as America's overdose crisis been caused by doctors overtreating patients with opioids. That was the subject of this month's SOHO forum debate held at the Sheen Center in downtown Manhattan. Adrienne Fueberman defended the proposition. She's a medical doctor and a professor of pharmacology and physiology at Georgetown University Medical Center. She argued that the overdose crisis traces back to pharmaceutical companies convincing doctors that opioids were safe and effective, causing rising rates of addiction. Dr. Jeffrey Singer, a surgeon and senior fellow at the Cato Institute, took the negative. He argued that the rate of overdoses and the rate at which doctors prescribe opioids aren't correlated. The real culprit, he said, was drug prohibition. This debate was moderated by SOHO forum director Gene Epstein. Defending the resolution, Adrienne Fueberman, Adrienne, please come to the stage. Taking the negative on the resolution, Jeff Singer, Jeff, please come to the stage. Jane, please close the voting. Adrienne, you have 17 and a half minutes to defend the resolution and to take this podium. Take it away, Adrienne. Good evening, and thank you so much for being here to discuss this important question. My conflict of interest disclosure is that I'm a paid expert witness at the request of plaintiffs in litigation regarding pharmaceutical marketing practices. Probably everyone in this audience knows someone in their circle who became addicted to opioids or died from an opioid overdose. I'm going to explain how so many people in the US got hooked on opioids, how physicians contributed to the opioid epidemic, and how doctors false beliefs about opioids were manipulated by the pharmaceutical industry. Although physicians didn't single-handedly cause the opioid epidemic, they were cleverly manipulated by pharmaceutical companies to become the primary contributor to the crisis of addiction and overdose that we have today. Opioids are excellent drugs for end-of-life care and cancer-related pain and for acute pain. Up until the 1990s, that's what they were used for. Physicians were once cautious about opioids and almost never prescribed them for arthritis or low back pain. Opioid manufacturers set out to change that. They promoted opioids by exaggerating the prevalence of and the importance of untreated pain. They constantly cited this study here, even though the authors of this study noted, protested that the study made no distinction between chronic severe pain and everyday aches and pains. Pharmaceutical companies convinced physicians against the evidence that opioids were safe and effective for chronic pain, including low back pain arthritis, fibromyalgia, and irritable bowel syndrome. They used physician influencers called key opinion leaders and they pressured physicians into prescribing opioids, even if they were reluctant to do so. They called them opiophobic and they claimed that they were withholding the best pain medication from their patients with chronic pain. Physicians aren't bad people. We want to help patients. It was a very persuasive argument to tell us that we were torturing our patients by withholding the best pain medication from them. This argument worked really well. They used drug reps, influencers, professional organizations, educational events, and articles in medical journals to convince physicians that long-term treatment of chronic pain rarely resulted in addiction and that it was effective and safe. In fact, it was neither. It turns out that opioids are the worst drugs for chronic pain, not just because they're addictive. They don't work for chronic pain. This is a systematic review of 96 randomized controlled trials that found that opioids are better than placebo, a little better than placebo for treating pain, and they're about as good as IV profan and related drugs, non-steroidal and inflammatory drugs, for improving pain and treating function. If you combine opioids and NSAIDs, you don't get additional relief from the opioids, but you do get more adverse effects. Unfortunately, opioids can make pain worse. They can cause hyperalgesia, which is an increased sensitivity to pain, and some pain patients actually develop even light touch will be painful to them. In many cases, lowering the dose of opioids in chronic pain patients will actually improve pain. Even though opioids generally don't help chronic pain, they're unbelievably difficult to quit, which draws a horrible thing to go through. It's physically painful, and the other symptoms include diarrhea, vomiting, light sensitivity, sweating, rapid heartbeat, rapid breathing, high blood pressure, anxiety, and what one ex addict is called psychic death. People who are addicted to opioids don't continue to use them because they feel good, or to get high. They use them to avoid the horrors of withdrawal, and while acute withdrawal can last days or weeks, many patients will have some symptoms, including depression, fatigue, insomnia, restless leg syndrome, for six months or longer. It's not a short-term thing. The expansion of the use of opioids from cancer-related pain and end-of-life care to the treatment of back pain and arthritis and other conditions for which they should never have been prescribed has resulted in hundreds of thousands of deaths and millions of shattered lives. In 30 years, about a quarter of a million Americans died specifically from overdosing from prescription opioids, and in the 20 years up to 2019 overdose deaths involving prescription opioids more than quadruple, and that's gotten even worse. Last year, there were more than 107,000 overdose deaths, and three-quarters of them involved in opioid. Now, opioid sales track quite closely to both opioid deaths and hospitalizations for opioid use disorder, and the deaths are really just the tip of the iceberg. Besides addiction, signs of overdose, opioids cause severe depression, including increased risk of suicide, respiratory depression, or suppressed breathing, and many other things. We've talked about hydrologies, yet cardiovascular events, immune suppression, not a particularly good thing in terms of COVID, and just in terms of the treatment costs of opioid addiction and overdose, it's a billion dollars a year in 2017, and that doesn't include the other costs of addiction, the loss of jobs, the loss of relationships, babies that are born dependent on opioids, kids ending up in foster care. It doesn't include any of those societal costs. So even a few days of opioids can cause problems, so people think a couple of days doesn't matter. Six percent of patients who take opioids for one day are still using opioids a year later, and about 30 percent of patients who use opioids for a month are still taking opioids a year later. And these are some other studies, even every additional day that somebody's taking an opioid increases the chances that they will be on those opioids chronically. And after surgery, about six percent of people become chronic opioid users. So these short courses, sorry, these short courses of opioids, and that becoming long courses, and long-term use is common in people who start on opioids. Now my opponent will tell you that addiction is rare in long-term opioid users. That's because he apparently has fallen for fairytales spread by opioid manufacturers who lied about addiction risk, saying that only one percent of patients become addicted. There's no reliable evidence that supports these claims. At the opioid manufacturer, drug reps told physicians that there was less than one percent of patients who became addicted. But in fact, a drug company studied Purdue, which makes oxycontin found that even in their own study, 13 percent of people became addicted. That one percent number comes from this one paragraph quarter in JIC letter in the New England Journal of Medicine, in which they looked at hospital records in which someone had taken at least one dose of opioids and was addiction actually mentioned in the record. This study is not worth the paper that it's printed on. But the use of this study and that lie about the one percent addiction rate is all part of a marketing strategy by the Sacklers, Purdue Pharmaceuticals, but also other opioid manufacturers as well. In documents that have been exposed in litigation, Richard Sackler said, we have to hammer on the abusers in every way possible. They're the culprits. They're the problem. They are reckless criminals. And other documents show that it was a marketing message to say it's not addiction. It's abuse. It's about personal responsibility because separating abusers, the so-called abusers, from the so-called legitimate pain patients was a marketing tactic. And some physicians were realizing that their patients were becoming addicted. So they were convinced, okay, I'm underusing opioids. I don't want to torture my patients. I'm giving them opioids. And they were noticing that their patients were coming in demanding higher doses and manifesting symptoms of addiction.  