Ep. 31: She's So High

0:06 Welcome to M4 Medicine, mystery, mayhem, and sometimes murder. I'm Andrea Marziano and RN with 35 years of experience across various fields. From direct patient care in hospitals to home health, geriatrics, and injury medicine, I face life, death, and everything in between. And I'm Crystal Miller and RN with 13 1/2 years of experience. My work spans home health, Hospice, emergency care, geriatrics, and occupational health. From the chaos of trauma based quiet moments with patients, I've seen stories that defy explanations. We've been friends for over 25 years and as nurses we've shared countless stories that have left us and our families speechless. Now we're bringing those stories and many more to you in medicine, mystery, mayhem, and sometimes murder.

0:53 Each week, we'll uncover cases that challenge the boundaries of medicine, sharing the human stories behind the science. From puzzling medical mysteries to shocking real life crimes, we'll bring you stories that'll leave you questioning everything you thought you knew while. We're both experiencing these nurses. We want to make it clear we're not here to give medical advice. This podcast is about storytelling, education and exploration, not diagnosing or treating medical conditions. This is medicine, mystery, mayhem and sometimes murder. Let's dive in. Hey Crystal, how are you doing? I'm doing well. How are you? I'm very well. Thank you. Anything exciting going on? I have another sister visit, so that was fun, you know, as we've already made well known, I guess.

1:37 But still, I moved here to Oklahoma from Utah a few years ago and majority of my family is still in Utah. And so I've had a few visitors, my parents and one of my sisters and her daughters and my oldest sister just came out to visit. That's cool. Yeah. It was a lot of fun. She's an empty nester, so. And she is a workaholic. I think it was fun for her to come out and just chill. And we went to the Cowboy Museum, which was really cool. It's huge. It's almost too big to do in one day, but. What is a cowboy museum pray tell? Do you have a bunch of taboo? Well, yeah, it's a, it's a, it's a cowboy of the history of the Sorry. It's a Museum of the history of Cowboys.

2:20 So like, they had saddles and hats and lots of beating by Native Americans, guns, stories about Cowboys. They had an interactive movie where it was a 360° movie that it was really cool that just told the history of cowboying. They also had a, they had a bunch of the bunch of stuff about westerns and cowboy TV and movies. It was cool. I never even knew such a place existed. I didn't either until my parents told me they had gone to it when they came out to visit, so we decided we'd have a look see and it was cool. And the best part? Cowboy movie. I mean, she did. She did enjoy it.

3:02 She enjoyed it a lot. The best part was the movie that was narrated by Sam Elliott because he's the greatest cowboy in town, although Tom Selleck is a close second I will say. Yeah, well, Tommy and I have gone back a long way. I. I do remember. You may be unaware of it, however. Sam Elliot is also unaware of of our special friendship so. Oh goodness, those poor men. I'm sure they have quite a few people that would happily be involved with them anyway, I'm sure. So what do you have for us today? Well, today, unrelated to Cowboys, I wanted to talk about opioids in the opioid crisis, and not only opioid crisis, but just also the complacency that kind of came about around opioids.

3:50 So my sources today are the US Department of Justice, the Purdue Pharma Litigation and Investigative Reporting, the American Medical Association Journal of Ethics on opioid prescribing and regulatory context, the Rothman Opioid Foundation, US congressional Opioid hearings, and the Gosport Independent Panel report from the UK. Wow. So this episode is not about a single event or a single villain. Instead, it's about a chain reaction, a gradual shift in how medicine understood pain, how clinicians prescribe treatment, how corporate incentives interacted with that shift, and what happened when normalization went largely unquestioned. The opioid crisis did not begin with fentanyl or with criminal prosecutions. It began with a belief that pain was undertreated and that modern medicine could respond more compassionately and effectively. That belief was not inherently wrong. For decades, many, many patients, particularly those living with chronic illness, cancer, or post surgical pain, experienced inadequate pain management. Clinicians were increasingly encouraged to treat pain more seriously, to measure it more consistently, and to view relief as a central component of care.

4:59 Overtime, this belief reshaped expectations among patients, clinicians, and healthcare systems alike, and those expectations influenced prescribing behavior. In this episode, we follow that shift step by step. We examine how the narrative around pain changed, how prescribing expanded in practice, how some actors exploited the environment that emerged, and how normalization could create harm even without clear malicious intent. These stories involving Purdue Pharma, opioid pill mills, Incest therapeutics and the Gosport Hospital scandal are distinct, but they reveal a shared pattern about systems, incentives and trust. Well, I remember back when I was first a nurse in the 80s, late 80s, early 90s, how pain was really ignored in a lot of situations.

5:50 And I'm sure you'll be talking about some of this, but especially people who were end of life pain situations, as you mentioned cancer, because I think the theory had been and it like many things, swings very far both directions. So in the 8 late 80s, as I remember it, people who are having a cancer end of life experience did not get much in the way of pain medications because people believed that they didn't feel the pain, right. But then they'd watch them and they'd be agitated, they'd be all upset and everything else. So they realized that maybe it was pain. So they started to address the pain. And then people were worried about them getting addicted. And everyone was saying yeah, but they're dying. So.

6:37 Even if they do, in this next 4 hours they're dying, actively dying. So they started to not worry about that and really look at keeping the patient comfortable. And then other people who had chronic pain, I have fibromyalgia, so I have chronic pain and I've never taken pain medications for it because I've seen the slippery slope that my clients have been on when they had this and other pain syndromes. So I've never taken pain medication for it because I don't think, I mean, I would love to be out of pain, but I think that is not the best way to go. There's a lot of things that I can do that help me more, I think and still have quality of life, but there's that balance. And then a lot of the pain medicine specialist got on board and they started being able to control it a little bit more. I'm interested to see what you say because I, I've experienced it for 36 years in the profession and to see what kinds of things you're going to bring out today. So carry on.

