed with virtually no risk of addiction. we went in 1990, the world supply of hydrocodone was three tons, it went to 43 tons in 2010.

supply, 43 tons, world 99% was used in our country. similar figures for oxycodone. it is a revolution and thinking, -- in thinking accomplished through marketing. that is why in charlotte or salt lake or new mexico or arizona or minneapolis -- places all over the country, you have this supply. in some areas, it is definitely exacerbated. overall, you are talking about a general change of mind on the part of many hundreds of thousands of doctors all across the country together with some of the stuff you were talking about. jill: i just want to add to that that we have heard lots of stories, a lot more glamorous than the things i looked at -- getting the bad guy, and there are bad apples out there. i think a lot of this is just sort of dull, unwitting participation in the system where we don't like regulation,

we valorize independent decision-making, and i think we are going to see that increasing in this next administration. when public health experts like me talk about regulation, we get pushback on that. they are called death panels instead of evidence-based medicine. i think if we have a medical culture and insurance culture and regulatory culture that doesn't like taking systemic evidence into account and forcing people to participate in a system like that, then we are going to end up with a lot of prescriptions, in part because they are bad apples. it is very important we have law enforcement dealing with the bad apples, but also because that is the way we tell doctors to practice. that is the message we send with the way we structure our insurance. that is how we reward them. that dentist who didn't want to take the call in the middle of the night, i don't blame him.

he is not paid to do it. we ought to have systems that pay people to take those calls. that would take a reform of our health care system, part of which obamacare was on the way to doing, but i think we are going to see the problem worsening. >> next question on your right. >> my name is robert and my question is, do you think the amount of attention given to this issue would be different if it wasn't the case that, as you described, it is more prominent in white communities? benjamin: i can't speak for statistics on racial demographics, but i do a lot of cases where the doctors we investigate had waiting rooms full of addicted african-americans. at least here in l.a., i haven't seen it being exclusively limited to white people.

maybe that is just l.a. maybe that's just the case i am seeing. it is just that from my perspective, it is a unique issue because it crosses every ethnic group and age group and class. as far as i can see it is , impacting everybody. i don't know if that answer your question at all. lisa: it's not that people of color can't get hurt from it, do not think you are immune from it. people of color are getting hurt from this. i think what's got the attention is that we have seen for the first time in 75 years a turnaround in life expectancy for white people and it is caused by this. we are not seeing it in these other racial groups. that is one of the shocking things. there was a paper that came out that showed this for this first opioidd that is the

epidemic and it is hitting white people in a particular way. if it were another racial group, i don't know. we have a fairly lousy history for dealing with problems that hit only some racial groups and not others. in this one, there is something very dramatic going on with this one group. >> final question on your left. >> i am a nurse practitioner and this is a great panel for the community. i hear you talking about the doctor-patient relationship, what about the nurses? the nurses are pivotal in this fight. there are the number one educator -- they are the number one population in health care that is forefront in dealing with patients. i have heard none of you mention a nurse.

lisa: my colleague harriet ryan interviewed the new surgeon general of the united states, a guy named dr. murphy i think. earlier this month, he dropped a report on the opioid problem. the product of a lot of work. he works in the same hospital ever since he was a resident, and when he became surgeon general of the united states, the nurses who had known him for his whole career said they gave him one request, do something about the opioid epidemic. i can tell you absolutely, they are on the front lines. nurses in the state of california practitioners can write these prescriptions and do work for doctors, so they can contribute to the problem and to the solution. they certainly are dealing with

a lot of the rehab centers and addiction treatment centers. i know they see it. they are on the front lines. a lot of them like you are looking for a solution. >> thank you and with that we are going to close our program. i would like to thank ucla for making this event possible this evening and thank all of you for joining us tonight. i invite everyone to join us at the reception afterwards. we can continue the conversation over wine and talk to our panelists and continue to pick their brains. thank you to our wonderful panelists for sharing your thoughts tonight. [applause] >> thank you. >> no problem.

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c-span's cities tour will explore san jose, california. here about silicon valley, home to many of the world's largest high-tech corporations including google, facebook, and apple. ethan baron talks about the success and challenges silicon valley has had on san jose and the region. >> silicon valley is moving. it is absolutely rampant and that raises the possibility that things will go in the other darker -- the other direction. >> larry gersten talks about his book "not so golden after all." studied this state 50 years or more. you realize this state is so topsy-turvy, it is like a roller coaster gone bad.

boom state economically and one year it can be in the whole. -- hole. announcer: we take to the beginnings of san jose. the --pablo was moved to from the original location to this location here. us is the lastd remaining structure of that puebla built in 1777. late 1800sy in the when this observatory was instructed was going through a heyday of discovery. it was one of the largest of its time in the world. announcer: watch c-span's cities tour of san jose, california.

working with our cable affiliates visiting cities across the country. vice president pence was in james hill, wisconsin, with paul ryan to talk about economies -- the economy and jobs with small business owners. he was asked about his use of a private email as governor of indiana and responded to a question on attorney general jeff sessions and the 2016 presidential election. >> why you decided to use your private email -- our pence: i am confident even all practices were in full compliance with all of indiana's laws that in my service as vice