Now, all of the symptoms of pseudo addiction are exactly the same as addiction, but they're not really due to addiction. They're due to untreated pain. So it's okay to just keep increasing the doses of opioids in those patients. So there's no evidence for pseudo addiction. It's just addiction renamed. But the term pseudo addiction, it eased prescriber's guilt. It eased their concern. They're seeing a patient who seems to be addicted and they're being told, oh, they just have untreated pain. If you increase the dose of opioids and the symptoms go away, then it must be pseudo addiction. Other terms that were co-opted by opioid manufacturers included dependence and tolerance, which were soothingly described as normal adaptive states. The words dependence and tolerance enabled physicians to overlook the warning signs of addiction. And then when somebody became frankly addicted, then they were called pseudo addiction and physicians had permission to keep raising opioid doses. And when a physician could no longer delude themselves, that their patient was addicted, the patient might decide that patient's no longer a legitimate pain patient. That patient is an abuser, might cut them off of opioids, an awful thing to do to someone dependent on opioids.  It's inhumane. Most patients who are on chronic opioids need to be tapered very slowly, even then it's an extremely difficult process and many people will remain on opioids for their entire lives. It's not only of users who become addicted, all opioids are addicted and there's no human that is immune from addiction. Everyone's susceptible. Addiction is common among people on chronic opioids. Eight to 12% of people with chronic pain become addicted. Other studies have found that a third of chronic pain patients meet criteria for opioid use disorder. Addiction is common among people with back pain or other types of chronic pain. So opioid manufacturers underplayed addiction risks and physicians played along. They really became these unwitting drug dealers. These again are the symptoms of withdrawal. Patients who are undergoing these symptoms can't use reason.  Now today, most deaths from opioids are due to fentanyl and street drugs. However, many users of heroin and fentanyl started out with prescription opioids. Here's the sequence. First, the physician prescribes opioids that are probably not needed, then patients become dependent and then maybe the physician gets nervous and cuts them off of the opioids or maybe the prescription opioids become too expensive, heroin's quite cheap, then the patient turns to street drugs. The epidemic of fentanyl overdose cannot be disentangled from the prescription opioid epidemic because prescription drug use leads to heroin use which then exposes people to the risks of fentanyl that are lacing the heroin supply. Between four and eight out of 10 heroin users started with prescription opioids. And if someone who prescribed opioids before has a risk of heroin use that's 19 times higher and about 5% of people who first misuse prescription opioids will go on to use heroin. So most heroin users started off with prescription opioids. And adolescents are particularly prone to addiction. The human brain doesn't fully mature until about 24 years old, kind of explains a lot. So adolescents are much more prone to become addicted and adolescents who are given a prescription opioid, most of them from a healthcare provider, were at three to four times the risk of heroin initiation. My opponent may imply that a generous hand with prescription opioids will protect people, but it's not actually true. Many people on heroin actually were prescribed an opioid within the past year. So this is a report from the Agency for Healthcare Research on Quality that shows that opioids are less effective than Tylenol or ibuprofen for kidney pain. So even for kidney stone pain, even for acute pain, opioids are not always necessary. They're less effective than nonsteroidal anti-inflammatories for dental pain. And by the way, dentists are the sixth highest prescribed prescriber of opioids and the number one prescriber to adolescents who are more likely to get addicted. After surgery, patients don't need as many opioids as surgeons are prescribing. In fact, many people end up with unused opioids. Up to 71% of opioids aren't used, but you know people are throwing away those opioids. They're sort of intrinsically valuable. They put them in the medicine cabinet where their kids, their kids' friends, their house guests can get them. So those, that overprescription contributes to addiction among people, even the ones who weren't prescribed the drugs. The US prescribed is prescribed more opioids than any other country since 1992. Opioid prescription has gone down some between 2009 and 2019, but we're still in the top three countries. We're still prescribing opioids inappropriately. A quarter of the people who go to the ER with a sprained ankle get an opioid. Half of women who have normal vaginal childbirth get opioids afterward. Some of these people are going to end up addicted to opioids that they were taking exactly as prescribed. Even children get opioids. And in 2019, one in 28 children and young adults under 21 got an opioid prescription. 41% got more than a three-day supply. Dentists and surgeons wrote most prescriptions. So how did physicians get yoked into helping opioid manufacturers make billions of dollars in profits? Well, promotion works. These are some of the things that go into promotion. KOLs are influencers, key opinion leaders. And studies show that the more drug reps visit doctors, the more opioids they prescribe, the more meals they give, the more gifts they give, the more payments, the more a physician describes. And meals even have a dose-related effect. Every meal prescribed, every meal given to a prescriber, results in a 0.7% increase in opioid prescribing. Now, opioid prescribing has gone down among physicians, but only the ones who aren't taking any gifts or payments from opioid manufacturers. One in 12 physicians takes money from opioid manufacturers. And among physicians who take money from opioid manufacturers, they actually are more likely to prescribe opioids. And anyway, overdose mortality increases significantly related to dollars received. So overdose deaths are actually, opioid promotion actually increases deaths. And restricting interactions with industry reduces opioid prescribing. But unfortunately, a lot of the continuing medical education that doctors get is provided by industry. And it always promotes the drugs. We've done a lot of research on that. In conclusion, opioids are the main driver of overdose deaths in the United States. And physicians are the main supplier of the initial opioids that hook people. People who overdosed on street opioids started their habit with opioids prescribed by their physicians. Many patients became addicted after taking prescription opioids, even the ones who took them exactly as prescribed. Others became addicted on pills left over from over prescription. Physicians became unwitting accomplices to opioid manufacturers in increasing and normalizing the use of opioids in the US. Many doctors meaning no harm inadvertently addicted patients to opioids. We would not have this crisis of opioid addiction and death we have today if it were not for doctors over treating patients with opioids. Thank you. I'd like to thank Jean and the Soho Forum for organizing this important debate and Dr. Foo Berman for agreeing to participate. When overdose deaths were mainly associated with minority urban and marginalized communities in the 1970s, 80s and early 90s, they were considered the user's fault. They were immoral and made bad choices. When white middle class people became more prominent among the overdose death numbers, they were considered victims of the pharmaceutical industry and doctors. Policymakers and opinion leaders have never placed the blame where it has always belonged on drug prohibition. This is not an opioid crisis. It's not even a fentanyl crisis. It's a prohibition crisis. And fair to recognize this fact is making patients suffer needlessly while causing overdose deaths to increase. Now, I'm not here to defend the business and marketing practices of the pharmaceutical companies. Nor am I here to defend a particular approach to treatment of acute or chronic pain. I don't know if Dr. Foo Berman is a clinician like me or if she primarily focuses on medical research and expert testimony. But as a medical doctor, I trust she would agree there are always robust debates among clinicians regarding the proper and rational treatment of a host of conditions from high blood pressure to diabetes to acute and chronic pain. And that patients in their clinical context vary, that there is no one right way to treat a wide range of medical conditions. That treatment must be individualized and clinicians must remain open to modifications and adjustments along the way. But these are topics for a different debate and perhaps a different forum. When I discussed this issue in 2018, the CDC reported roughly 47,000 opioid related overdose deaths. And a prescription opioid dispensing rate of just over 51 per hundred persons. And 66% of opioid related overdose deaths that year involved illicit fentanyl. By the end of 2020, the dispensing rate had dropped to 43 per 100. While the opioid related overdose death rate tops 71,083% of which involved illicit fentanyl. We recently had the devastating report of roughly 108,000 total overdose deaths in 2021. 77,000 of which involved opioids of all types. 