7:37 Sure. In the in the 1990s, medicine was increasingly focused on improving pain treatment. Professional organizations, patient advocacy groups, and healthcare institutions emphasized that pain was frequently undertreated and that clinicians should respond more aggressively to patient discomfort. Like you were saying, right, And this is right. About that time, this environment created a receptive context for new pharmaceutical approaches to pain management, including extended release opioid medications. When Purdue Pharma introduced Oxycontin, it was presented as a long acting opioid that can provide sustained relief and improved quality of life. Marketing materials and educational messaging emphasized convenience, effectiveness, and most controversially, suggested that addiction risk was lower when opioids were used appropriately for pain treatment. That claim later became central to litigation and regulatory scrutiny, but at the time it contributed to changing perception among many clinicians. Well, I was interested in interesting in that regard. What I was taught when I was in nursing school is that I'm using my hands as demonstration listeners. I put one hand up, fingers open, the other hand joins that other and it closes what are considered the cogs of pain. And when those cogs are closed and all the pain medication is going into those spaces, things are OK. And people aren't usually going to get addiction because they're not feeling the high that they get when there's extra pain medication flowing around in the

9:10 system. And that theory was very well, that was very well thought of and spread in the late 80s, early 90s. So I imagine we've, well, I know we've learned a lot since then that maybe that wasn't as true as we thought. So. Well, it, it is true, but there's a caveat and that is let's say you have so, so the way the opioids work, there's a receptor on a cell or whatever. There's a receptor and that receptor is either is filled with a pain signal or if you're taking opioids, it's filled with an opioid signal. So basically those opioids go in and they fill that receptor spot with themselves instead of the pain signal.

9:53 And so when Andrea was doing that demonstration with the five fingers spread apart and the kind of the cogs fitting in like in a watch works or clockwork, that is true. Those those five areas get filled in with that opioid pain medication instead of instead of the pain signal. But what it turns out our body does is it then responds to the pain or the cause of the pain by creating another receptor point and creating another receptor point and creating another receptor point. So then suddenly you've got quote UN quote, 5 opioids in your 5 pain receptors that were making you feel comfortable, but now you have 5 opioid signals in nine receptors. So now you've got 4 receptors that don't have that and you're out of opioids, right?

10:41 You only had enough to fill 5 receptors. And so now you've got to take more opioids to fill those new receptors and those that grows and grows. And so you can see how that could go from, I mean, we're way, we're way putting the, the cart before the horse, but I'm fine with it. But you can see how that can go from, you know, simply taking Lortab because you have back pain to heroin because it's $8 a bag instead of $100 a pill for oxyglatin right on the street, street, street prices. And so, and so that's the problem. And that's what unfortunately what was ignored or I don't, I don't know. I didn't look to see when we discovered this part of it, but well, I think it was, I think it, I'm not saying it was ignored by medicine and clinicians. I'm saying it was, it was ignored by big pharma, by a. Pharmaceutical country, I totally agree with. I think that as clinicians, we started seeing it backfiring pretty early on.

11:38 I think it was maybe 5 or 10 years in to the real push of let's deal with everybody's pain, and then we started shifting over to things like biofeedback, meditations, other kinds of strategies to deal with the pain instead of just opioids. That's how it worked in my practice anyway. But the problem with that is in a lot of cases, the floodgates were open and it's very difficult to, yeah, it's very difficult to put a flood back into a levy. Hard to close the gates back up. Yeah, so one of the things that Purdue Pharma did, and I don't know if you've seen the movie Dope Sick with Michael Keaton, it's a great, it's a great movie about Purdue and the Oxycontin scandal. But one of the things they did is as they sent out their pharmaceutical reps, their marketing material and their marketing push was that Oxycontin was not Oxycontin contin.

12:33 Gosh, it's so hard when there's Oxycontin, oxycodone, Oxycontin. So this is Oxycontin with an NOXYCONTIN. They said that Oxycontin was not addictive, that it was somehow miraculously, unlike other opioids, not addictive. And yeah, well, and they pushed it and they pushed it hard. So the result was not an immediate transformation, but it was a gradual cultural shift. Doctors started believing this, this marketing, right. Opioids begin to move beyond their traditional association with severe or end of life pain and into routine medical care, including treatment for chronic musculoskeletal conditions, back injuries, and recovery after relatively common procedures. Pain assessment became more standardized, patient satisfaction measures increasingly included pain control, and prescribing patterns expanded accordingly. Do you remember the 5th vital sign? The pain scale.

13:26 Yeah, the so one of the things that was actually a came from marketing was this fifth vital sign. So we have, you know, traditionally we had heart rate, blood pressure, temperature and oxygen saturation, right? That right for I think. We had some. Yeah, yeah. And then they started, they started into, they started calling it the 5th vital signs where, you know, you had to, it was part of what was required in every assessment, which is fine. I think that that's still is accurate. But it's the commercialization of it and the gimmicking of it that I disagree with from the from these pharmaceutical companies, right. You know, it's an important, it's important to recognize that most clinicians were acting in good faith.

14:09 They were responding to evolving guidelines, to patient needs, to professional expectations. However, once prescribing norms shift, they tend to reinforce themselves. Patients come to expect relief, clinicians seek to avoid under treatment, and healthcare systems adapt workloads to reflect prevailing practices. Over time, something that once felt exceptional can begin to feel routine, even when long term risks are not fully understood. I remember when I got my first tattoo long time ago, I was able to get Lortab to have that tattoo, to get that tattoo and. You mean you were actually on Lortab when they gave you the tattoo? I got Lortab to have the tattoo. I didn't, yeah, I didn't tell the. I didn't tell the tattoo people. As a Lortab, they wouldn't give me a tattoo. I know that's what I was thinking because. Back actually way, way earlier.