87% of those involved fentanyl. Prescribing rates and overdose deaths obviously aren't correlated. Researchers at the University of Pittsburgh and the CDC reported in 2018 that drug overdoses have been growing exponentially since at least the late 1970s, well before the FDA approved oxycontin in 1996. Their study concludes, quote, the US drug overdose epidemic has been inextricably tracking along an exponential growth curve since at least 1979. This historical pattern of predictable growth for least 38 years suggests that the current opioid epidemic may be a more recent manifestation of an ongoing longer term process. This process may continue along this path for several more years into the future. End of quote. It's just common sense that if overdose deaths were occurring years before opioids were widely used for treatment, then the treatment, the opioid prescriptions does not explain the deaths. Effect does not precede cause. While these researchers were only able to track the rise in overdose deaths back to 1979, a 2019 report by the Joint Economic Committee of Congress found overdose deaths began to rise as early as 1959. When I began my surgical practice in the 1980s, both doctors and patients feared opioids and pain went under-treated. By the late 1980s, as research suggested that opioids had a low addictive potential and overdose potential, doctors were encouraged to overcome that fear. In fact, in 1989, National Institute on Drug Abuse Director Charles Schuster stated, quote, we haven't dealt these drugs with the mysterious power to enslave that has been overrated, close quote. And in 1993, National Institute on Drug Abuse newsletter stated, quote, these drugs are rarely abused for medical purposes. Thousands of patients suffer needlessly, close quote. That's 1993. Now, many people, including apparently my opponent, wrongly confused chemical dependence and addiction, and some doctors are guilty of this, doing this as well. But they are different. Dependence refers to the body's adaptation to a drug such that abrupt cessation can cause withdrawal symptoms. Opioids are among those drugs that can cause dependence, but they are far from the only drugs to do so. Many drugs fit this description. Beta blockers use to treat hypertension, create dependence, and abrupt cessation can cause a fatal withdrawal reaction. Anti-epileptic drugs also generate dependence. Same with antidepressants. Would anybody suggest a person whose blood pressure is being well-controlled with a beta blocker is a beta blocker addict? Let me take it a step further. Would anyone suggest that because a patient has been on a beta blocker for a long time and has been doing its intended job, the patient must be taken off it because their body developed a dependence on the drug? Yet this is what is now being said about chronic pain patients who've had their pain controlled for several years with ongoing opioid treatment. While dependence is physiological, addiction is behavioral. Addiction is defined as compulsive use despite negative consequences. Addiction is a compulsive behavior disorder in which a person develops an unhealthy relationship with the drug. The person becomes addicted to the drug. The drug doesn't addict the person.  As recently as 2016 in the New England Journal of Medicine article, doctors Nora Volkow and Thomas McClellan, the director and deputy director of the National Institute on Drug Abuse Today, said, reported quote, unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. Addiction only occurs in a small percentage of persons who are exposed to opioids even among those with pre-existing vulnerabilities. Close quote. Multiple Cochrane studies, the most respected and rigorous reviews on medical literature, show addiction to prescription opioids in chronic pain patients is very uncommon. According to the Debase Resolution, overprescribing opioids caused an epidemic of opioid addiction which in turn caused the overdose crisis. How do I make the slide work here? Try. Did it come on? Okay. Is this the first slide? Yeah. I think we can make sure it's the first slide. Yeah. I guess it is. Okay. So this is from the National Survey on Drug Use and Health, which is conducted by the Substance Abuse and Mental Health Services Administration. It shows the trends in substance use disorder among adults from 2002 to 2014. After 2014, they changed the nomenclature and terminology of their questionnaire. The blue line represents alcohol use disorder and the green line represents all illicit drugs. See if I get the next slide to advance. Yeah. No. I want to go back. Okay. Now, this slide breaks down the trend by specific drugs. The blue line represents prescription pain pills. The green line is cocaine. The orange line at the bottom is heroin. And the red line at the top is cannabis. Now, I'm not an epidemiologist, but I studied epidemiology in medical school. And I seem to recall that an epidemic would require the essentially flat line that charts the percentage of adults with addiction to prescription drugs to go up somewhere along that timeline. For the resolution to make sense, this line cannot be flat. In January 2019, I co-authored a paper with Dr. Michael Shatman of Tufts University and Jacob Sullivan of Reason Magazine, published in the Journal of Pain Research in UCDC and other data from 2002 to 2014. Bottom line, during that decade, per capita pain reliever prescriptions doubled, while non-medical use of prescription pain relievers and addiction to pain relievers was unchanged. There was no correlation between prescription volume and non-medical use of addiction to prescription pain pills. Let me share just a few more important facts with the audience. The National Survey on Drug Use and Health consistently shows roughly one-quarter of non-medical users of prescription pain pills got their drugs from a doctor. Three-quarters, the large majority, get them from a friend, a relative or a dealer. A 2007 study in the American Journal of Psychiatry found that 78% of oxycontin addicts admitted to rehab got their oxycontin from a friend, a relative or a dealer. And 78% also had reported prior treatment for substance use disorder. And 92% of them reported poly-drug use most commonly with cocaine. The overwhelming majority of drug overdose deaths have been what's so-called poly-drug deaths with substances such as cocaine, meth, Xanax and alcohol. The New York City Department of Health concluded over 97% of overdoses had multiple drugs on board. By 2017, the CDC reported a fewer than 10% of overdoses involved prescription opioids alone without these other dangerous substances. A 2019 study in North Carolina found at least three-quarters of North Carolina opioid-related overdose deaths involved cocaine, meth and alcohol. Now clearly, if the opioid overdose deaths were due to overprescribing opioids, the bodies would contain opioids. Doctors are not prescribing poly-drug cocktails. We're not prescribing to our patients opioids plus cocaine plus meth plus alcohol. And why would a dependence on opioids compel a person to use them with cocaine, meth, Xanax and alcohol? A study by researchers at Harvard and Johns Hopkins published in the BMJ in 2018 followed over half million patients treated with opioids for acute postoperative pain between 2008 and 2016. Contrary to what my opponent said, they found a total misuse rate of 0.6%. And that was over half a million patients followed at the database. Cicero and others at Washington University in St. Louis found that 33% of heroin addicts admitted for drug rehab in 2015 stated they initiated non-medical drug use with heroin. Heroin was their gateway drug. 9% said that in 2005 to Cicero. So heroin addicts seem to be increasing all on their own without the help of physician prescribers. And by the way, the study referred to earlier that said most heroin addicts start with prescription opioids. That's true, but it's misleading. They start with diverted prescription opioids that they were using recreationally with their friends. They didn't start as patients. Study after study finds the overdose rate from prescription opioids taken in a medical setting ranges either from 0.022% to 0.04%. Listen to this one. Seniors over age 65 are prescribed dopamine 60% more often than young adults age 25 to 34. Yet young adults die from overdoses four times more often than seniors. So where does this leave us? Drug prohibition makes non-medical use of drugs more dangerous because the black market is a dangerous place to buy drugs. They may be adulterated and adults and purity are not assured. There's also something that economists call the iron law of prohibition. As law enforcement becomes more intense, the potency of the prohibited substance increases. The more potent the drug is, the more banged for the buck, the smaller the volume it takes for a given high, and thus the easier it is to hide from law enforcement. Basically, the harder the law, the harder the drug. The iron law explains why cannabis has become more potent over the years and why crack cocaine was even developed, why phenyl tube propanone was found as a way to produce more potent mixtures of meth, and as why fentanyl is replacing heroin. Non-medical drug use has been on the increase for decades, we now learn, and in recent years people appear more willing to take risks with drug use than did earlier generations of drug uses. Why? Frankly, no one knows for sure and speculation on the answer draws us far field from the debate topic, but we do know that in the late 1990s and early 2000s, as opioids became more liberally prescribed, more prescription opioids were diverted into the black market for non-medical use, whether it's recreational or self-medication. Was that a bad thing? We can argue the point, but quite frankly, as a medical doctor committed to harm reduction, I would prefer non-medical users to use diverted pharmaceutical grade prescription opioids. We know what they are, what they say they are, the dose is what it says on a bottle, and there's no concern that they may be laced with something. As the blame for the overdose crisis shifted to opioid prescribing, prescribing rates came way down. As a result, non-medical users shifted to the next best thing. First heroin, then heroin and fentanyl. This slide shows CDC data through 2016 before fentanyl became predominant. In this slide, the red line represents prescription volume, the green line represents overdose deaths from all opioids, the blue line represents overdoses from prescription opioids, the forest green line represents heroin, and the orange line represents fentanyl.  To be accurate, by the way, research from UC San Francisco suggests that most non-medical opioid users don't prefer fentanyl, they view it as a contaminant. They prefer heroin or diverted prescription pain pills, but the dangerous black market doesn't give them many options. Shopping for illicit drugs is not like shopping on Amazon. Now this next slide shows CDC at the end of 2020, there were 93,000 total overdose deaths, 68,000 were opioid related, and by that time, fentanyl was involved in 83% of overdose deaths. Fentanyl is the orange line in this slide. Prescription pain pills are represented by that light green flat line near the very bottom. And pain patients are the collateral damage in this misguided war on opioids.  At the same time, current opioid policy has driven up the overdose rate by driving non-medical users to more dangerous alternatives as the supply of diverted prescription opioids has trickled down to according to the DEA in 2019 quote, less than 1% of the total quantity of controlled substances that is distributed to retailers. In summary, blaming the overdose rate on bad behavior, careless choices, devilish doctors or corrupt chemical companies just evades the truth. The great bulk of damage done by non-medical drug use is the result of drug prohibition. And until we end drug prohibition, the overdose rate will inexorably increase. Thank you. Okay, so there are a number of statements that have been made. One of the statements was that Nora Volkow, the head of the National Institute on Drug Abuse has said that addiction is rare. Well, in an interview where she was asked to put a number to that, she said 8%. And that an 8% to 12% is the number that is on the National Institute of Drug Abuse website and is the number that I quoted as well, 8% to 12%. So the head of NIDA does not think that the addiction rate is 1%. She has said that it is 8%. The Cochrane reviews were mentioned as well. These are usually systematic reviews of randomized controlled trial. However, the Cochrane review that was mentioned here was bizarrely a review of 26 studies, only one of which was a randomized controlled trial. And that was in placebo control that was just comparing two opioids. The 25 other studies were case series and uncontrolled studies. And those are completely unreliable. And 16 of those studies didn't actually report any addiction rate. They didn't say whether any of the patients had become addicted or not to the reported 3%, a 3% addiction rate. So that 0.22% is completely misleading. The Cicero study was also mentioned that 33%, the number of people, the percentage of people who starts with heroin, start with heroin has gone up over time from 8% to 33%. That's true, but that's still completely overwhelmed by the number of people who began on prescription opioids. 51% of people who go on to heroin started with oxycodone or hydrocodone, and then others started with other prescription opioids. The argument that other drugs cause withdrawal, certainly true. There are other drugs that can cause withdrawal. But you don't see people out on the street looking for beta blockers or antidepressants. They're not addicted to those drugs. Addiction is, there was also a point made about that, yes, although 75% of opioid overdose deaths involve an opioid, that many of those involve poly substances, that's quite true. Sometimes those people might combine benzodiazepines like Valium, for example, with opioids, and that actually really increases the risk of death. So certain drugs like benzodiazepines, when combined with opioids, increase the risk of death. However, benzodiazepines on their own have a very low, much lower rate of death. It's the opioid that's killing people. Sometimes that poly substance uses combining something with Benadryl.  And there was also a point made that addiction is continued use despite negative consequences. Well, if you have a cooperative physician who's continuing to give you higher doses of opioids, you may not have those same negative consequences, but you're still addicted. The problem is addiction. There are different groups of people who are addicted to opioids. There were older urban addicts who started with heroin in the 1970s, and then there were younger people who became addicted to prescription opioids, but then were unable to continue getting those opioids from doctors because if you're a 25-year-old healthy guy, it's hard to convince your physician to keep giving you opioids. Those patients went to the streets. They got addicted to heroin. The reason those deaths went up is because the illicit supply of opioids has become laced with fentanyl. It's become highly dangerous. The deaths are because the supply got more dangerous. It's not that prescription opioids had nothing to do with it. Many patients started on prescription opioids. They ended up on the streets looking for heroin. They're dying because the illicit opioid products have become extremely dangerous. That's what's killing people. Before I even get started, I think it's belittling the poly-drug use as opioids with some Benazryl is really not being honest. At least half of the time it's cocaine, and about a third of the time it's methamphetamine. Like I say, we don't tell people now, don't make sure you don't take cocaine along at the same time. Dr. Fuberman criticized a lot of these quality studies that I've cited and Cochrane studies are the gold standard. I restrain myself. Many of the claims that she made in her slide presentation from hyperalgesia to a lot of the other so-called side effects of suicide and suicidality. These are not confirmed. These are correlations and they've not been shown to have causation. I could share your pick as well, but I'm going to stay away from that because I want to give a couple of more important points that I didn't have the time to make in my initial presentation. Remember I told you that I want to show you that slide that it ended in 2014? With changed terminology, the National Survey on Drug Use and Health reported from 2015 to 2019 and they found that prescription medication pain medication misuse fell from 4.7 percent in 2015 to 3.5 percent in 2019 and that the amount of people with what they now call opioid use disorder, so it's not broken down by prescription pain pills, heroin, fentanyl, it's just opioid use disorder, that also fell from two and a half million to one and a half million. They also found heroin initiation decreased by 57 percent from 2018, but methamphetamine use rose a half a percent from a half a percent to 0.8 percent in the year 2018 to 2019. It's also important to know that the median lethal dose for oxycodone is 100 milligrams per kilogram in a rat or 810 milligram pills if you were taking oxycodone and the median lethal dose for hydrocodone is 375 milligrams per kilogram in a rat or 4,000 7.5 milligram Vicodin pills. The National Survey on Drug Use and Health has shown that opioid prescribing peaked in the year 2012 and total opioid use in 2014 was less than, was total opioid use was less in 2014 than in 2012. Now another interesting thing Dr. Friedman correctly shows we're number one in the world in opioid prescribing. Germany is number two and they rank second only to us and their prescribed prescription volume rate kind of tracks closely with ours. It's peaked up in the late 90s, it peaked in 2012 and it's coming down just like ours is and interestingly they reported that their addiction rate has been unchanged for this entire century, but another thing that differentiates them from us even though like us the opioid prescribing didn't increase the addiction rate, but they're over those rates among the lowest in the world and that's because since the late 1980s Germany has embraced harm reduction from needle exchange programs to safe consumption sites to methadone and buprenorphine treatment so that's why they're over those rates is lower and then I'm pretty much going to finish up here but I did want to point out that very recently in the journal public health reports which is put out by the Surgeon General's office in 2019 a study was done that span the years 2013 to 2015 where in the Massachusetts Department of Health and Boston University they used the prescription drug database and they linked it up with toxicology reports and they found quote only 1.3 percent of the seedings had an active prescription of each opioid detected in a toxicology report on a date of death so again this all basically as weight to my argument that we have a growing population of non-medical drug users when opioids were prescribed more liberally that made for more opioids to be diverted into black into the black market for non-medical use and now there's that's no longer available they've moved on to other things meanwhile the people who need it are being given things like Tylenol which multiple studies have now shown is the same as placebo or they've been putting on dangerous drugs like NSAIDs which can cause kidney failure bone marrow depression and ulcers thank you thank you to both we we now go to the Q&A section in the evening and I see people lining up at the mic to ask their questions as I'm going to be honoring questions from the streamers and