14:55 This just reminded me way, way earlier, way earlier in the Let's see if let me do a little head math. In the late 90s, I was able and I say able. I didn't ask for this, but I was able to get Lortab for migraines, which I, you know, I know now Lortab can't touch a migraine. Like that's those are apples and oranges. It can also make it worse. Yeah, that was actually my first experience with taking an opioid and not getting pain relief from it and just feeling like weird. And it was my that was like my, that was my point, right? Where I could have gone either way.

15:35 I think I could have gone like oh this weird is good but I was like this weird sucks and I did not like it. I think people tend to be on one side of the fence or the other. I don't think a lot of people are right in the middle. Yeah, I agree. As the narrative around pain changed, behavior changed alongside it. Prescribing patterns do not transform overnight. They shift gradually through daily clinical decisions, patient expectations and institutional practices. This incremental change created an environment in which high volume prescribing became more plausible and in some cases, less likely to trigger immediate concern. It's within that environment that opioid pill mills emerged. The term pill mill can invoke images of overtly illicit operations, but many of these clinics appeared outwardly conventional. They operated in office settings, employed medical staff, and conducted patient visits that resembled standard care.

16:25 The defining characteristic was thought appearance. But prescribing behavior, specifically the provision of large quantities of controlled substances without adequate evaluation, monitoring or medical justification. Common warning signs eventually became widely recognized, including cash only payment models, Yikes times, Yikes to the Yikes degree, extremely brief appointments, minimal diagnostic testing, and prescription volumes that far exceeded typical clinical practice. In some regions, certain clinics developed reputations that attracted patients traveling significant distances, suggesting that high volume prescribing was both visible and at times tolerated before regulatory intervention occurred. So have you seen their representations of pill mills television or maybe even seen one in real life? I don't know.

17:15 I haven't seen one in real life. Yeah, well, I heard about him, especially as I was living through this as a nurse, where the doctors were pulling back on the prescriptions because they realized that there was a big problem being created. So people started pill shopping. They go to these places for the pills. And it was before there was a nationwide system saying who was on what and the pharmaceutical, I don't know what, I can't remember what it's called, but where it's all connected on the computer. So someone would get flagged if they have another opioid prescription. It was really easy to pill and or doctor shot. So we did see it and we saw some of the results of it and we saw a lot more people becoming addicted or staying addicted. I'd I should probably say that staying addicted rather than becoming addicted because they already were addicted in most places.

18:06 Well, the thing that gets me part of the problem with this opioid epidemic that we've had in the US is that how many, how many news stories have you seen where the car is in the middle of an intersection and both the driver and the passenger are just doped out? Like they've shot up at the intersection at the red light. And they've been a lot, a lot, unfortunately, far too many where a child is in the car, right. It's astounding to me how far this has gone to the point where suburban neighborhoods have a heroin problem. You know, the affluent have a heroin problem like, and it all stems from, and we're going to get into this a little bit more, but it all stems from this cry, this call for change, which I think was legitimate.

18:57 Like you were saying, we need to treat pain better. We need to be more responsive to people's complaints of pain. And the people who took advantage of that by saying, hey, we have an answer. That's a miracle. I mean, frankly, that's what they were saying. Whether they use that word or not, that's what they were saying. We have an answer. We have an answer to this call. And that answer was actually when ice picked to the eyeball. The existence of pill mills reflects a complex intersection of factors rather than a single cause. Chronic pain is real and often difficult to treat, and many patients sought relief in a healthcare system that increasingly emphasized addressing pain. At the same time, expanding prescribing norms altered expectations and created pressures that affected both clinicians and patients.

19:41 Long term opioid therapy became more common, and in that context, high volume prescribing could appear less anomalous than it might have been earlier decades. Like we were saying, research indicates that exposure to prescription opioids played a meaningful role in the product trajectory of the opioid crisis, including increased risk of dependence for some individuals. Pill mills contributed to this exposure by amplifying prescribing patterns beyond what was medically appropriate. However, they did not create the environment in which such practices could occur, they operated within it. As prescribing volume increase, the influence of financial and systemic incentives became more pronounced. Setting the stage for more deliberate forms of exploitation.

20:25 So I'm curious to know if you've heard of Incest I Insys, INSYS Therapeutics or their product Subsys? Don't think so. OK. I hadn't heard of it before I did this research either. I'd heard of Purdue a lot, right? But Insys, I'd never heard of. So Insys Therapeutics represents a later phase in this, in this trajectory in which existing prescribing norms created opportunities for targeted manipulation. The company's primary product, Subsys, was a fentanyl spray approved for breakthrough cancer pain. Fentanyl has legitimate medical uses but is significantly more potent than many other opioids, making careful prescribing oversight particularly important. A lot of St. drugs have fentanyl in them now too. A lot that's.

21:13 Why people are dying? Right now, Yep, Yep. It's so bizarre to me because why are you killing your customers bro? Right. That doesn't seem like it could business strategy. I digress. Federal Investigations letter later demonstrated that INSYS implemented programs that incentivize prescribing through speaker events that in numerous instances functioned as payments linked to prescription volume. While speaker programs are common within pharmaceutical markets, evidence presented in court showed that some events had little substantive educational content and that prescribing patterns were closely tied to participation. I'm really curious to know if you've ever been to a speaker event. I know you're not a prescriber, and I'm not a prescriber, but I have been to 1.