also asking for questions from the audience but then as well uh uh both uh debaters have the right to ask each other a question at any time would either of you debaters like to exercise that right at this time okay Jeff make sure your mic is near your mouth ask your question yeah I'd like I'd like to ask uh Dr. Fuberman so based upon the resolutions that opioid over-treating with opioids caused the overdose crisis would would you then advocate or would you then say that if we completely stopped all opioid prescribing got down to zero the overdose rate was going to start to come down um if we were I mean it's unreasonable to think that the opioid prescribing rate would come down to zero because of course some opioid prescribing is is is perfectly legitimate for end-of-life care for cancer related pain etc but yet over prescribing has fed this epidemic and will continue to feed this epidemic there's a bit of a lag it's about eight years um one study found that it's about eight years from when someone starts prescription opioids to to when they start using heroin but the epidemic that we have here is an addiction epidemic and it is and then when people end up on the street that's when they're being exposed to these dangerous drugs so yes absolutely we were to lower if we were to lower the rate of opioid prescribing it would also lower um it would also lower the risk of addiction and of overdose okay because the data show that the prescribing really has come down the prescription vibe has come down close to 60 percent since 2011 and the overdose rate has soared so you're saying if we bring it down to let's say two percent that's going to make a hairpin turn and start coming down I just want to make sure I understand so heroin um the heroin it fentanyl really entered the market about 2014 and that's when you really start to see deaths go up the problem is is that that fentanyl has made the illicit market for opioids much more dangerous that is the problem and the the question that I have for you I know that you are on the record saying that prescriptions are um government mandated um provision slips in and that drugs should just be available um do you believe that um that potent opioids such as oxycodone and heroin should be available over the counter yes absolutely I think that people shouldn't have to get adults shouldn't have to get permission from another adult to put something into their body and it's of course uh you know if we had a legal market then we see overdose rates come down dramatically because we have accountability and and it'd be the market and and the tort law would regulate drugs okay uh uh yes all right we got by the way you guys can exercise the same right just each other a question at any time but I want to get some audience questions again please uh phrase your question ask a question no need to identify yourself take it away so what's your question uh dr pinkberg when we heard the number of figures how many what would you say is the percentage of naive opioid painkiller users who become addicted the number naive um so somebody who starts on opioids um the the the general number that's accepted is about 8 to 12 percent of people who start out oh excuse me speaking to the mic sorry give give miss my give miss let me talk to them tonight hold the mic up to his mouth please how many people in this room have taken an opioid painkiller okay no you don't have to ask the question of the audience okay thank you okay thank you yeah thank you for your question sir uh next question please yeah yeah yeah that's like going after the animal act on the johnny karsten show my name is josh bloom from the american council on science and health and our motto is we debunk junk and i'm sure you know and just like uh many of the 100 articles and op-eds i've written about our particular slant on what's going on in this country i just want to call you out on one number and that was the 103 000 overdose deaths in whatever it was 2020 2019 little close to his mouth please a little close to his mouth okay no no so i've called people out in writing for playing a trick and that trick is combining the legal pill prescriptions with fentanyl to come up with a number that is artificially high and it it would be like um combining submarine and automobile accidents to describe how um dangerous transportation was it gives my question is are you aware that this number of 103 000 is misused to paint a different picture than it is really going on because fentanyl of course most of that so that's my question i guess the question to address to dr. few burman uh take it away dr. burman um so the number is actually over 107 000 overdose deaths in 2021 that's the cdc centers for disease control and prevention a number includes overdoses um from um from not just opioids but but but of all all drugs including methamphetamine including cocaine etc so the 75 it was about 75 percent were due to an opioid many of those are due to fentanyl there's a very dangerous illicit fentanyl supply and that's not the least bit misleading since as i've explained the people who are dying from fentanyl are using heroin and um they're using heroin because many of them started off with prescription opioids and then had to go to the streets to get heroin i will also point out that the american council on science and health is very heavily industry funded um i should meet uh dr. singer jeff do you have i just like to say that i i i would think you would agree with me on this that we use the term opioids too loosely because opioids is a category of drugs that involve uh either uh a derivative of the opium poppy those are opiates or they've been modified slightly chemically those are opioids or they could be completely synthetic opioids so it's a whole class of drugs and when the general public hears opioids they're thinking the ones that the doctors describe but in fact as you pointed out there were 108 thousand close to 180 thousand overdose deaths this last year uh and that included deaths of cocaine methamphetamine benzodiaze the whole works out of that around 77 000 were from that big broad class of opioids but uh dr. blue makes a very valid point because 89 percent of them contain fentanyl 89 percent of those 77 000 overdose deaths contain fentanyl and actually 25 percent of the 77 000 overdose deaths had methamphetamine and 26 had cocaine so saying i think this is and this is not your fault i'm saying this is a fault we've all made we gotta tighten up the nomenclature and be more specific because we create this impression out there that all opioids are causing these deaths and it's really the street opioids all opioids are addictive all opioids can cause death and prescription opioids lean to street drug use i need a couple of questions for streamers dr. adrien the question had to do with your point about opioids not treating pain and or i think he said they're not much better than placebo and could you more information on that um sure there are many studies and there there have been systematic reviews that have been done opioids don't work well for chronic pain they do work for acute pain but we're finding out more and more that that that you can use other drugs to treat acute pain i mean i would have said a few years ago if you have a kidney stone please give that person opioids like that it's it's really horrible pain um and opioids but it turns out that actually nonsteroidal anti-inflammatories um can also work for kidney stone pain i think that's amazing by the way although Tylenol acetaminophen it's a very weak painkiller i completely agree with you that it's it's a very weak painkiller it actually has um can be extremely effective when it's combined with a nonsteroidal anti-inflammatory drug it can actually increase the effect of the NSAID so it's kind of a magic combination combining ibuprofen or another NSAID um with Tylenol even though the Tylenol on its own is really quite weak so um yeah this comes out of dental research and other acute pain research so um and it's not true that they're more dangerous than opioids there are about 16,500 deaths um from uh from nonsteroidal anti-inflammatory drugs compared to you know 100,000 opioid um and by the way the even the deaths that are attributed to NSAIDs um even that's an exaggeration because sometimes they include all gastrointestinal bleeding deaths um as possibly the being related to NSAIDs anyway just to get into the weeds but NSAIDs um are not more dangerous than opioids i hope i'm demonstrating to you how dangerous opioids are i'll come in for yeah anybody can come in the question jeff you don't have to ask me any comment from yeah i think you phone into that opioid trap again that we just talked about you're right 16,000 some and put and change deaths through the NSAIDs 13,000 and change deaths through the prescription opioids in the latest numbers so NSAIDs actually kill more people in prescription opioids that's number one number two if i have a kidney stone anybody is there please give me opioids and i also don't want Tylenol which can kill my liver and it's very dangerous in fact the restrictions are how much you should take a day because it's much more dangerous than opioids which don't kill bigger than the mic don't cause cardiopathy don't cause pancreatitis you just said Tylenol is more dangerous than opioids did i say Tylenol is more dangerous no i think if you take too much Tylenol you can damage your liver i agree with that uh next question questions for dr singer uh you had mentioned that this is a prohibition problem is there any evidence for uh there are