22:01 I wish I could remember the drug that it was for, but I remember I was there because I was the director of nursing for a nursing home. The speaker event is for people who are only drug reps or doctors. Usually it's for doctors, it's for prescribers. It's for prescribers. OK, so the doctor that was the the medical director of my facility had invited me to this one and it was crazy. I like I said, I don't remember what drug it was for, but it was this high end meal like like Ruth's Chris high end meal and widened and dined.

22:41 And then while we were eating, they passed out Flyers and talked about how great their drug was. And I remember at the time, I don't, I wish I could remember what drug it was, but I remember at the time being like, they're really pushing this drug that I don't think we need in our facility. Yeah, yeah. And I feel like that's why they had me there was so that I would basically back up the medical director. Do you think all the drugs that are now on TV, do you think instead of doing those speaker events, they've now brought it to the public? So the public demands it. I wouldn't be surprised. I mean, I don't know that, but I totally wouldn't be surprised because yeah, it felt, it felt clandestine. And I mean, it felt akin to being in a Speakeasy during Prohibition, you know what I mean? Like it was.

23:24 Did you need your password? Yeah, you need your password. You needed your gold. You needed your gold gilded invitation. Oh my goodness, that's wild though. It was wild. It was wild. So in 2019, multiple executives were convicted in a racketeering conspiracy involving physician bribery and deceptive practices related to insurance approvals, according to the US Department of Justice reporting. That reminds me, did you know that there's also a website where you can go and see what incentives your doctor is getting for specific prescription medications? So they're not kickbacks because kickbacks are illegal. That's right. There is a work around.

24:06 Yeah. There's a loophole where your doctor can be incentivized in some way to prescribe a certain brand of medication. And you can. I wish I knew what that was. You can look it up. Can look up what incentive? What? I don't remember any of my doctors names anymore that I worked with, but I just remembered one. That's funny. Anyway, if I find it, I'll put it in the show notes because it's really interesting to go and look and see what what incentives folks have. That's crazy. And that's not to say that, I mean, you know, they can be incentivized whether they were going to prescribe it or not, like, right, there are going to be some drugs that that are are that makes sense to prescribe and just happen to also have an incentive.

24:47 I don't want to vilify doctors by any stretch, but I mean, if you if I were to look up my doctor and they were incentivized to prescribe a whole bunch of medications from only one pharmaceutical company, I might question it. And this is almost my personal opinion. Again, I don't want to vilify doctors as a whole. But anyway, there was a time when it was actual bribery. Like I said, multiple executives, executives were convicted. I'm rack and tiercing on racketeeracy. That's the new that's the new phrase for racketeering conspiracy. It's Racketeeracy. Very serious. And these convictions marked a notable shift in accountability, as pharmaceutical misconduct had historically resulted more often in corporate settlements than in criminal convictions for leaderships. Yeah.

25:37 Court records also indicated that employees sometimes Vikram's. Why can't I talk today? I don't know. Court records also indicated that employees sometimes misrepresented patient diagnosis to facilitate insurance coverage for the drug. Oh no. Yeah, So INSIST did not create the prescribing environment that allowed this strategy to succeed, but it leveraged it. The healthcare system, already accustomed to broader opioid prescribing, became vulnerable to incentives that promoted stronger medications and higher volumes. This phase of the opioid crisis highlights the distinction between systemic pressures and intentional misconduct, illustrating how structural change can create conditions that some actors choose to exploit. And I want to reiterate that when I say the distinction between systemic pressures and intentional misconduct, I'm specifically saying that necessarily not intentional misconduct from the prescribers, I think that both Insist and Purdue were behind systemic pressures and, and frankly, intentional misconduct.

26:40 I they knew what they were doing. And, and that's been proven through, you know, many lawsuits and, and other historical events. So, So what happens when our culture changes? What happens when our culture shifts and opioids are not a last resort? So much of our public discussion on the opioid crisis crisis focuses on addiction distribution of corporate behavior. However, opioid related harm can also emerge within routine clinical care through patterns that develop gradually and become normalized over time. The Gosport case illustrates how prescribing culture, institutional hierarchy, and delayed accountability can intersect in ways that are difficult to detect while they are unfolding.

27:26 So before I start with this story, I want to make it very clear that the Godsport Hospital case is not a direct result of the United States opioid crisis. It's just another example of how complacency and small shifts and changes can turn into large scale problems. Boiling the frog as it were, right? You drop the frog in boiling water, it's going to pop out as fast as it can. You put a frog in water and start it to boil, it'll it'll let itself become soup. There are some medical scandals that begin with a clear event, a single mistake, a whistleblower document, a lawsuit that exposes everything at once.

28:08 Gosport was not that kind of story. Gosport unfolded slowly, quietly, and in ways that were easy to overlook in real time. Gosport War Memorial Hospital in Hampshire, England, was not an acute emergency hospital. It was a Community Hospital that primarily cared for older patients who were recovering, stabilizing, or transitioning from hospital treatment to home or long term care. Families expected rehabilitation, monitoring and supportive care. Many patients admitted there were vulnerable, but they were not necessarily dying. Would this be like our rehab facilities here? Yeah. This would be like our rehab facilities, exactly like Medicare rehab facilities. So somewhere you would go for like a knee replacement to recover, hip replacement, orif, you know, fracture repair like that. In the late 1980s and throughout the 1990s, one thing began happening that families struggle struggled to explain. Relatives would be admitted for recovery, sometimes after surgery, sometimes after illness, and their condition would deteriorate rapidly.

29:08 In a number of cases, death followed soon after admission. Individually, these deaths did not always appear suspicious. The patients were elderly, many had complex health issues. Medicine often involves uncertainty, and unexpected decline is not uncommon in older populations. What made Gosport different was the pattern families begin noticing similarities, particularly around medication. One of the This kills me, one of the medications repeatedly raised in concerns was diamorphine, powerful opioid used legitimately in end of life care and severe pain management. So do you know what diamorphine is? I remember hearing of it, but I don't really know.