other countries that don't have prohibition and would any statistics kind of back up the claim from those countries actually unfortunately there's no country that has ended drug prohibition but there are a couple of countries that have kind of done pretty decent halfway steps for example in 2001 Portugal at that time had the highest overdose death rate from street drugs in the entire entire european union they decided to decriminalize drugs uh so they no longer arrested people for drug use and uh they they stopped stigmatizing people who were using street drugs and they were putting all their efforts that were going into law enforcement and put it into harm reduction type programs like needle exchange programs those type of things they now have the lowest overdose death rate in europe and interestingly they have a lower teen drug use rate than the rest of european union countries they have an adult drug use rate of about the same as the rest of europe the problem with decriminalization is you still got to get your drugs on the black mark so you still don't know what's in it and and so it's it's certainly better than putting people in cages because they chose to use a substance that's different than what you choose to use to alter your mental consciousness but but the problem is you're still making them have to use stuff that you don't know what's in it i'll come in from you agent on the question oh yeah i just want to say that i really agree with dr singer about harm reduction techniques that have the importance of them in portugal and that we should be using harm reduction techniques more um more than us so okay i have a question from a streamer i guess the logic of it is mainly addressed to you agent uh with most of the country's focus um excuse me um also most of the country's focus and resources on opioids aimed at addiction and overdose numbers shouldn't it concern everyone that no one is capturing data on untreated or under treated pain is the data on untreated and under treated pain no yeah chronic pain is a really difficult it's a really um it's a really difficult um issue in people um opioids can really affect um pain processing chronic pain is a terrible problem we really need to have better research on um on chronic pain we um there there there have been there have been a number we need to look at non-pharmacological more pharmacologic therapies we need to look at over-the-counter therapies we need to look at combinations of things uh drugs aren't the only answer um in in fact um you know i've already said that opioids don't work very they don't work well for chronic pain the the the thing for which there is the most um evidence from randomized controlled trials is actually exercise it'd be very difficult to get chronic pain decisions to exercise but that's actually really helpful other things um that can be helpful are um and these these are these are from systematic reviews um that that have been that have been done um by by by government agencies other things that can be helpful or spinal manipulative therapy massage and other kinds of things but we need to have a lot we we it's a terrible problem like we need to have a lot of more research on what really works for chronic pain opioids are not the answer well i would just like to say uh i don't treat chronic pain i'm a surgeon so i treat acute pain but i'm a clinician and i like i said in my opening remarks as as you know there's a lot of debate in the in the clinical research literature about the treatment of pain and i know many well-respected academic researchers believe there is a role for opioids now what where opioids used way more often than it needed to be i don't think anybody would disagree with that but to say that they really it really is not helpful to treat with chronic pain is also something in cases because there's a lot of evidence that in some cases it is and that's what clinicians are always debating because no two patients are like those two clinical contexts are the same so this is one of those areas where we need a lot more research but but nobody knows the right answer yet there's actually no reliable evidence that opioids are effective for chronic pain in there there are a few there are there are certainly cases in which a patient does find on opioids and doesn't go up over years and that that helps them but those cases are rare and opioids should be the last thing that that that we that we try for chronic pain patients because the adverse consequences are so severe next question so i think it's the first debate where by the q and i haven't made a decision trying to think about blame i know the tendency is usually to blame prescribing physicians and doctors but what role do uh like government run medical insurance companies like medicare medicaid have in this like there have been there have there been incentives like kickbacks given that like have made physicians prescribe these more like where's where's the federal government's responsibility in this uh please start with that question jeff yes jeff take me agree with you there were they have been incentives uh medicare particularly when they reimburse hospitals or get a hospital's doctor's they uh they want patient satisfaction questionnaires answered out and that influences the pain and so if if patients say i wasn't satisfied with the control of my pain that might affect the way medicare remunerates providers so there is some evidence that that provider incentive for providers to be much more liberal with the pain medicine because they want to get a good question a good a good write up by the patients but another thing i think it's important to know again you can't if a person has their pain controlled on an opioid let's say for 10 years and they're taking the same steady dose for 10 years you can't say they're addicted you could say they're 10 they definitely can't really depend on it but you can't say they're addicted because it all depends on addiction is a behavioral disorder when you have compulsive use despite negative consequences that you said there's no negative consequences because you're getting your uh your pain medication but you can't jump to the conclusion that if that person had wasn't on that pain medication they start using anyway despite negative consequences and all too often many patients some are desperate enough to go to the black market but some commit suicide uh comment on the question um yes but also just to that um that that last point um opioids can cause chronic depression there's a higher rate of suicide among um among opioids that's not proven that's correlation on causation it's at it's um it's it's it's absolutely been shown but also um yeah anyway so i have to say that people on opioids who are on pain are chronically depressed because they're in pain in response to in response to your question i love this question because um i'm i'm playing physicians less than pharmaceutical companies opioid manufacturers they really affected every source of information that physicians have and not just physicians they also affected payers they also affected the the joint commission on the hospital accreditation to get them uh physicians and other healthcare providers were being required to break patients in the hospital um several every several several hours asking them are you in pain rate your pain on this pain pain scale if they rated their pain seven or higher they were basically required to give patients opioids um because of those patient satisfaction and um uh ratings and i'm i'm very happy to say that um physicians healthcare provide um healthcare professionals for responsible opioid prescribing or prop has gotten the government to take out not to count those questions anymore um on on on treatment of pain that were pressuring prescribers to to give patients opioids in in the hospital so that that actually is not being counted anymore towards um towards hospital ratings which is great but that that all came from opioid manufacturers they're they're really much more important question from a streamer uh for dr few burman um what is the justification for treating cancer pain with opioids but not treating chronic illnesses like sickle cell or other chronic illnesses um so um for for end of life um pain opioids are are absolutely the best thing and for cancer related pain um not just for end of life pain but for cancer related pain um there is the evidence that opioids actually um work quite well so there's just good evidence that they work um sickle cell of course um the chronic disease and can cause um the exacerbations um and um and those are often um often treated with with short courses of opioids and um and that is certainly uh sometimes indicated uh coming to you about the question and the answer i think it's a very good question because uh just be do you have to be terminally ill to get pain relief i mean if there are a lot of conditions people would doesn't work for chronic and we were at scoliosis surgery who are miserable and um they deserve pain relief too absolutely we need more research on things that will actually work without harming them uh next question uh this is to dr few burman so you know doctors are educated smart licensed and yet you're suggesting that they were duped or maybe even outright thrived into over prescribing so do you think that it's wise to have doctors or anyone's sort of as gatekeepers if you know based on what you said it sounds like they might not be trusted in this role oh thanks so much for asking that question so um i've written a paper with a social psychologist on like how