29:48 It's heroin, full stop. Yes, it's medicinal heroin, so at Gosport, opioids were often administered using syringe drivers, which deliver continuous medication over time. Syringe drivers are standard tools in palliative care, but their use carries significant implications. Initiating strong opioids can indicate that a patient is nearing end of life, and dosing decisions must be carefully individualized. Families later reported that these medications were sometimes started without clear explanations and in situations where their relatives were not believed to be dying. I'm described being told that medication was being used to keep patients comfortable, only to see rapid deterioration afterwards.

30:29 Over time, these experiences accumulated into a shared concern that something systematic might be occurring. So imagine your mother is in rehab because she had a hip replacement and she's not only strung out because she's high, but she's she's dying. My mom's had two, two knee replacements. She had them at the same time. And I saw her in rehab and I cannot imagine her not being alert and oriented and just chilling and talking with us. You know what I mean? Like horrible. The case that eventually brought broader attention involved Gladys Richards, who died in 1998 after admission for rehabilitation following a hip fracture.

31:12 Her family questioned the medication she received, particularly the use of opioids, and pursued answers through formal channels. Their persistence became one of the catalysts for ongoing investigation. What followed was not immediate clarity. Instead, Gosport became a story defined by delay. Multiple investigations were launched over the years, police reviews, internal inquiries, professional assessments, yet none produced definitive accountability at the time. Families repeatedly encountered explanations that framed deaths as clinically understandable, even when patterns suggested otherwise. As more records were reviewed and more families connected with one another, concerns increasingly centered on prescribing practices.

31:55 Reports described routine initiation of strong opioids, sometimes without detailed documentation of pain assessment or end of life decision making. The language used in records, including instructions such as quote, make comfortable, appear, frequently raising questions about whether assumptions about prognosis were influencing treatment decisions. Can you imagine a doctor giving you full access to opioids with the only instruction being make comfortable, not a dosage, not a not a time frame make comfortable. No, because also, if for no other reason, what the heck does that mean, right? What's comfortable from my perspective? I mean, in my perspective, comfortable means your pains probably no more than a four or five out of 10. Some people make comfortable might mean 0. Out of 10, right out of 10.

32:47 And that's going to be a whole different. Place maybe it's make myself as a nurse comfortable so if my. So you don't pay me? If my patients not right, if my patients not crying out in pain, I'm much more comfortable, right? Exactly. That's a wild horrible Yeah. I can't even see how that could have been a thing. So, decades later, the Gosport Independent Panel was established to examine the evidence comprehensively. Its 2018 report became the most authoritative account of what occurred. The panel concluded that at least 456 patients had their lives shortened after receiving opioids in ways it considered inappropriate and that. In that facility. Yes. Oh my heavens. But wait. But Gladys died, I presume.

33:29 Gladys died, yeah. OK, because we never talked about her, we just said her family was wondering. She was the catalyst for like her family was the first to really speak up and be like, yo, what happened here? And she'd already died when they started speaking up. Oh, I see. I she died in 1998. Yeah. I I didn't catch that part. I wasn't sure how Gladys played into this. I'm sorry. Go ahead. She. Was she was the one that she had the loudest family? Yeah, yeah, I got that. Her family's asking questions. I just didn't realize that she died from it. 400 and how many? People, 456 patients. Oh, I haven't, and I have no idea how many they cycled through, but that seems like a really high amount. Well, that number could be higher because they're missing records. So that's 456 that we know about that we were able to document. So the whole hospital is a serial killer. Yeah, so important.

34:19 It's important to note that a significant proportion of those patients were not admitted for end of life care, like they were admitted to recover and died instead. So the panel described the prescribing pattern as an institutional practice rather than isolated error. This characterization is critical because it reframes the story. Gosport was not simply about individual clinical decisions. It was about how practices can become normalized within a system, particularly when hierarchical structures discourage questioning and oversight mechanisms respond slowly. While families played a central role in bringing attention to Gosport, the story cannot be understood without acknowledging the nurses who raised concerns from inside the hospital.

35:02 One of the most important figures was staff nurse Allison McCourt. In the early 90's, the court began to feel that prescribing practices on the ward were unsafe. She observed patients being started on strong opioids in circumstances where she did not believe they were appropriate. Nurses often have close, continuous contact with patients. Often. Often nurses. Nurses, mostly for their entire career, have close, continuous contact with patients, placing them in a position to notice patterns that may not be immediately visible through episodic physician visits. The court raised concerns internally, questioning medication decisions and documentation. According to later investigations and reporting, these concerns were not effectively acted upon. Instead, she experienced professional difficulty. After speaking up, her career progression was affected, and she eventually left the hospital. The pattern of raising concerns encouraging resistance is common in healthcare whistleblowing narratives. It reflects structural challenges rather than individual conflict alone.

36:05 Hierarchy, uncertainty and fear of professional repercussions can make it difficult for staff to challenge prescribing decisions, particularly when those decisions are framed as compassionate care. They didn't say anything about this in Gosport. But there's also the level of certainly as a nurse, I'm sure you've experienced it too. I've had experiences of essentially I'm the doctor, you're the nurse, shut up. And I not always that directly, but you know, sometimes indirectly and sometimes passive aggressively. But that's that's the thing that absolutely definitely happens. This idea of I, I had more education than you, so I know more. So I don't want to hear your opinion.

36:47 Another defining feature of Gosport is the length of time families waited for recognition. Many spent years, sometimes decades, seeking answers about what happened to their relatives. Investigations reopened repeatedly, new evidence emerged, and public attention fluctuated. For families, uncertain uncertainty itself became part of the harm. And that's another thing that I think is interesting is that the fact that they were closing and reopening investigations. When you see something in the news long enough, it's old news, right? I'm trying to think of a good example. It's not controversial. I'm sorry you. Can think of a lot of controversial. Ones so could I you know, let's well. No, I get it.

37:27 And if we hear, OK, even just think about things like major storms and things like that that are less controversial. And when I hear about when you've got hurricane season or tornado, you have tornadoes, right, tornadoes in your area. Yeah. So when it's tornado season, it almost becomes unimportant, I think. It just becomes another thing. Yeah, just because another thing that you're hearing about. And not only that, there's also. Yeah, exactly. And so you become accustomed to it, just like drugs. It's also, there's also just the the idea that other things can over shadow it. Right. When you've heard about this Gosport Hospital news for three weeks in a row and then suddenly somebody's murdered in the West End, that's much more interesting and new and, you know, not as boring as boring old Gosport Hospital. Like, I'm not saying it's boring to the families, because it's not.

38:20 But like, I can see why public public attention would fluctuate. Who's on also? Pharma right now, right? You and I are, but who else? Well, but also back back to the Gosport thing, if my family wasn't in there, it doesn't really affect me, as cold as hard as that is. And especially if I don't understand what is really being said. Because it could be my family, it could be could be me, it could be my children, it could be any of those things. But that's a different story because it didn't affect me that day. Right. The Gosport story therefore sits at the intersection of medicine, ethics and institutional accountability. It highlights how powerful medications can shift from appropriate use to problematic practice when assumptions go unchallenged, documentation is incomplete, and concerns raised by staff or families fail to trigger decisive action.

39:08 You know, I always go back to you. If you didn't document it, it didn't happen. Exactly. Unfortunately, that has a reverse effect that if you did it and you didn't document it, there can be horrible results, right? If I go and give somebody oxycodone and I don't write it down, and you come in on a shift and you see that they were due for oxycodone, guess what you're going to do? You're going to give them another one because they were due for it. There's no indication they received it. Right, right. And maybe you'll bring this up, but to backtrack, in this hospital, did they have incentivized medication distribution It was this part of? This was not a part of it. So this was just an example of this is, you know, this is just another example of how without, without, without external pressures can still happen.

39:57 It can become an institutionalized norm without. Didn't did they ever say why they were doing this? Because it seems if there's not an incentive financially for it. As far as I could tell, because they could. I really think that even though we were being tongue in cheek a little bit, I think to some degree it was like, if they're not calling my name, then I'm more comfortable. Right. Because why would you give somebody recovering? I mean, you and I both had hip replacements. Why would you give somebody recovering from that basically medicinal heroin? Yeah, I did just fine with whatever I was on the Percocet, maybe for for a few days. Yeah.

40:38 Not for, not for. Yeah, exactly. It may have just been that that it became an it started as an easy way out and then became the norm. I, I it didn't really say specifically other than just that. I mean, again, it goes back to the whole the order of keep comfortable. That's not a prescription that's it becomes so subjective. Like we already said, what is comfortable and comfortable for who and to what degree of comfort. And I mean, it's so open-ended. And I think that's that's how it happened. And when you think about drugs that have been in air, quote Vogue, you think of people who were literally using cocaine back in the.

41:21 Ages 80s, yeah. Even before that for a long time. Well, the 80s was the heyday. Yeah, they had their muscle boxes through forever and they were taking cocaine, apparently, which everyone. But it was in all their medicines, right? Yeah. Because it was healthy, right? So I wonder, I think about this and if I had a Doctor Who ordered me to give a medication that I knew was medicinal heroin, and they asked me that today, I I wouldn't feel like I could give that medication because I've seen so much about heroin and what it does and how it kills people and all of the things. So I wonder if the people who were giving it really knew what they were giving.

42:02 I think if this is in the UKI don't even know if medicinal heroin is available in the US. This was in the UK and I don't even know if it's still available. But I mean, I wonder if when they were administering it, they knew what it was and what its potentials were. I would think not because I think that wasn't really figured out till later, but I'm not sure. Possibly it was. It didn't. It was had a name, right? That wasn't heroin, it was I just diamorphine. Diamorphine sounds a lot like morphine, which we do use. Yeah, I wouldn't know if I would have thought anything different about it. It's just somebody made another crazy name for a drug 'cause. They're all crazy names, 'cause. They're all crazy names. Exactly. Yeah, most of them. I can't pronounce them anyways. All right.

42:46 So although these cases differ in geography, actors, and specific mechanisms, they reveal A consistent pattern. Changes in professional beliefs can influence clinical behavior, which can create opportunities for both unintentional overuse and deliberate exploitation. Financial incentives, institutional pressures, and regulatory delays appear across all four stories, contributing to environments in which responsibility becomes diffuse and corrective action occurs slowly. Healthcare systems depend fundamentally on trust, trust in professional judgement and regulatory oversight, and in shared norms about appropriate care. When prescribing practices evolved rapidly, that trust can mask emerging risks. Harm often develops incrementally through processes that appear reasonable in isolation, making it difficult to identify systemic problems until they are widespread.

43:33 What makes these stories particularly unsettling is not simply the presence of wrongdoing, but the role of normalization. Many of the decisions described occurred within ordinary workflows, documented through standard procedures, and framed and language consistent with patient care. This does not diminish accountability where misconduct occurred, but it highlights how systemic change can produce unintended consequences alongside intentional actions. The opioid crisis was not the result of a single decision or actor. It emerged through cumulative shifts in belief, practice, incentives, and oversight. Examining these shifts together helps explain why the crisis developed gradually and why recognition often lagged behind impact.