social psychology is used to um is it used to manipulate physicians and um decisions um maybe more gullible than the than the general population um a lot of the techniques that pharmaceutical companies use are they're actually pretty conventional sales techniques they have some specific ones as well like most um physicians don't come from uh they don't have the sales background they don't come from families that have sales background they don't you know recognize these kinds of techniques and um you know we're very very smart in some ways but or maybe sort of lacking in some street smart and um and what most of the education the continuing education of physicians is funded by pharmaceutical companies in fact the FDA actually asked opioid manufacturers to fund continuing medical education for physicians on the safety on prescribing opioids safely and my group has done an analysis of this industry funded CME and of course it's chock full of marketing messages you don't ask you know the industry selling opioids to educate physicians on the safety of opioids so i mean i think the answer here is really is independent um education of physicians and that is possible there are independent drug therapeutics uh newsletters um farmed out does independent of CME with that's available free on the web for anybody to see so there there is industry independent and we have lists of industry independent continuing medical education on our site so that's what i think we need coming i think you sell us clinicians short you think we're that stupid that if uh an opioid sales rep comes to my office and gives me all these papers maybe even gives me a pen maybe two pants one is real fancy you know in pen ballpoint pens that all of a sudden i said well i'm going to start prescribing opioids at that those of my patients because this guy gave me a pen how can i say no after the pen when i you know we're not that dumb we are critical thinkers just like uh research physicians are we think too i'm like i'm going to have to really send you some of our papers but no okay now i just have to say you some of mine i'll have to tell you about the social psychology of experiments so it turns out that small gifts actually work much better than big gifts so there's a great social psychology experiment in which they had students do like a really boring task it was like moving pegs from one peg board to the other and then twisting them or something it was really dumb and then afterward they said to the students we'll pay i'll pay you to tell the next student this was interesting so some of the students they said i'll pay you the equivalent of like five dollars to tell the next student this was an interesting experiment and then the others they said i'll pay you the equivalent of two hundred dollars later they interviewed the the the students on how interesting was that task that you did the ones who took two hundred dollars said oh i just lied i mean two hundred bucks a lot of money for a student i i just lied to the next student because i wanted two hundred dollars the ones who took five dollars said um it was kind of interesting nobody wants to be the person bought off for five dollars like you understand being bought off a large amount of money right but what happens is you actually change your thinking you'd know in order to to reduce that cognitive dissonance of like i'm not the kind of person you're going to be bought off by five dollars or by tuna fish sandwich you actually change your thinking those small gifts are extremely effective what you're saying can't be proven there are studies and i've done that for more than 35 years as a clinician takes care of patients and has dealt with life in death situations i i find that offensive to be honest with you okay well data uh next question dr singer i'd like to project forward into the world that you were suggesting where heroin and uh oxycontin and all of these drugs and new drugs that manufacturers would come up with will be available over the counter without an intellectual source um advising people on the medical use of these things so that people can go and hear whatever the manufacturer says about these companies or about their drugs and believe the advertising or not but people will be able to use them over the counter without a control in that world do you think that the corporations will be able to out compete the black market in providing drugs that addicts will use in other words will addicts continue to buy over the counter or will a black market be better at marketing and selling better drugs quote unquote and continue to have situations like fentanyl and such will the black market go away it all depends on how the government handles for example in california with illegalized cannabis they taxed it and regulated it so much that a lot of the cannabis users in california said screw it i'll get a better deal for my team dealer i don't have to pay as much when they go to a cannabis store and they're not going to arrest me anymore because it's now illegal so it depends if we really allow it to be uh you know we don't over tax but over regulate so we can compete the black a rational person we'd much rather go into a store where they can see the labeling of the product they can see what's in it they can ask the the person who's selling on two questions they can do comparison shopping and they can also sue the manufacturer uh if if the if the product just just like with alcohol let me just use we we don't have to get a prescription to get alcohol my drug dealer is named total wine i didn't have to get a prescription when i go to that dealer i ask the people i look on the bottle if it says 45 alcohol it never even dawns on me may have fentanyl in it or may have some other arsenic because it's legal so the answer is yes i think that if you legalize all drugs and allow them to be regulated and allow allow people to to sue and have accountability like we have with alcohol i think you'll see deaths come down and and i think it's going to be positive uh coming from you dr agent yeah on the question no okay this question has been coming up a great deal from the streamers and so it's somewhat repetitious maybe i'll first love it at you dr singer why is there no data on the millions of disabled people who are now suffering why are there no policy groups or task forces aimed at supporting people in pain and their providers so uh can you address that question i i i don't have the answer to that question i think we're seeing more and more uh pain patient advocacy groups get it more organized and more vocal and uh more and more lawmakers uh are familiar with either friends or relatives or chronic pain sufferers who've seen who are having trouble even getting you know more doctors are refused to treat any pain because they're just so afraid of getting in trouble with their licensing board over the law that they're actually not seeing pain that the primary care doctors are referring people to pain management specialists rather than take on the pain patient and then the pain management specialists are booked up so you can't get in for months or they don't want to take new patients so as more and more patients are getting vocal about this i think it's going to stimulate the studies that they're asking for but but i agree that they're on enough uh want to address that question okay i'm afraid we have time for just one final question please ask a question hi i'll be very concise and i am an analyst at reason so i'll give that affiliation out there just does have bias real quick uh what is your evidence dr. fuberman that addiction has increased over the last 20 years these the data that dr. singer cited that's from the federal government it shows pretty stable rates of of heroin plus pain relief addiction what are the time series that show that addiction has actually increased with the prescribing oh there's plenty of evidence from the government about about addiction decreasing about addiction increasing so an addiction to to the addiction range of prescription opioids has been has been more more stable but but as i've already said you know the the street drugs are people you know start with prescription opioids and then end up going to street drugs we we we actually don't know what the rate of addiction is because there's so few people who who enter treatment you know so you we can use the number of people who enter into treatment as a proxy but that's something that we really we we need to have more data we need to have more data on the exact numbers um the the um there've been you know some small studies um that that have been done um in massachusetts for example they found that um about five percent of the um population um is has opioid overuse um has opioid use disorder but we we um we like some of those national um you want to address the question everybody saw the slides but that's from the government it's a flat line and germany's date is the same and they're the second highest opioid prescribed in country in the world okay uh that concludes the q and a part of the evening we go to the summaries uh dr burman you have you've learned you have seven and a half minutes to summarize take it blessed pharmaceutical companies created a a far-reaching highly affected campaign to convince physicians other health care providers and patients that opioids were underused rarely addictive and safe for long-term use these were lies opioids don't work for chronic pain and they're the most dangerous painkiller physicians and dentists introduced millions of patients to opioids increasing doses over