44:17 Ultimately, these cases raise an enduring question for healthcare and other complex systems. When practices become routine, what mechanisms help professionals recognize when those practices no longer aligned with patient safety? The challenge is not only identifying clear misconduct, but also noticing the subtle points at which normalization begins to obscure risk. Wow. Well, you know, I have an opposite thing where when I did have my second hip replacement, I was in, I had gone through recovery and I was in a room because they were keeping me to make sure, I'm sorry, no, it was my knee. So they were keeping to make sure that we had good pain control. And I was in tense pain.

44:58 I mean, really, really intense pain. And I've been told that the knee was a lot harder than the hip. So I just thought, OK, well, I guess that's it. And so much pain that I was throwing up, my blood pressure was sky high and everything was going on and I just wasn't OK. And I said, could you guys talk to my doctor about what's being ordered for pain and because it's not working? And they said, well, we're giving you Tylenol. And I said, wait, what? You're giving me Tylenol and I'm just out of a total knee replacement. Well, yeah, we thought you must have had an addiction problem. And I said, well, First off, nobody asked me and I don't.

45:39 So they had. What had happened is the medication sheet had gotten separated from the orders. And we're. Giving me Tylenol. Oh. My goodness, six hours after a total knee. Oh, I cannot imagine. I can and it was terrible, but I didn't want to be a big whiner baby because I'm like, well, they said it was going to hurt more and then they called my doctor and he was livid. I'm sure he said no, that's not right. I mean, I was having violent emesis because I was so much worse. And anyway, he ended up giving me his phone number because he said. That's never going to get by the way is puking her guts out.

46:22 There's it was. Awful. I could go into more detail, but we don't need that. Anyway, he came in that night and apologized to me for that happening because it was. It was unacceptable. But what it showed to me is there's that swing the other way too. And a lot of cases where they thought it was probably because I was had been a drug addict and I couldn't have any, well, nobody thought to ask me right? If that was the situation, because if it is, what else can we do? Can we assist you with deep breathing? Can we whatever. I mean, there are other besides Tylenol for a major surgery that could have helped. I mean, even if I need more nerve block or something like that.

47:05 But nobody asked me. And the only reason I finally demanded for them to talk to my doctor because not only I was getting worried about my blood pressure because it was like 170 / 120. It was terrible. And it was just my body saying, hey, something's. We don't like this. Yeah, that side of it too. And then I finally got the medication I needed and it was still painful because it was a painful procedure, but at least it was tolerable at that point. I just, I couldn't believe it. And people might say, well, you're a nurse, didn't you read your orders? No, I was also a patient post op on narcotics, I thought. And so it wasn't my job to make sure my medications were right. It was my job to. That's funny. Yeah.

47:46 When I had my hip replacement, they said that to me. They're like, I know you're a nurse, but I'm your nurse. So I'm going to give you your medications. I'm going to tell you what they are and I'm going to give them to you when they're when they're scheduled. I'm like, OK, no problem, right? But it's interesting, right? Oh, I was just going to say it, but when I was coming out of surgical recovery and surgical medications, it didn't occur to me to to check my orders. Your chart, right? Could I please make sure you're doing it right? Right, so something interesting that happens drug seeking is is a big part of the opioid crisis and just opioid problems in general. And we didn't really cover that much other than like pill mills and and pill shopping and doctor shopping. But it's something that people watch for, particularly in the emergency room.

48:33 And my sister had an experience where she went into, she went into the emergency room and she was lashing out and she was grouchy and she was crying and she was being just a jerk. And they decided that she was drug seeking. And so they were, they kept coming in and asking her questions about I'm, I'm intentionally burying the lead by the way they kept, they came in and they were asking her, you know, kept asking her the same questions in different ways, trying to get out of her what she really wanted. And she was just being belligerent and not answering their questions, just basically being a jerk. She kept telling them, I have diabetes, I have diabetes. And they kept just coming in and being like, now you know, what's your level of pain? Anyway, Long story short, she was in DKA or diabetic ketoacidosis, which basically means she was dying and the blood to her brain was not sufficiently insulin. Her blood sugar was almost 800.

49:33 So her brain just wasn't working because it wasn't being fed the proper blood, right? Just her blood was all jacked. So they finally got her blood sugar and they put her on 2 separate bags of Ivsi mean of Ivs, 2 separate IV bags of insulin. She had insulin going into both of her arms. And and so for those lay people who don't know, IV insulin is rare and a big deal. And so to have it going in two arms at the same time is huge. Anyway, So, yeah, so just like the egg on their face and they had to come in the next day and apologize for basically treating her like a drug addict. And I think, you know, I know that there's, I know that we have to, we can't just give in to drug seekers all the time. I totally get that.

50:20 But I do feel like a lot of people have become jaded with the drug seekers and that they've lost some of their compassion, right? It's just really like, again, it's just another nuance and side effect of this crisis of this epidemic that we've been in since the 90s of of opioid abuse and overuse. And I don't know that there's there is a place in medicine for opioids. I want to say that like you and I, we just talked about how we've had surgeries and we've used them after surgery effectively, though I'm not, I'm not vilified opioids themselves, but I do think that I do hope, this is just my hope.

51:00 I hope that pharmaceutical companies can come up with some, some things that are not that don't have such high risks to them, right? And I know that they're developing all the time and I just, it would be nice to see pain control be less scary and less less of a tightrope walk. Well, and also I think in the surgeries I've seen people coming out of, there are a lot more nerve blocks being used and lower levels of narcotics and the heavier meds being used. And I just want to clarify for our listeners, drug seeking behavior is someone coming in to an emergency room, a clinic, a doctor's office looking for the stronger narcotics to be able to control their pain. And I don't even say that in an air quote kind of way, because if a person is addicted to a pain medication, when they start coming off of it, their pain levels can be very well it's. Like I said, right, with the more receptors, more receptors, more receptors, I mean, consider how much pain you're in. If you let's say you knock your shin into something, right? And you're that hurts acutely a lot, right? And you might have to be 10 out of 10 pain for five seconds. Well, consider that they've gone way past 10 out of 10 pain at this point.

52:18 I know that that's an oxymoron, but like their ten now is your 10,000. Right, right. It's a legitimate pain that they can have. However, solving the problem is not the use of narcotics. Usually there are a lot of things that can happen in between and that should happen. I think one of our other problems in our society is that saying, OK, you're now addicted to these meds, so you don't get them anymore at all, goodbye. And that's not a good solution either because they still have the same problem. They just don't have any way to get through it. And so there are a lot of medications now that can be used to bridge that time.

52:59 But some of those medications, Suboxone and stuff are not not really any less dangerous. They just fill a spot. Getting off of these things can be very challenging and a lot of people are afraid or embarrassed if they have this issue. Addiction does tend to run in families, but it doesn't always have to. So when we ask, have you had anyone in your family has ever had any any problems with medications? That means any problem with medication, whether it means they get sick, they get addicted, they have whatever the allergic reaction, whatever, whatever it is. Well, if if the person has a family history of it, that is definitely a red flag potential. Let's talk about it. And there's times where I've known people when I was working as a case manager who came in for surgery and refused narcotics all together because they had a personal addiction problem.

53:46 Some of them I couldn't believe they had the surgery they did and didn't have narcotics on board. But they said it is not worth the risk to me to go back down that road. And I get it. We used other medic other methods we talked about as as as I had mentioned before, things like biofeedback, 10s units, things like that, that are really distraction methods. But sometimes that can get a person through a situation and it is a devastating situation. I know several people who have died of overdoses and it's devastating. And when a person is an addiction pathway, it's horrible for their family, it's horrible for their friends. They it's horrible for them. They even though they're air quote solving a problem, they're not.

54:31 A lot of the unhoused are in drug addiction situations or have been and the problem is huge and to my knowledge we don't have a really great solution. We don't. We definitely don't. Devastating on the other hand, is like many things, like we also alluded to, that for people who are having legitimate pain, pain appropriate for the circumstances, it can be very hard to get the medications they need. There's got to be, I think the pendulum as always swings really far one way, really far the other. And hopefully it's getting a little bit more centered so that pain control is maintained, however, addiction is reduced. I appreciate. That you pointing out that we need to be vigilant in reducing the stigma for people who are have addiction to opioids or issues like that, because a lot of times it's not something that they actively chose.

55:26 It's a circumstance that basically came upon them through sometimes their own actions, sometimes the actions of others, a combination of both. But always I put out a call for empathy and kindness. One of the things from the Course of Miracles, I don't think I've ever said this in this podcast, but Course of Miracles is just a a book that's a spiritual book that I'm not going to go into. But one of the things I love from it is that it says that everything in the world is either love or a call for love. And you know, I like to live my life always answering calls for love with love. Now, am I perfect? No, I'm not. Can I be a jerk sometimes? Absolutely, yes. But like that is my guiding.

56:07 That is my guiding idea of that. Sometimes when somebody's just being a real jerk, it's really that they just they're just asking for love. And do you have to go over and give them a hug? No, but you can. You can show love by not responding with anger or unkindness or whatever. So. Well like the example of your sister who was really being wack a doodle in the emergency room. Maybe ask yourself, why would this person? You can put other adjectives about it. Why would this beautiful, loving, compassionate person act like this? Or just why would this person act like this?

56:47 This is. This seems unusual. Well, why does this person keep telling you they have diabetes? That's one thought, right? Like. OK, so you have diabetes, Big whoop. Like why should I care about that? Why should I care about that, right? Like. It can cause behavioral issues. I think that a lot of times we jump to conclusions and many times the conclusion is probably correct. However, the person is in that situation as we were just talking about, not even necessarily because of something they actively chose to get to this point at some time in their life. I don't think there's anybody who took drugs the first time and say, gosh, I hope I'm addicted and unhomed and dying of some weird thing. Yeah, that sounds good. I don't think that happens. I think most people who have addiction issues have other problems that they have not been able to deal with appropriately, whether it's a mental health issue or even a physical issue.

57:36 Sure, this is what they created as a result. Now for whatever reasons, this another whole podcast. But if we can, as people in our communities, families, environments can look at it a little bit differently, maybe we can be a little more proactive and assisting for solutions instead of just blaming the problem. Yeah, just judgment. Yeah, I agree. Wow. Well, this was not a very cheerful episode, but it really gives some food for thought. Give some food for thought and maybe looking at ways that we can support each other a little bit better. Yeah, I agree. Great. Well, thank you. Thank you. All right, if you've made it this far, clearly you like a little mayhem with your medicine.

58:19 Or you just enjoy hearing us ramble about weird medical mysteries. Either way, we'd love you for it. So hit that follow or subscribe button wherever you're listening. And toss us a rating or review while you're at it. Helps other curious weirdos find the show. And we know there are a lot of you out there. Oh so many. Come join the chaos. Thanks for listening to Medicine, Mystery, mayhem, and sometimes Murder. Do you have an idea for an episode of this podcast? Just want to say hi? You can get in touch with us at our M4 pod. That's OURM thenumberfourpod@gmail.com. We read every e-mail, and sometimes we even respond just like real professionals. Because we are.

59:04 Old friends with new twists and lots of body bags.