time as patients became dependent on them when physicians became uncomfortable with the amount of opioids patients were consuming some stopped prescribing them leaving addicted patients to buy opioids on the street and exposing those patients to the risks of deadly forms of fentanyl inappropriate prescribing of opioids created and continues to create a pool of people dependent on opioids and willing to do anything to get those opioids if their medical supply is cut off physicians were the initial suppliers of opioids that caused the epidemic of opioid addiction that we are currently struggling with and they're ultimately a major cause of the two-thirds of overdose deaths that are associated with an opioid physicians didn't do this on purpose we were manipulated by opioid manufacturers to believe things that weren't true we're guilty of naivete we're guilty of being gullible we're guilty of not defending our profession from being manipulated by pharmaceutical companies but we physicians are guilty nonetheless of unleashing our current epidemic of opioid addiction and overdose on the united states you're somebody jeff singer i'm just going to summarize the points in the beginning this is in a medical conference so we're not having a panel of different doctors arguing over what's the best way to treat pain and whether opioids work or don't work the resolution is that overtreating patients with opioids caused the overdose crisis i've already presented everyone information showing that the overdose rate has been growing exponentially at least since the late 1970s and shows no end of stopping some evidence suggests it started growing in 1959 i presented evidence showing that the overall majority of people who use prescription opioids non-medically got them from a friend or relative or a dealer i showed evidence showing that the majority of overdose drug overdose that's a poly drug and that there's no reason to think that a patient who's been put on opioids by a physician has suddenly feels compelled to mix them with cocaine and methamphetamine and alcohol and xanax and i and my whole thesis is that we've had a growing population of non-medical drug users willing to take risks that in my generation non-medical drug users weren't willing to take and there are much more dangerous drugs out there because of the iron law prohibition during the late 1990s early 2000s when doctors were prescribing opioids much more liberally there were a lot of opioids available for diversion into the black market and that's what was used if anyone here remembers college days in the early 2000s people would use oxycontin at parties okay and then when that source dried up people who had developed habits or not even a cellular habit they were recreational users so they went looking for it and they got either counterfeit oxycontin that was really fentanyl or they started using whatever was more available this has always been a prohibition crisis and i'm going to end the way the way i open which is in the in the 70s and 80s and early 90s when people were dying of overdose deaths then we blamed it on them we said they were immoral and they were making banned life choices but then we didn't start involving white middle class people in the late 90s early 2000s we blamed it on the greedy pharmaceutical companies and the fooled the doctors who were manipulated it's always been about drug prohibition and it's going to get worse until we recognize it thank you asian and thank you jeff for a very civil uh albeit very spirited exchange jane please open the final vote uh yes no or undecided america's overdose crisis is the result of doctors overtreating patients with opioids it looks as though jane has the results and i have here in my hand the soul form tootsie roll that goes to the winner of this debate a soul form tootsie roll of great value of course jane please give me the results okay the resolution read the my god the overdose crisis is a result of doctors overtreating patients with opioids the yes vote went from 31.4 percent to 39.5 percent that was the yes vote it picked up 8.14 points 8.14 points that's the number to be well the no vote went from 37.21 percent to 45.35 percent it also picked up 8.14 points the virus tootsie roll among you two however because asian you're gonna have to go on the road we give you the tootsie roll jeff she's gonna get the tootsie roll


Item number SCP-1004 Object Class Safe Special Containment Procedures All copies of SCP-1004-1 and DASH-2 are to be kept in Secure Containment Locker 17 at Site-37. At no point are any copies of SCP-1004 to be used for recreational purposes. Following the events of Incident 1004-Dale, researchers are no longer allowed to view the output of SCP-1004, even when filtered or via secondary device. Only D-classes are allowed to view the output of SCP-1004. Use of SCP-1133-7 and SCP-894 instances by researchers and control subjects has been approved or deemed appropriate in preventing undesired spread of SCP-1004's effects. The Foundation has set out to prevent anyone from receiving copies of SCP-1004 by a planned and ordered process of unrequested electronic mailings, many of which include computer viruses, malware, or electronic worms. A program has also been designed and disseminated to all electronic mail providers to help prevent SCP-1004 from spreading. Description SCP-1004 is a computer program found on either a CD, SCP-1004-2, or a 3.5-inch discette, SCP-1004-1, either of which will be hand-labeled with the words FACTORY PORN. Contained on this disc is a single executable file, labeled the FACTORY.EXE, a 1 kilobyte program. Running the program results in a window opening on the computer, within which the factory logo is displayed. The logo fades to black, and replaced by the words, what would you like to see? At this point, the user may input any selection of words, from the ambiguous to the precise. Once the request has been input, the program will pull up several dozen images of pornographic content, each of which leads to a full video on the subject. Many of these videos appear to have never been made in real life. Watching videos in SCP-1004 have a cumulative effect.  After approximately 100 straight hours of viewing pornography on SCP-1004, even the most normal of viewers will display an interest in scatology play, the torture and murder of living beings, bestiality, pedophilia, and combinations of the previous. The deadening and reactivity to sexual gratification will encourage them to either seek out such things in real life, or seek to mutilate themselves and their genitalia. It should be noted that SCP-1004 displays no compulsive properties. Users are free at any time to stop using the program. The majority of users continue to use SCP-1004, because it is the easiest way to find a desired pornography. If stated above, any word or combination of words may be entered. This has been used by many victims to view popular members of high social standing in the bedroom, giving rise to many rumors of celebrity sex tapes. The thought has been positive that such videos could be used for the blackmailing of politicians who are antithetical to the Foundation's cause. Unfortunately at this time, all attempts to make recordings of SCP-1004 have resulted in only tape static. Several researchers have claimed to be able to see humanoid shapes moving in the static, but this effect has not been seen on subsequent playthroughs. SCP-1004 appears to spread through the use of electronic messages, sent seemingly at random. Messages generally claim to have certain celebrity performing sexual acts or to have certain depraved acts on tape that are illegal in many jurisdictions. A link included in the message requests users to enter their home address. The resulting copy of SCP-1004 show up in a plain brown wrapper within three days, through bulk mail with no return address. The Foundation currently contains 37 copies of SCP-1004-1 and 23 copies of SCP-1004-2. Incident 1004-Dale Researcher Adam Dale was found to be encouraging D-class subjects to watch SCP-1004 and to copulate with each other for his pleasure. It was determined Researcher Dale had been affected by SCP-1004, despite never having watched it directly, only monitoring the test through a video feed. Any and all indirect viewing of SCP-1004 has been cancelled.


I'm gonna go to bed. Okay. On a warm summer's evening In a party going nowhere Bill met Keith the gambler The train had been asleep When Bill saw the bat dawns One dream day's were over He and John got together And put the doc to sleep He said Bill I've made a life Out of gambling people's money Not caring where it came from Or who would lose their job So if you'd make me leader I promise to be funny And I'll be ready every day To flip and flop You've got to know not to trust him Not to believe him Know what he tells you Won't be the truth We can't let him run the country Cause he's just not able You need more than a cheeky smile To rule the roost Now little John Boy knows That's a secret to surviving It's not telling anyone What he really thinks So he'll just say whatever Murray's written for him But when you're swallowing he did rest You begin to stink And sitting in the darkness Of his kind I'll mention John asks the question Can I get away with it Cause if you've not no policy And if you've got no vision People soon enough without That you're full of You've got to know not to trust him Not to believe him Know what he tells you Won't be the truth We can't let him run the country Cause he's just not able You need more than a cheeky smile To rule the roost